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09/11/2014

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Primary Care -- AAFP

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The "Get Up and Go Test" evaluates for
which one of the following? (check one)
A. Risk of falling
B. Effects of peripheral neuropathy
C. Kinetic tremor
D. Neurocardiogenic syncope
E. Central causes of vertigo

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A. Risk of falling. The "Get Up and Go


Test" is the most frequently recommended
screening test for mobility. It takes less
than a minute to perform and involves
asking the patient to rise from a chair,
walk 10 feet, turn, return to the chair, and
sit down. Any unsafe or ineffective
movement with this test suggests balance
or gait impairment and an increased risk of
falling. If the test is abnormal, referral to
physical therapy for complete evaluation
and assessment should be considered.
Other interventions should also be
considered, such as a medication review
for factors related to the risk of falling.

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Cardiovascular Board Review Questions
01
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You see a 23-year-old gravida 1 para 0 for
her prenatal checkup at 38 weeks
gestation. She complains of severe
headaches and epigastric pain. She has had
an uneventful pregnancy to date and had a
normal prenatal examination 2 weeks ago.
Her blood pressure is 140/100 mm Hg. A
urinalysis shows 2+ protein; she has
gained 5 lb in the last week, and has 2+
pitting edema of her legs. The most
appropriate management at this point
would be: (check one)

D. Admitting the patient to the hospital,


treating with parenteral magnesium
sulfate, and planning prompt delivery
either vaginally or by cesarean section.
This patient manifests a rapid onset of
preeclampsia at term. The symptoms of
epigastric pain and headache categorize
her preeclampsia as severe. These
symptoms indicate that the process is well
advanced and that convulsions are
imminent. Treatment should focus on
rapid control of symptoms and delivery of
the infant.

A. Strict bed rest at home and


reexamination within 48 hours
B. Admitting the patient to the hospital for
bed rest and frequent monitoring of blood
pressure, weight, and proteinuria
C. Admitting the patient to the hospital for
bed rest and monitoring, and beginning
hydralazine (Apresoline) to maintain blood
pressure below 140/90 mm Hg
D. Admitting the patient to the hospital,
treating with parenteral magnesium
sulfate, and planning prompt delivery
either vaginally or by cesarean section

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Cardiovascular Board Review Questions
02
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An asymptomatic 3-year-old male presents
for a routine check-up. On examination
you notice a systolic heart murmur. It is
heard best in the lower precordium and has
a low, short tone similar to a plucked
string or kazoo. It does not radiate to the
axillae or the back and seems to decrease
with inspiration. The remainder of the
examination is normal. Which one of the
following is the most likely diagnosis?
(check one)
A. Eisenmenger's syndrome
B. Mitral stenosis
C. Peripheral pulmonic stenosis
D. Still's murmur
E. Venous hum

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D. Still's murmur. There are several benign


murmurs of childhood that have no
association with physiologic or anatomic
abnormalities. Of these, Still's murmur
best fits the murmur described. The cause
of Still's murmur is unknown, but it may
be due to vibrations in the chordae
tendinae, semilunar valves, or ventricular
wall. A venous hum consists of a
continuous low-pitched murmur caused by
the collapse of the jugular veins and their
subsequent fluttering, and it worsens with
inspiration or diastole. The murmur of
physiologic peripheral pulmonic stenosis
(PPPS) is caused by physiologic changes
in the newborns pulmonary vessels. PPPS
is a systolic murmur heard loudest in the
axillae bilaterally that usually disappears
by 9 months of age. Mitral stenosis causes
a diastolic murmur, and Eisenmenger's
syndrome involves multiple abnormalities
of the heart that cause significant signs and
symptoms, including shortness of breath,
cyanosis, and organomegaly, which should
become apparent from a routine history
and examination.

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Cardiovascular Board Review Questions
03
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A 35-year-old African-American female
has just returned home from a vacation in
Hawaii. She presents to your office with a
swollen left lower extremity. She has no
previous history of similar problems.
Homan's sign is positive, and
ultrasonography reveals a noncompressible
vein in the left popliteal fossa extending
distally. Which one of the following is true
in this situation? (check one)
A. Monotherapy with an initial 10-mg
loading dose of warfarin (Coumadin)
would be appropriate
B. Enoxaparin (Lovenox) should be
administered at a dosage of 1 mg/kg
subcutaneously twice a day
C. The incidence of thrombocytopenia is
the same with low-molecular-weight
heparin as with unfractionated heparin
D. The dosage of warfarin should be
adjusted to maintain the INR at 2.5-3.5
E. Anticoagulant therapy should be started
as soon as possible and maintained for 1
year to prevent deep vein thrombosis
(DVT) recurrence

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B. Enoxaparin (Lovenox) should be


administered at a dosage of 1 mg/kg
subcutaneously twice a day. The use of
low-molecular-weight heparin allows
patients with acute deep vein thrombosis
(DVT) to be managed as outpatients. The
dosage is 1 mg/kg subcutaneously twice
daily. Patients chosen for outpatient care
should have good cardiopulmonary
reserve, normal renal function, and no risk
for excessive bleeding. Oral
anticoagulation with warfarin can be
initiated on the first day of treatment after
heparin loading is completed.
Monotherapy with warfarin is
inappropriate. The incidence of
thrombocytopenia with low-molecularweight heparin is lower than with
conventional heparin. The INR should be
maintained at 2.0-3.0 in this patient. The
2.5-3.5 range is used for patients with
mechanical heart valves. The therapeutic
INR should be maintained for 3-6 months
in a patient with a first DVT related to
travel.

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Cardiovascular Board Review Questions
04
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A 73-year-old male with COPD presents
to the emergency department with
increasing dyspnea. Examination reveals
no sign of jugular venous distention. A
chest examination reveals decreased breath
sounds and scattered rhonchi, and the heart
sounds are very distant but no gallop or
murmur is noted. There is +1 edema of the
lower extremities. Chest radiographs
reveal cardiomegaly but no pleural
effusion. The patient's B-type natriuretic
peptide level is 850 pg/mL (N <100) and
his serum creatinine level is 0.8 mg/dL (N
0.6-1.5). Which one of the following
would be the most appropriate initial
management? (check one)
A. Intravenous heparin
B. Tiotropium (Spiriva)
C. Levalbuterol (Xopenex) via nebulizer
D. Prednisone, 20 mg twice daily for 1
week
E. Furosemide (Lasix), 40 mg
intravenously

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E. Furosemide (Lasix), 40 mg
intravenously. B-type natriuretic peptide
(BNP) is secreted in the ventricles and is
sensitive to changes in left ventricular
function. Concentrations correlate with
end-diastolic pressure, which in turn
correlates with dyspnea and congestive
heart failure. BNP levels can be useful
when trying to determine whether dyspnea
is due to cardiac, pulmonary, or
deconditioning etiologies. A value of less
than 100 pg/mL excludes congestive heart
failure as the cause for dyspnea. If it is
greater than 400 pg/mL, the likelihood of
congestive heart failure is 95%. Patients
with values of 100-400 pg/mL need further
investigation. There are some pulmonary
problems that may elevate BNP, such as
lung cancer, cor pulmonale, and
pulmonary embolus. However, these
patients do not have the same extent of
elevation that those with acute left
ventricular dysfunction will have. If these
problems can be ruled out, then individuals
with levels between 100-400 pg/mL most
likely have congestive heart failure. Initial
therapy should be a loop diuretic. It should
be noted that BNP is partially excreted by
the kidneys, so levels are inversely
proportional to creatinine clearance.

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Cardiovascular Board Review Questions
05
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A 35-year-old white male with known
long QT syndrome has a brief episode of
syncope requiring cardiopulmonary
resuscitation. Which one of the following
is most likely responsible for this episode?
(check one)

D. Torsades de pointes. Patients with long


QT syndrome that have sudden arrhythmia
death syndrome usually have either
torsades de pointes or ventricular
fibrillation. Sinus tachycardia would not
explain the syncope, and atrial flutter and
asystole are not usual in long QT
syndrome.

A. Sinus tachycardia
B. Atrial flutter with third degree block
C. Asystole
D. Torsades de pointes

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Endocrine Board Review Questions 01
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A 49-year-old female who takes multiple
medications has a chemistry profile as part
of her routine monitoring. She is found to
have an elevated calcium level. All other
values on the profile are normal, and the
patient is not currently symptomatic.
Follow-up testing reveals a serum calcium
level of 11.2 mg/dL (N 8.4-10.2) and an
intact parathyroid hormone level of 80
pg/mL (N 10-65). Which one of the
following should be discontinued for 3
months before repeat laboratory evaluation
and treatment? (check one)

A. Lithium. Lithium therapy can elevate


calcium levels by elevating parathyroid
hormone secretion from the parathyroid
gland. This duplicates the laboratory
findings seen with mild primary
hyperparathyroidism. If possible, lithium
should be discontinued for 3 months
before reevaluation (SOR C). This is most
important for avoiding unnecessary
parathyroid surgery. Vitamin D and
calcium supplementation could contribute
to hypercalcemia in rare instances, but
they would not cause elevation of
parathyroid hormone. Raloxifene has
actually been shown to mildly reduce
elevated calcium levels, and furosemide is
used with saline infusions to lower
significantly elevated calcium levels.

A. Lithium
B. Furosemide (Lasix)
C. Raloxifene (Evista)
D. Calcium carbonate
E. Vitamin D
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Endocrine Board Review Questions 02
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In a patient with a solitary thyroid nodule,
which one of the following is associated
with a higher incidence of malignancy?
(check one)

A. Hoarseness. When evaluating a patient


with a solitary thyroid nodule, red flags
indicating possible thyroid cancer include
male gender; age <20 years or >65 years;
rapid growth of the nodule; symptoms of
local invasion such as dysphagia, neck
pain, and hoarseness; a history of head or
neck radiation; a family history of thyroid
cancer; a hard, fixed nodule >4 cm; and
cervical lymphadenopathy.

A. Hoarseness
B. Hyperthyroidism
C. Female gender
D. A nodule size of 2 cm
E. A freely movable nodule

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Gastrointestinal Board Review Questions
01
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A 36-hour-old male is noted to have
jaundice extending to the abdomen. He is
breastfeeding well, 10 times a day, and is
voiding and passing meconium-stained
stool. He was born by normal spontaneous
vaginal delivery at 38 weeks gestation
after an uncomplicated pregnancy. The
mother's blood type is A positive with a
negative antibody screen. The infants total
serum bilirubin is 13.0 mg/dL. Which one
of the following would be the most
appropriate management of this infants
jaundice? (check one)
A. Continue breastfeeding and supplement
with water or dextrose in water to prevent
dehydration
B. Continue breastfeeding, evaluate for
risk factors, and initiate phototherapy if at
risk
C. Discontinue breastfeeding and
supplement with formula until the jaundice
resolves
D. Discontinue breastfeeding and
supplement with formula until total serum
bilirubin levels begin to decrease

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B. Continue breastfeeding, evaluate for


risk factors, and initiate phototherapy if at
risk. In 2004 the American Academy of
Pediatrics published updated clinical
practice guidelines on the management of
hyperbilirubinemia in the newborn infant
at 35 or more weeks gestation. These
guidelines focus on frequent clinical
assessment of jaundice, and treatment
based on the total serum bilirubin level,
the infants age in hours, and risk factors.
Phototherapy should not be started based
solely on the total serum bilirubin level.
The guidelines encourage breastfeeding 812 times daily in the first few days of life
to prevent dehydration. There is no
evidence to support supplementation with
water or dextrose in water in a
nondehydrated breastfeeding infant. This
infant is not dehydrated and is getting an
adequate number of feedings, and there is
no reason to discontinue breastfeeding at
this time.

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Gastrointestinal Board Review Questions
02
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For 2 weeks, a 62-year-old male with
biopsy-documented cirrhosis and ascites
has had diffuse abdominal discomfort,
fever, and night sweats. His current
medications are furosemide (Lasix) and
spironolactone (Aldactone). On
examination, his temperature is 38.0 C
(100.4 F), blood pressure 100/60 mm Hg,
heart rate 92 beats/min and regular. The
heart and lung examination is normal. The
abdomen is soft with vague tenderness in
all quadrants. There is no rebound or
guarding. The presence of ascites is easily
verified. Bowel sounds are quiet. The
rectal examination is normal, and the stool
is negative for occult blood. You perform
diagnostic paracentesis and send a sample
of fluid for analysis. Which one of the
following findings would best establish the
suspected diagnosis of spontaneous
bacterial peritonitis? (check one)

C. Neutrophil count >300/mL. Diagnostic


paracentesis is recommended for patients
with ascites of recent onset, as well as for
those with chronic ascites who present
with new clinical findings such as fever or
abdominal pain. A neutrophil count
>250/mL is diagnostic for peritonitis.
Once peritonitis is diagnosed, antibiotic
therapy should be started immediately
without waiting for culture results. Bloody
ascites with abnormal cytology may be
seen with hepatoma, but is not typical of
peritonitis. The ascitic fluid pH does not
become abnormal until well after the
neutrophil count has risen, so it is a less
reliable finding for treatment purposes. A
protein level >1 g/dL is actually evidence
against spontaneous bacterial peritonitis.

A. pH <7.2
B. Bloody appearance
C. Neutrophil count >300/mL
D. Positive cytology
E. Total protein >1 g/dL

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Gastrointestinal Board Review Questions
03
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A 32-year-old meat cutter comes to your
office with persistent symptoms of nausea,
vomiting, and diarrhea which began about
36 hours ago on the last day of a 5-day
Caribbean cruise. His wife was sick during
the first 2 days of the cruise with similar
symptoms. On the ship, they both ate the
"usual foods" in addition to oysters.
Findings on examination are negative, and
a stool specimen is negative for white
cells. Which one of the following is the
most likely cause of his illness? (check
one)

C. Norwalk virus. Recent reports of


epidemics of gastroenteritis on cruise ships
are consistent with Norwalk virus
infections due to waterborne or foodborne
spread. In the United States, these viruses
are responsible for about 90% of all
epidemics of nonbacterial gastroenteritis.
The Norwalk-like viruses are common
causes of waterborne epidemics of
gastroenteritis, and have been shown to be
responsible for outbreaks in nursing
homes, on cruise ships, at summer camps,
and in schools. Symptomatic treatment is
usually appropriate.

A. Escherichia coli
B. Rotavirus
C. Norwalk virus
D. Hepatitis A
E. Giardia species

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Integumentary Board Review Questions
01
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A 45-year-old white male consults you
because of a painless, circular, 1-cm white
spot inside his mouth, which he noticed 3
days ago. You are treating him with
propranolol (Inderal) for hypertension, and
you know him to be a heavy alcohol user.
After a careful physical examination, your
tentative diagnosis is leukoplakia of the
buccal mucosa. You elect to observe the
lesion for 2 weeks. On the patients return,
the lesion is still present and unchanged in
appearance. The best course of
management at this time is to (check one)
A. reassure the patient and continue to
observe
B. discontinue propranolol
C. treat with oral nystatin
D. order a fluorescent antinuclear antibody
test
E. perform a biopsy of the lesion

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E. perform a biopsy of the lesion.


Leukoplakia is a white keratotic lesion
seen on mucous membranes. Irritation
from various mechanical and chemical
stimuli, including alcohol, favors
development of the lesion. Leukoplakia
can occur in any area of the mouth and
usually exhibits benign hyperkeratosis on
biopsy. On long-term follow-up, 2%-6%
of these lesions will have undergone
malignant transformation into squamous
cell carcinoma. Oral nystatin would not be
appropriate treatment, as this lesion is not
typical of oral candidiasis. Candidal
lesions are usually multiple and spread
quickly when left untreated. A fluorescent
antinuclear antibody test is also not
indicated, as the oral lesions of lupus
erythematosus are typically irregular,
erosive, and necrotic. An idiosyncratic
reaction to propranolol is unlikely in this
patient.

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Integumentary Board Review Questions
02
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Your hospital administrator asks you to
develop a community screening program
for melanoma. Which one of the following
is true concerning screening for this
disease? (check one)
A. Screening for melanoma is not
indicated since the disease is rare
B. Screening for melanoma is not
indicated since screening takes too much
time
C. No definite clinical evidence has shown
that screening for melanoma reduces
mortality
D. Because of sunbathing, female patients
are the most important population to
screen

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C. No definite clinical evidence has shown


that screening for melanoma reduces
mortality. There have been no randomized,
controlled trials or other definitive data to
indicate that screening for melanoma
reduces mortality. There are, however,
factors which indicate that screening
would be beneficial, including the
increasing prevalence of the disease and
the fact that screening is time-effective and
safe. If screening is performed,
populations at greatest risk should be
considered. Men, especially those over age
50, have the highest incidence of
melanoma.

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Musculoskeletal Board Review Questions
01
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Osteoporotic bone loss can be caused or
accelerated by prolonged use of which one
of the following medications? (check one)
A. Hydrochlorothiazide
B. Phenytoin
C. Raloxifene (Evista)
D. Diazepam (Valium)
E. Fluoxetine (Prozac)

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B. Phenytoin. Secondary osteoporosis can


result from a variety of endocrine,
nutritional, or genetic disorders, as well as
from prolonged use of certain medications.
Anticonvulsants such as phenytoin
increase the hepatic metabolism of vitamin
D, thereby reducing intestinal calcium
absorption. Other medications that
adversely affect bone mineral density
include glucocorticoids, cyclosporine,
phenobarbital, and heparin. Thiazide
diuretics reduce urinary calcium loss and
are believed to preserve bone density with
long-term use. Benzodiazepines and SSRIs
have not been associated with increases in
bone loss or in hip fractures. Raloxifene, a
selective estrogen receptor modulator, is
indicated for the prevention and treatment
of osteoporosis in postmenopausal women.

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Musculoskeletal Board Review Questions
02
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An overweight 13-year-old male presents
with a 3-week history of right lower thigh
pain. He first noticed the pain when
jumping while playing basketball, but now
it is present even when he is just walking.
On examination he can bear his full weight
without an obvious limp. There is no
localized tenderness, and the patella tracks
normally without subluxation. Internal
rotation of the hip is limited on the right
side compared to the left. Based on the
examination alone, which one of the
following is the most likely diagnosis?
(check one)
A. Avascular necrosis of the femoral head
(Legg-Calv-Perthes disease)
B. Osteosarcoma
C. Meralgia paresthetica
D. Pauciarticular juvenile rheumatoid
arthritis
E. Slipped capital femoral epiphysis

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E. Slipped capital femoral epiphysis. This


is a classic presentation for slipped capital
femoral epiphysis (SCFE) in an adolescent
male who has probably had a recent
growth spurt. Pain with activity is the most
common presenting symptom, as opposed
to the nighttime pain that is typical of
malignancy. Obese males are affected
more often. The pain is typically in the
anterior thigh, but in a high percentage of
patients the pain may be referred to the
knee, lower leg, or foot. Limited internal
rotation of the hip, especially with the hip
in 90; flexion, is a reliable and specific
finding for SCFE and should be looked for
in all adolescents with hip, thigh, or knee
pain. Meralgia paresthetica is pain in the
thigh related to entrapment of the lateral
femoral cutaneous nerve, often attributed
to excessively tight clothing. Legg-CalvPerthes disease (avascular or aseptic
necrosis of the femoral head) is more
likely to occur between the ages of 4 and 8
years. Juvenile rheumatoid arthritis
typically is associated with other
constitutional symptoms including
stiffness, fever, and pain in at least one
other joint, with the pain not necessarily
associated with activity.

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Musculoskeletal Board Review Questions
03
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A 21-year-old white female presents to the
emergency department with a history
consistent with a lateral ankle sprain that
occurred 2 hours ago while she was
playing softball. She complains of pain
over the distal anterior talofibular
ligament, but is able to bear weight. There
is mild swelling, mild black and blue
discoloration, and moderate tenderness to
palpation over the insertion of the anterior
talofibular ligament, but the malleoli are
nontender to palpation. Which one of the
following statements is true regarding the
management of this case? (check one)
A. Anteroposterior, lateral, and 30 degrees
internal oblique (mortise view)
radiographs should be done to rule out
fracture
B. Stress radiographs will be needed to
rule out a major partial or complete
ligamentous tear
C. The patient should use crutches and
avoid weight bearing for 10-14 days
D. Early range-of-motion exercises should
be initiated to maintain flexibility
E. For best results, functional
rehabilitation should begin within the first
24 hours after injury

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D. Early range-of-motion exercises should


be initiated to maintain flexibility. This
patient has an uncomplicated lateral ankle
sprain and requires minimal intervention.
The Ottawa ankle rules were developed to
determine when radiographs are needed
for ankle sprains. In summary, ankle
radiographs should be done if the patient
has pain at the medial or lateral malleolus
and either bone tenderness at the back
edge or tip of the lateral or medial
malleolus, or an inability to bear weight
immediately after the injury or in the
emergency department, or both. If the
patient complains of midfoot pain and/or
bone tenderness at the base of the fifth
metatarsal or navicular, or an inability to
bear weight, radiographs should be
ordered. Sprains can be differentiated from
major partial or complete ligamentous
tears by anteroposterior, lateral, and 30
degrees internal oblique (mortise view)
radiographs. If the joint cleft between
either malleolus and the talus is >4 mm, a
major ligamentous tear is probable. Stress
radiographs in forced inversion are
sometimes helpful to demonstrate stability,
but ankle instability can be present with a
normal stress radiograph. Grade I and II
ankle sprains are best treated with RICE
(rest, ice, compression, elevation) and an
air splint for ambulation. NSAIDs are used
for control of pain and inflammation. Heat
should not be applied. Early range-ofmotion exercises should be initiated to
maintain flexibility. Weight bearing is
appropriate as tolerated and functional
rehabilitation should be started when pain
permits. Exercises on a balance board will
help develop coordination.

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Neurologic Board Review Questions 01
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A 16-year-old white female is brought to
your office because she has been "passing
out." She tells you that on several
occasions while playing in the high-school
band at the end of the half-time show she
has "blacked out." She describes feeling
lightheaded with spots before her eyes and
tunnel vision just prior to falling. Friends
in the band have told her that she appears
to be pale and sweaty when these episodes
occur. No seizure activity has ever been
observed. In each instance she regains
consciousness almost immediately; there is
no postictal state. She has been seen in the
emergency department for this on two
occasions with normal vital signs, physical
findings, and neurologic findings. A CBC,
a metabolic profile, and an EKG are also
normal. Which one of the following tests
is most likely to yield the correct
diagnosis? (check one)
A. A sleep-deprived EEG
B. 24-hour Holter monitoring
C. A pulmonary/cardiac stress test
D. An echocardiogram
E. Tilt table testing

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E. Tilt table testing. Reflex syncope is a


strong diagnostic consideration for
episodes of syncope associated with a
characteristic precipitating factor. The
major categories of syncope include
carotid sinus hypersensitivity, and neurally
mediated and situational syncopes. The
most common and benign forms of
syncope are neurally mediated or
vasovagal types with sudden hypotension,
frequently accompanied by bradycardia.
Other terms for this include
neurocardiogenic, vasomotor,
neurovascular, or vasodepressive syncope.
Most patients are young and otherwise
healthy. The mechanism of the syncope
seems to be a period of high sympathetic
tone (often induced by pain or fear),
followed by sudden sympathetic
withdrawal, which then triggers a
paradoxical vasodilatation and
hypotension. Attacks occur with upright
posture, often accompanied by a feeling of
warmth or cold sweating, lightheadedness,
yawning, or dimming of vision. If the
patient does not lie down quickly he or she
will fall, with the horizontal position
allowing a rapid restoration of central
profusion. Recovery is rapid, with no focal
neurologic sense of confusion or headache.
The event can be duplicated with tilt
testing, demonstrating hypotension and
bradycardia.

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Neurologic Board Review Questions 02
==============================
=========================
You evaluate an 80-year-old white male
who is a heavily medicated chronic
schizophrenic. You note constant,
involuntary chewing motions and
repetitive movements of his legs. Which
one of the following is the most likely
diagnosis? (check one)
A. Neuroleptic malignant syndrome
B. Acute dystonia
C. Huntington's disease
D. Tardive dyskinesia
E. Oculogyric crisis

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D. Tardive dyskinesia. The patient has


classic signs of tardive dyskinesia.
Repetitive movement of the mouth and
legs is caused by antipsychotic agents such
as phenothiazines and haloperidol.
Neuroleptic malignant syndrome consists
of fever, autonomic dysfunction, and
movement disorder. Acute dystonia
involves twisting of the neck, trunk, and
limbs into uncomfortable positions.
Huntington's disease causes choreic
movements, which are flowing, not
repetitive. Oculogyric crisis involves the
eyes.

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Patient-Based Systems Board Review
Questions
==============================
=========================
The American College of Obstetricians
and Gynecologists and the American
Academy of Pediatrics support the
advance provision of drugs and
instructions for emergency contraception
to sexually active women, so that they
have ready access to them if they are
needed. The evidence shows that advance
provision of emergency contraception
(check one)
A. decreases pregnancy rates on a
population level
B. decreases the time from unprotected sex
to use of emergency contraception
C. decreases contraception use by the
patient prior to sexual activity
D. increases rates of sexually transmitted
infection
E. increases rates of unprotected
intercourse

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B. decreases the time from unprotected sex


to use of emergency contraception. A
Cochrane review including randomized,
controlled trials (RCTs) compared
standard access to emergency
contraception (EC) with advance
provision. The review found eight trials,
five of which were conducted in the U.S.
Two of the RCTs were sufficiently
powered to show a difference in pregnancy
rates. No study showed that giving
advance EC reduced pregnancy rates on a
population level. However, women who
were provided with advance EC took the
pills an average of approximately 15 hours
sooner than women without advance
access. Five studies that reported on
contraception use did not show a
difference in type or frequency of regular
contraception use among women who
were provided advance EC. Women
randomized to the advance EC groups
were 2.5 times more likely to use EC once,
and 4 times more likely to use it 2 or more
times, compared to those without advance
access. Three studies reported rates of
sexually transmitted infection and none
found differences between the advance and
standard access EC groups. Six studies
reported rates of unprotected sexual
intercourse and found no difference. The
Cochrane review concludes that advance
access to EC appears to be safe, but does
not reduce pregnancy on a population
level. However, advance provision might
be beneficial because it increases the speed
and frequency of EC use.

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Population-Based Care Board Review
Questions
==============================
=========================
Which one of the following is
recommended for routine prenatal care?
(check one)

D. HIV screening. HIV screening is


recommended as part of routine prenatal
care, even in low-risk pregnancies.
Counseling about cystic fibrosis carrier
testing is recommended, but not routine
testing. Hepatitis C and parvovirus
antibodies are not part of routine prenatal
screening. Routine screening for bacterial
vaginosis with a vaginal smear for clue
cells is not recommended.

A. Hepatitis C antibody testing


B. Parvovirus antibody testing
C. Cystic fibrosis carrier testing
D. HIV screening
E. Examination of a vaginal smear for clue
cells
==============================
=========================
Psychogenic Board Review Questions 01
==============================
=========================
Which one of the following sleep
problems in children is most likely to
occur during the second half of the night?
(check one)
A. Confusional arousals
B. Sleepwalking
C. Sleep terrors
D. Nightmares

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D. Nightmares. Nightmares occur in the


second half of the night, when rapid eye
movement (REM) sleep is most
prominent. Parasomnias, including
sleepwalking, confusional arousal, and
sleep terrors, are disorders of arousal from
non-REM (NREM) sleep. These are more
common in children than adults because
children spend more time in deep NREM
sleep. Such disorders usually occur within
1-2 hours after sleep onset, and coincide
with the transition from the first period of
slow-wave sleep.

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Psychogenic Board Review Questions 02
==============================
=========================
A 34-year-old white male presents with a
history and findings that satisfy DSM-IV
criteria for bipolar disorder. Which one of
the following treatment options is the most
effective for long-term management of the
majority of patients with this disorder?
(check one)
A. Electroconvulsive therapy (ECT)
B. Tricyclic antidepressants
C. SSRIs
D. Monoamine oxidase (MAO) inhibitors
E. Lithium

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E. Lithium. Electroconvulsive therapy


(ECT) is as effective as medication for the
acute treatment of the severe depression
and/or mania of bipolar disorder.
However, ECT should be reserved for
patients with severe mood syndromes who
may be unable to wait for mood-stabilizing
drugs to take effect. Neuroleptic
(antipsychotic) drugs are effective in acute
mania, but are not recommended for longterm use because of side effects. Bipolar
depression generally responds to tricyclic
antidepressants, SSRIs, and MAO
inhibitors, but when used as long-term
therapy these drugs may induce episodes
of mania. Anticonvulsants, such as
carbamazepine, valproic acid, and
benzodiazepines, have been useful
adjuncts combined with lithium in patients
with breakthrough episodes of mania
and/or depression. Lithium is the classic
mood stabilizer. It has been shown to have
antimanic efficacy, prophylactic efficacy
in bipolar disorder, and some efficacy in
prophylaxis against bipolar depression.
Lithium remains the drug of choice for
long-term treatment of the majority of
patients with bipolar illness.

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Psychogenic Board Review Questions 03
==============================
=========================
The mother of a 3-year-old male is
concerned that he doesn't like being held,
doesn't interact much with other children,
and rarely smiles. Of the following, which
feature would be most helpful in
distinguishing Asperger's syndrome from
autism in this patient? (check one)
A. Normal language development
B. Delayed gross motor development
C. Repetitive fine motor mannerisms
D. Preoccupation with parts of objects
E. Focused patterns of intense interest

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A. Normal language development. The


DSM-IV categorizes Asperger's syndrome
and autism as pervasive developmental
disorders. In both conditions, children
have significant difficulties with social
interactions, although the impairment is
more severe and sustained in autism. Both
Asperger's and autism may be associated
with symptoms of repetitive motor
mannerisms, restricted patterns of interest
(which are abnormal in focus or intensity),
or preoccupation with parts of objects.
However, unlike children with Asperger's
syndrome, autistic children have serious
problems with communication skills,
either in the development of speech itself
or in the ability to carry on a conversation.
Normal, age-appropriate language skills in
a 3-year-old would rule out a diagnosis of
autism. It is an important distinction to
make, as the prognosis for independent
functioning in children with Asperger's
syndrome is significantly better than in
children with autism.

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Psychogenic Board Review Questions 04
==============================
=========================
An 85-year-old white male with terminal
pancreatic cancer is expected to survive
for another 2 weeks. His pain has been
satisfactorily controlled with sustainedrelease morphine. He has now developed a
disturbed self-image, hopelessness, and
anhedonia, and has told family members
that he has thought about suicide.
Psychomotor retardation is also noted. His
family is supportive. His daughter feels he
is depressed, while his son feels this is
more of a grieving process. Which one of
the following would be most appropriate
for managing this problem? (check one)
A. Reassurance
B. Alprazolam (Xanax)
C. Trazodone (Desyrel)
D. Olanzapine (Zyprexa)
E. Methylphenidate (Ritalin)

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E. Methylphenidate (Ritalin).
Distinguishing between preparatory grief
and depression in a dying patient is not
always simple. Initially one should
evaluate for unresolved physical
symptoms and treat any that are present. If
the patient remains in distress, mood
should be evaluated. If it waxes and wanes
with time and if self-esteem is normal, this
is likely preparatory grief. The patient may
have fleeting thoughts of suicide and likely
will express worry about separation from
loved ones. This usually responds to
counseling. In patients with anhedonia,
persistent dysphoria, disturbed self-image,
hopelessness, poor sense of self-worth,
rumination about death and suicide, or an
active desire for early death, depression is
the problem. For patients who are expected
to live only a few days, psychostimulants
such as methylphenidate should be used.
For those who are expected to survive
longer, SSRIs are a good choice.

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Random Board Review Questions 01
==============================
=========================
A 30-year-old previously healthy male
comes to your office with a 1-year history
of frequent abdominal pain, nonbloody
diarrhea, and a 20-lb weight loss. He has
no history of travel outside the United
States, antibiotic use, or consumption of
well water. His review of systems is
notable for a chronic, intensely pruritic
rash that is vesicular in nature. His review
of systems is otherwise negative and he is
on no medications.
The most likely cause of his symptoms is:
(check one)
A. lactose intolerance
B. irritable bowel syndrome
C. collagenous colitis
D. celiac sprue
E. Crohn's disease

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D. celiac sprue. Celiac sprue is an


autoimmune disorder characterized by
inflammation of the small bowel wall,
blunting of the villi, and resultant
malabsorption. Symptoms commonly
include diarrhea, fatigue, weight loss,
abdominal pain, and borborygmus;
treatment consists of elimination of gluten
proteins from the diet. Extraintestinal
manifestations are less common but may
include elevated transaminases,
osteopenia, and iron deficiency anemia.
Serum IgA tissue transglutaminase (TTG)
antibodies are highly sensitive and specific
for celiac sprue, and a small bowel biopsy
showing villous atrophy is the gold
standard for diagnosis. This patient's rash
is consistent with dermatitis herpetiformis,
which is pathognomonic for celiac sprue
and responds well to a strict gluten-free
diet.
Lactose intolerance, irritable bowel
syndrome, collagenous colitis, and Crohn's
disease are in the differential diagnosis for
celiac sprue. However, significant weight
loss is not characteristic of irritable bowel
syndrome or lactose intolerance. The
diarrhea associated with Crohn's disease is
typically bloody. Collagenous colitis does
cause symptoms similar to those
experienced by this patient, but it is not
associated with dermatitis herpetiformis.

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=========================
Random Board Review Questions 02
==============================
=========================
You see a 22-year-old female who
sustained a right knee injury in a recent
college soccer game.She is a defender and
executed a sudden cutting maneuver. With
her right foot planted and her ankle locked,
she attempted to shift the position of her
body to stop an oncoming ball and felt her
knee pop. She has had a moderate amount
of pain and swelling, which began within 2
hours of the injury, but she is most
concerned about the loss of knee
hyperextension.

B. Lachman. Anterior cruciate ligament


(ACL) tears occur more commonly in
women than in men. The intensity of play
is also a factor, with a much greater risk of
ACL injuries occurring during games than
during practices. The most accurate
maneuver for detecting an ACL tear is the
Lachman test (sensitivity 60%-100%,
mean 84%), followed by the anterior
drawer test (sensitivity 9%-93%, mean
62%) and the pivot shift test (sensitivity
27%-95%, mean 62%) (SOR C).
McMurray's test is used to detect meniscal
tears.

Which one of the following tests is most


likely to be abnormal in this patient?
(check one)
A. Anterior drawer
B. Lachman
C. McMurray
D. Pivot shift

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=========================
Random Board Review Questions 03
==============================
=========================
As the medical review officer for a local
business, you are required to interpret
urine drug tests. Assuming the sample was
properly collected and handled, which one
of the following test results is consistent
with the history provided and should be
reported as a negative test? (check one)
A. Diazepam (Valium) identified in an
employee taking oxazepam prescribed by a
physician
B. Morphine identified in an employee
undergoing a prescribed methadone pain
management program
C. Morphine identified in an employee
taking a prescribed cough medicine
containing codeine
D. Tetrahydrocannabinol above the
threshold value in an employee who
reports secondary exposure to marijuana
E. Tetrahydrocannabinol identified in an
employee taking prescribed tramadol
(Ultram)

C. Morphine identified in an employee


taking a prescribed cough medicine
containing codeine. Results of urine drug
test panels obtained in the workplace are
reported by a Medical Review Officer
(MRO) as positive, negative, dilute,
refusal to test, or test canceled; the
drug/metabolite for which the test is
positive or the reason for refusal (e.g., the
presence of an adulterant) or cancellation
is also included in the final report. The
MRO interpretation is based on
consideration of many factors, including
the confirmed patient medical history,
specimen collection process, acceptability
of the specimen submitted, and qualified
laboratory measurement of drugs or
metabolites in excess of the accepted
thresholds. These thresholds are set to
preclude the possibility that secondary
contact with smoke, ingestion of poppy
seeds, or similar exposures will result in an
undeserved positive urine drug screen
report. Other findings, such as the
presence of behavioral or physical
evidence of unauthorized use of opiates,
may also factor into the final report.
When a properly collected, acceptable
specimen is found to contain drugs or
metabolites that would be expected based
on a review of confirmed prescribed use of
medications, the test is reported as
negative. Morphine is a metabolite of
codeine that may be found in the urine of
someone taking a codeine-containing
medication; morphine is not a metabolite
of methadone. Oxazepam is a metabolite
of diazepam but the reverse is not true.
Tetrahydrocannabinol would not be found
in the urine as a result of tramadol use.

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Random Board Review Questions 04
==============================
=========================
A 30-year-old female asks you whether
she should have a colonoscopy, as her
father was diagnosed with colon cancer at
the age of 58. There are no other family
members with a history of colon polyps or
cancer.
You recommend that she have her first
screening colonoscopy: (check one)
A. now and every 5 years if normal
B. now and every 10 years if normal
C. at age 40 and then every 5 years if
normal
D. at age 40 and then every 10 years if
normal
E. at age 50 and then every 5 years if
normal

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C. at age 40 and then every 5 years if


normal. Patients should be risk-stratified
according to their family history. Patients
who have one first degree relative
diagnosed with colorectal cancer or
adenomatous polyps before age 60, or at
least two second degree relatives with
colorectal cancer, are in the highest risk
group. They should start colon cancer
screening at age 40, or 10 years before the
earliest age at which an affected relative
was diagnosed (whichever comes first) and
be rescreened every 5 years. Colonoscopy
is the preferred screening method for this
highest-risk group, as high-risk patients
are more likely to have right-sided colon
lesions that would not be detected with
sigmoidoscopy.

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Random Board Review Questions 05
==============================
=========================
Which one of the following is most
consistent with obsessive-compulsive
disorder in adults? (check one)
A. Impulses related to excessive worry
about real-life problems
B. A belief by the patient that obsessions
are not produced by his or her own mind,
but are "inserted" thoughts
C. Recognition by the patient that the
obsessions or compulsions are excessive or
unreasonable
D. Compulsions that bring relief to the
patient rather than causing distress
E. Full remission with treatment
==============================
=========================
Random Board Review Questions 06
==============================
=========================
Which one of the following patients
should be advised to take aspirin, 81 mg
daily, for the primary prevention of stroke?
(check one)
A. A 42-year-old male with a history of
hypertension
B. A 72-year-old female with no chronic
medical conditions
C. An 80-year-old male with a history of
depression
D. An 87-year-old female with a history of
peptic ulcer disease

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C. Recognition by the patient that the


obsessions or compulsions are excessive or
unreasonable. The DSM-IV criteria for
obsessive-compulsive disorder (OCD)
indicate that the patient at some point
recognizes that the obsessions or
compulsions are excessive or
unreasonable. The impulses of OCD are
not related to excessive worry about one's
problems, and the patient recognizes that
they are the product of his or her own
mind. In addition, the patient experiences
marked distress because of the impulses.
Full remission is rare, but treatment can
provide significant relief.

B. A 72-year-old female with no chronic


medical conditions. The U.S. Preventive
Services Task Force (USPSTF) has
summarized the evidence for the use of
aspirin in the primary prevention of
cardiovascular disease as follows:
The USPSTF recommends the use of
aspirin for men 45-79 years of age when
the potential benefit from a reduction in
myocardial infarctions outweighs the
potential harm from an increase in
gastrointestinal hemorrhage (Grade A
recommendation)
The USPSTF recommends the use of
aspirin for women 55-79 years of age
when the potential benefit of a reduction in
ischemic strokes outweighs the potential
harm of an increase in gastrointestinal
hemorrhage (Grade A recommendation)
The USPSTF concludes that the current
evidence is insufficient to assess the
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balance of benefits and harms of aspirin


for cardiovascular disease prevention in
men and women 80 years of age or older
(Grade I statement)
The USPSTF recommends against the use
of aspirin for stroke prevention in women
younger than 55 and for myocardial
infarction prevention in men younger than
45 (Grade D recommendation)
In summary, consistent evidence from
randomized clinical trials indicates that
aspirin use reduces the risk for
cardiovascular disease events in adults
without a history of cardiovascular
disease. It reduces the risk for myocardial
infarction in men, and ischemic stroke in
women. Consistent evidence shows that
aspirin use increases the risk for
gastrointestinal bleeding, and limited
evidence shows that aspirin use increases
the risk for hemorrhagic strokes. The
overall benefit in the reduction of
cardiovascular disease events with aspirin
use depends on baseline risk and the risk
for gastrointestinal bleeding.

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Random Board Review Questions 07
==============================
=========================
Breastfeeding a full-term, healthy infant is
contraindicated when which one of the
following maternal conditions is present?
(check one)
A. Chronic hepatitis B infection
B. Seropositive cytomegalovirus carrier
state
C. Current tobacco smoking
D. Herpes simplex viral lesions on the
breasts
E. Undifferentiated fever

D. Herpes simplex viral lesions on the


breasts. Breastfeeding provides such
optimal nutrition for an infant that the
benefits still far outweigh the risks even
when the mother smokes tobacco, tests
positive for hepatitis B or C virus, or
develops a simple undifferentiated fever.
Maternal seropositivity to cytomegalovirus
(CMV) is not considered a
contraindication except when it has a
recent onset or in mothers of low
birthweight infants. When present, the
CMV load can be substantially reduced by
freezing and pasteurization of the milk. All
patients who smoke should be strongly
encouraged to discontinue use of tobacco,
particularly in the presence of infants, but
smoking is not a contraindication to
breastfeeding.
Mothers with active herpes simplex lesions
on a breast should not feed their infant
from the infected breast, but may do so
from the other breast if it is not infected.
Breastfeeding is also contraindicated in the
presence of active maternal tuberculosis,
and following administration or use of
radioactive isotopes, chemotherapeutic
agents, "recreational" drugs, or certain
prescription drugs.

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Random Board Review Questions 08
==============================
=========================
You are asked to perform a preoperative
evaluation on a 55-year-old white female
with type 2 diabetes mellitus prior to
elective femoral-anterior tibial artery
bypass surgery. She is unable to climb a
flight of stairs or do heavy work around
the house. She denies exertional chest
pain, and is otherwise healthy.
Based on current guidelines, which one of
the following diagnostic studies would be
appropriate prior to surgery because the
results could alter the management of this
patient? (check one)
A. Pulmonary function studies
B. Coronary angiography
C. Carotid angiography
D. A dipyridamole-thallium scan
E. A hemoglobin A1c level

==============================
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D. A dipyridamole-thallium scan. Family


physicians are often asked to perform a
preoperative evaluation prior to noncardiac
surgery. This requires an assessment of the
perioperative cardiovascular risk of the
procedure involved, the functional status
of the patient, and clinical factors that can
increase the risk, such as diabetes mellitus,
stroke, renal insufficiency, compensated or
prior heart failure, mild angina, or
previous myocardial infarction.
This patient is not undergoing emergency
surgery, nor does she have an active
cardiac condition; however, she is
undergoing a high-risk procedure (>5%
risk of perioperative myocardial
infarction) with vascular surgery. As she
cannot climb a flight of stairs or do heavy
housework, her functional status is <4
METs, and she should be considered for
further evaluation. The patient's diabetes is
an additional clinical risk factor.
With vascular surgery being planned,
appropriate recommendations include
proceeding with the surgery with heart rate
control, or performing noninvasive testing
if it will change the management of the
patient. Coronary angiography is indicated
if the noninvasive testing is abnormal.
Pulmonary function studies are most
useful in patients with underlying lung
disease or those undergoing pulmonary
resection. Hemoglobin A1c is a measure of
long-term diabetic control and is not
particularly useful perioperatively. Carotid
angiography is not indicated in
asymptomatic patients being considered
for lower-extremity vascular procedures.
B. malaria. Clinical clues to the diagnosis
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Random Board Review Questions 09
==============================
=========================
A 21-year-old African-American female
has been confused and delirious for 2 days.
She has no significant past medical
history, and she is taking no medications.
She recently returned from a missionary
trip to Southeast Asia. During your initial
examination in the emergency department,
she has several convulsions and rapidly
becomes comatose. Her temperature is
37.9C (100.3F) and her blood pressure is
80/50 mm Hg. A neurologic examination
shows no signs of meningeal irritation and
a cranial nerve evaluation is normal. There
is a mild, bilateral, symmetric increase in
deep tendon reflexes. All other physical
examination findings are normal.
Laboratory Findings

of malaria in this case include an


appropriately targeted recent travel history,
a prodrome of delirium or erratic behavior,
unarousable coma following a generalized
convulsion, fever, and a lack of focal
neurologic signs in the presence of a
diffuse, symmetric encephalopathy. The
peripheral blood smear shows
normochromic, normocytic anemia with
Plasmodium falciparum trophozoites and
schizonts involving erythrocytes,
diagnostic of cerebral malaria. Treatment
of this true medical emergency is
intravenous quinidine gluconate.
Vitamin B 12 deficiency is a
predominantly peripheral neuropathy seen
in older adults. Ehrlichiosis causes
thrombocytopenia but not hemolytic
anemia. Sickle cell disease presents with
painful vaso-occlusive crises in multiple
organs. Coma is rare.

Hemoglobin........................... 7.0 g/dL (N


12.0-16.0)
Hematocrit............................ 20% (N 3646)
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 6500/mm3 (N 4300-10,800)
Platelets. ............................. 450,000/mm3
(N 150,000-350,000)
Serum bilirubin
Total............................... 5.0 mg/dL (N
0.3-1.1)
Direct.............................. 1.0 mg/dL (N
0.1-0.4)
The urine is dark red and positive for
hemoglobin. CT of the brain shows neither
bleeding nor infarction.

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The most likely diagnosis is: (check one)


A. vitamin B12 deficiency
B. malaria
C. ehrlichiosis
D. sickle cell anemia
==============================
=========================
Random Board Review Questions 10
==============================
=========================
A painful thrombosed external hemorrhoid
diagnosed within the first 24 hours after
occurrence is ideally treated by: (check
one)
A. appropriate antibiotics
B. office banding
C. office cryotherapy
D. thrombectomy under local anesthesia
E. total hemorrhoidectomy

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D. thrombectomy under local anesthesia.


A thrombosed external hemorrhoid is
manifested by the sudden development of
a painful, tender, perirectal lump. Because
there is somatic innervation, the pain is
intense, and increases with edema.
Treatment involves excision of the acutely
thrombosed tissue under local anesthesia,
mild pain medication, and sitz baths. It is
inappropriate to use procedures that would
increase the pain, such as banding or
cryotherapy. Total hemorrhoidectomy is
inappropriate and unnecessary.

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=========================
Random Board Review Questions 11
==============================
=========================
A 75-year-old male consults you after his
family expresses concern about his loss of
interest in his usual activities. They believe
he has become increasingly withdrawn
since the death of his wife 8 months
earlier. You note he has lost 8 kg (18 lb)
since his last office visit 6 months earlier.
He does not drink alcohol. His physical
examination is unremarkable for his age
except for a blood pressure of 105/70 mm
Hg. Detailed laboratory studies, including
thyroid function tests, are all within
normal limits. He tells you he would be
fine if he could just get some sleep. His
Mini-Mental State Examination is normal,
but he is obviously clinically depressed.

B. mirtazapine (Remeron). Trazodone may


be useful for insomnia, but is not
recommended as a primary antidepressant
because it causes sedation and orthostatic
hypotension at therapeutic doses.
Bupropion would aggravate this patient's
insomnia. Tricyclic antidepressants may be
effective, but are no longer considered
first-line treatments because of side effects
and because they can be cardiotoxic.
Mirtazapine has serotonergic and
noradrenergic properties and is associated
with increased appetite and weight gain. It
may be particularly useful for patients with
insomnia and weight loss.

The most appropriate medication for his


depression would be: (check one)
A. trazodone (Oleptro)
B. mirtazapine (Remeron)
C. bupropion (Wellbutrin)
D. amitriptyline
E. nortriptyline (Pamelor)

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Random Board Review Questions 12
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The most appropriate advice for a 50-yearold female who has passed six calcium
oxalate stones over the past 4 years is to:
(check one)
A. restrict her calcium intake
B. restrict her intake of yellow vegetables
C. increase her sodium intake
D. increase her dietary protein intake
E. take potassium citrate with meals
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Random Board Review Questions 13
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Which one of the following is a
recommended treatment for presumptive
methicillin-resistant Staphylococcus
aureus (MRSA) infection? (check one)

E. take potassium citrate with meals.


Calcium oxalate stones are the most
common of all renal calculi. A lowsodium, restricted-protein diet with
increased fluid intake reduces stone
formation. A low-calcium diet has been
shown to be ineffective. Oxalate restriction
also reduces stone formation. Oxalatecontaining foods include spinach,
chocolate, tea, and nuts, but not yellow
vegetables. Potassium citrate should be
taken at mealtime to increase urinary pH
and urinary citrate (SOR B).

D. Doxycycline. Community-acquired
methicillin-resistant Staphylococcus
aureus (MRSA) is resistant to -lactam
and macrolide antibiotics, and is showing
increasing resistance to fluoroquinolones.
FDA-approved treatments include
clindamycin and doxycycline. Other
commonly used treatments include
minocycline and
trimethoprim/sulfamethoxazole.

A. Azithromycin (Zithromax)
B. Dicloxacillin
C. Levofloxacin (Levaquin)
D. Doxycycline
E. Cephalexin (Keflex)

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Random Board Review Questions 14
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A 3-year-old toilet-trained female is
brought to your office by her mother, who
has noted a red rash on the child's
perineum for the last 5 days. The rash is
pruritic and has been spreading. The
mother has treated the area for 3 days with
nystatin cream with no obvious
improvement. The child has not used any
other recent medications and has no
significant past medical history. Your
examination reveals a homogeneous, beefy
red rash surrounding the vulva and anus.
The most likely etiologic agent is: (check
one)

E. group A Streptococcus pyogenes. The


epidemiology of group A streptococcal
disease of the perineum is similar to that of
group A streptococcal pharyngitis, and the
two often coexist. It is theorized that either
auto-inoculation from mouth to hand to
perineum occurs, or that the bacteria is
transmitted through the gastrointestinal
tract. In one study, the average age of
patients with this disease varied from 1 to
11 years, with a mean of 5 years. Girls and
boys were almost equally affected. The
incidence is estimated to be about 1 in 200
pediatric visits and peaks in March, April,
and May in North America. The condition
usually presents with itching and a beefy
redness around the anus and/or vulva and
will not clear with medications used to
treat candidal infections.

A. Malassezia furfur
B. Escherichia coli
C. Haemophilus influenzae
D. Staphylococcus aureus
E. group A Streptococcus pyogenes

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Random Board Review Questions 15
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You are helping a hospice program
manage the symptoms of a 77-year-old
male with end-stage colon cancer. He has
required increasingly higher doses of his
opioid medication to control symptoms of
pain and dyspnea.

A. Constipation. Constipation is one


adverse effect of opioid treatment that
does not diminish with time. Thus, this
effect should be anticipated, and
recommendations for prevention and
treatment of constipation should be
discussed when initiating opioids. Nausea
and vomiting, mental status changes,
sedation, and pruritus are also common
with the initiation of opioid treatment, but
these symptoms usually diminish with
time, and can be managed expectantly.

In this situation, it should be kept in mind


that which one of the following adverse
effects of opioids does NOT diminish over
time? (check one)
A. Constipation
B. Nausea
C. Mental status changes
D. Pruritus
E. Sedation
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Random Board Review Questions 16
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Two doses of varicella vaccine are
recommended for: (check one)
A. adults under 60 years of age who
develop shingles
B. all children with normal immune status
C. only immunocompromised individuals
D. only children between 12 months and
13 years of age

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B. all children with normal immune status.


Two doses of varicella vaccine are
recommended for all children unless they
are immunocompromised, in which case
they should not be immunized against
varicella, or with other live-virus vaccines.
Shingles is evidence of prior varicella
infection and is a reason not to vaccinate
with varicella vaccine.

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Random Board Review Questions 17
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A 53-year-old female presents to the
emergency department following a fall.
She is found to have an ankle fracture and
a blood pressure of 160/100 mm Hg. She
tells the emergency department physician
that she is not aware of any previous
medical problems. A focused
cardiovascular examination is otherwise
normal. You are the patient's regular
physician, and the emergency physician
calls your office for further information
about the blood pressure elevation. You
confirm that this is a new problem.
Which one of the following would you ask
the emergency physician to do? (check
one)
A. Administer a dose of intravenous
labetalol (Trandate) and ask the patient to
follow up in your office within the week
B. Administer nifedipine (Adalat,
Procardia), 10 mg; discharge the patient
once the blood pressure falls to 140/90 mm
Hg; and ask the patient to follow up with
you tomorrow
C. Prescribe an appropriate
antihypertensive agent and have the patient
follow up with you in a month
D. Order an EKG and chest radiograph,
and ask the patient to see you in a week if
the results are normal
E. Perform no further evaluation of the
hypertension, but ask the patient to follow
up with you within a month

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E. Perform no further evaluation of the


hypertension, but ask the patient to follow
up with you within a month.
Uncomplicated hypertension is frequently
detected in the emergency department.
Many times this is a chronic condition, but
it also may result from an acutely painful
situation. Hypertensive emergencies,
defined as severe blood pressure elevations
to >180/120 mm Hg complicated by
evidence of impending or worsening target
organ dysfunction, warrant emergent
treatment. There is no evidence, however,
to suggest that treatment of an isolated
blood pressure elevation in the emergency
department is linked to a reduction in
overall risk. In fact, the aggressive
reduction of blood pressure with either
intravenous or oral agents is not without
potential risk.
The appropriate management for the
patient in this scenario is simply to
discharge her and ask her to follow up
with you in the near future.

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Random Board Review Questions 18
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When added to compression therapy,
which one of the following has been
shown to be an effective adjunctive
treatment for venous ulcers? (check one)

D. Pentoxifylline (Trental). Pentoxifylline


is effective when used with compression
therapy for venous ulcers, and may be
useful as monotherapy in patients unable
to tolerate compression therapy. Aspirin
has also been shown to be effective. Other
treatments that have been studied but have
not been found to be effective include oral
zinc and antibiotics (SOR A).

A. Warfarin (Coumadin)
B. Enoxaparin (Lovenox)
C. Clopidogrel (Plavix)
D. Pentoxifylline (Trental)
E. Atorvastatin (Lipitor)

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Random Board Review Questions 19
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A 55-year-old male sees you for a followup visit for hypercholesterolemia and
hypertension. He is in good health, does
not smoke, and drinks alcohol
infrequently. His medications include a
multiple vitamin daily; aspirin, 81 mg
daily; lisinopril (Prinivil, Zestril), 10 mg
daily; and lovastatin (Mevacor), 20 mg
daily. His vital signs are within normal
limits except for a BMI of 33.4 kg/m2 .
At today's visit his ALT (SGPT) level is
55 IU/L (N 10-45) and his AST (SGOT)
level is 44 IU/L (N 10-37). The remainder
of the liver panel is normal.

E. Metabolic syndrome. Non-alcoholic


fatty liver disease (NAFLD) is the most
common cause of abnormal liver tests in
the developed world. Its prevalence
increases with age, body mass index, and
triglyceride concentrations, and in patients
with diabetes mellitus, hypertension, or
insulin resistance. There is a significant
overlap between metabolic syndrome and
diabetes mellitus, and NAFLD is regarded
as the liver manifestation of insulin
resistance.
Statin therapy is considered safe in such
individuals and can improve liver enzyme
levels and reduce cardiovascular morbidity
in patients with mild to moderately
abnormal liver tests that are potentially
attributable to NAFLD.

Which one of the following is the most


likely cause of the elevation in liver
enzymes? (check one)
A. A side effect of lovastatin
B. Gallbladder disease
C. Hepatitis A
D. Alcoholic liver disease
E. Metabolic syndrome

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Random Board Review Questions 20
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An 82-year-old white male suffers from
chronic low back pain. He is on warfarin
(Coumadin) for chronic atrial fibrillation,
tamsulosin (Flomax) for benign prostatic
hyperplasia, and famotidine (Pepcid) for
gastroesophageal reflux disease.

A. The lidocaine patch (Lidoderm).


Topical lidocaine produces very low serum
levels of active drug, resulting in very few
adverse effects (SOR C). Hydrocodone
could produce any opiate-type effect.
Nortriptyline and duloxetine could
aggravate this patient's atrial arrhythmia
and cause urinary retention. Celecoxib
could aggravate his reflux problem.

Which one of the following analgesic


medications would have the least potential
for adverse side effects? (check one)
A. The lidocaine patch (Lidoderm)
B. Hydrocodone/acetaminophen
C. Nortriptyline (Pamelor)
D. Duloxetine (Cymbalta)
E. Celecoxib (Celebrex)
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Random Board Review Questions 21
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Which one of the following treatments for
type 2 diabetes mellitus often produces
significant weight loss? (check one)
A. Exenatide (Byetta)
B. Glipizide (Glucotrol)
C. Pioglitazone (Actos)
D. Insulin detemir (Levemir)
E. Insulin lispro (Humalog)

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A. Exenatide (Byetta). Of the many


currently available medications to treat
diabetes mellitus, only metformin and
incretin mimetics such as exenatide have
the additional benefit of helping the
overweight or obese patient lose a
significant amount of weight. Most of the
other medications, including all the insulin
formulations, unfortunately lead to weight
gain or have no effect on weight.

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Random Board Review Questions 22
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Actinic keratosis is a precursor lesion to:
(check one)
A. keratoacanthoma
B. nodular melanoma
C. superficial spreading melanoma
D. basal cell carcinoma
E. cutaneous squamous cell carcinoma

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E. cutaneous squamous cell carcinoma.


Actinic keratoses are precursor lesions for
cutaneous squamous cell carcinoma. The
conversion rate of actinic keratoses into
squamous cell carcinoma has been
estimated to be 1 in 1000 per year. Thicker
lesions, cutaneous horns, and lesions that
show ulceration have a higher malignant
potential. Although sun exposure is a risk
factor for both melanoma and basal cell
carcinoma, there are no recognized
precursor lesions for either. Actinic
keratosis is not a precursor lesion to
keratoacanthoma.

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Random Board Review Questions 23
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A 56-year-old white male reports lower
leg claudication that occurs when he walks
approximately one block, and is relieved
by standing still or sitting. He has a history
of diabetes mellitus and hyperlipidemia.
His most recent hemoglobin A 1c level
was 5.9% and his LDL-cholesterol level at
that time was 95 mg/dL. Current
medications include glyburide (DiaBeta),
metformin (Glucophage), simvastatin
(Zocor), and daily aspirin. He stopped
smoking 1 month ago and began a walking
program. A physical examination is
normal, except for barely palpable dorsalis
pedis and posterior tibial pulses. Femoral
and popliteal pulses are normal.
Noninvasive vascular studies of his legs
show an ankle-brachial index of 0.7
bilaterally, and decreased flow.

C. Cilostazol (Pletal). The patient


described has symptomatic arterial
vascular disease manifested by intermittent
claudication. He has already initiated the
two most important changes: he has
stopped smoking and started a walking
program. His LDL-cholesterol is at target
levels; further lowering is not likely to
improve his symptoms. In the presence of
diffuse disease, interventional treatments
such as angioplasty or surgery may not be
helpful; in addition, these interventions
should be reserved as a last resort.
Cilostazol has been shown to help with
intermittent claudication, but additional
antiplatelet agents are not likely to
improve his symptoms. Fish oil and
warfarin have not been found to be helpful
in the management of this condition.

Which one of the following would be most


appropriate for addressing this patient's
symptoms? (check one)
A. Fish oil
B. Warfarin (Coumadin)
C. Cilostazol (Pletal)
D. Dipyridamole (Persantine)
E. Clopidogrel (Plavix)

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Random Board Review Questions 24
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Which one of the following organisms is
NOT killed by alcohol-based hand
disinfectants? (check one)

E. Clostridium difficile. Sporulating


organisms such as Clostridium difficile are
not killed by alcohol products.
Staphylococcus aureus, Pseudomonas
aeruginosa, and Klebsiella pneumoniae are
killed by alcohol products (SOR A).

A. Methicillin-resistant Staphylococcus
aureus (MRSA)
B. Methicillin-sensitive Staphylococcus
aureus
C. Pseudomonas aeruginosa
D. Klebsiella pneumoniae
E. Clostridium difficile

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Random Board Review Questions 25
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A 46-year-old female presents to your
office with a 2-week history of pain in her
left shoulder. She does not recall any
injury, and the pain is present when she is
resting and at night. Her only chronic
medical problem is type 2 diabetes
mellitus.
On examination, she has limited
movement of the shoulder and almost
complete loss of external rotation.
Radiographs of the shoulder are normal, as
is her erythrocyte sedimentation rate.
Which one of the following is the most
likely diagnosis?
(check one)

A. Frozen shoulder. Frozen shoulder is an


idiopathic condition that most commonly
affects patients between the ages of 40 and
60. Diabetes mellitus is the most common
risk factor for frozen shoulder. Symptoms
include shoulder stiffness, loss of active
and passive shoulder rotation, and severe
pain, including night pain. Laboratory tests
and plain films are normal; the diagnosis is
clinical (SOR C).
Frozen shoulder is differentiated from
chronic posterior shoulder dislocation and
osteoarthritis on the basis of radiologic
findings. Both shoulder dislocation and
osteoarthritis have characteristic plain film
findings. A patient with a rotator cuff tear
will have normal passive range of motion.
Impingement syndrome does not affect
passive range of motion, but there will be
pain with elevation of the shoulder.

A. Frozen shoulder
B. Torn rotator cuff
C. Impingement syndrome
D. Chronic posterior shoulder dislocation
E. Osteoarthritis

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Random Board Review Questions 26
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Which one of the following is an
appropriate rationale for antibiotic
treatment of Bordetella pertussis
infections? (check one)
A. It delays progression from the catarrhal
stage to the paroxysmal stage
B. It reduces the severity of symptoms
C. It reduces the duration of illness
D. It reduces the risk of transmission to
others
E. It reduces the need for hospitalization

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Random Board Review Questions 27
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The preferred method for diagnosing
psychogenic nonepileptic seizures is:
(check one)
A. inducing seizures by suggestion
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D. It reduces the risk of transmission to


others. Antibiotic treatment for pertussis is
effective for eradicating bacterial infection
but not for reducing the duration or
severity of the disease. The eradication of
infection is important for disease control
because it reduces infectivity. Antibiotic
treatment is thought to be most effective if
started early in the course of the illness,
characterized as the catarrhal phase. The
paroxysmal stage follows the catarrhal
phase. The CDC recommends macrolides
for primary treatment of pertussis. The
preferred antimicrobial regimen is
azithromycin for 3-5 days or
clarithromycin for 7 days. These regimens
are as effective as longer therapy with
erythromycin and have fewer side effects.
Children under 1 month of age should be
treated with azithromycin. There is an
association between erythromycin and
hypertrophic pyloric stenosis in young
infants. Trimethoprim/sulfamethoxazole
can be used in patients who are unable to
take macrolides or where macrolide
resistance may be an issue, but should not
be used in children under the age of 2
months. Fluoroquinolones have been
shown to reduce pertussis in vitro but have
not been shown to be
clinically effective (SOR A).
D. video-electroencephalography (vEEG)
monitoring. Inpatient videoelectroencephalography (vEEG)
monitoring is the preferred test for the
diagnosis of psychogenic nonepileptic
seizures (PNES), and is considered the
gold standard (SOR B). Video-EEG
monitoring combines extended EEG
monitoring with time-locked video
acquisition that allows for analysis of
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B. postictal prolactin levels


C. EEG monitoring
D. video-electroencephalography (vEEG)
monitoring
E. brain MRI

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clinical and electrographic features during


a captured event. Many other types of
evidence have been used, including the
presence or absence of self-injury and
incontinence, the ability to induce seizures
by suggestion, psychologic tests, and
ambulatory EEG. While useful in some
cases, these alternatives have been found
to be insufficient for the diagnosis of
PNES.
Elevated postictal prolactin levels (at least
two times the upper limit of normal) have
been used to differentiate generalized and
complex partial seizures from PNES, but
are not reliable (SOR B). While prolactin
levels are often elevated after an epileptic
seizure, they do not always rise, and the
timing of measurement is crucial, making
this a less sensitive test than was
previously believed. Other serum markers
have also been used to help distinguish
PNES from epileptic seizures, including
creatine phosphokinase, cortisol, WBC
counts, lactate dehydrogenase, pCO2 , and
neuron-specific enolase. These also are not
reliable, as threshold levels for
abnormality, sensitivity, and specificity
have not been determined.
MRI is not reliable because abnormal
brain MRIs have been documented in as
many as one-third of patients with PNES.
In addition, patients with epileptic seizures
often have normal brain MRIs.

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Random Board Review Questions 28
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A 72-year-old male has had persistent
interscapular pain with movement since
rebuilding his deck 1 week ago. He rates
the pain as 6 on a 10-point scale. A chest
radiograph shows a thoracic vertebral
compression fracture.
Which one of the following would be most
appropriate at this point?
(check one)

B. Markedly decreased activity until the


pain lessens, and follow-up in 1 week.
This patient has suffered a thoracic
vertebral compression fracture. Most can
be managed conservatively with decreased
activity until the pain is tolerable, possibly
followed by some bracing. Vertebroplasty
is an option when the pain is not improved
in 2 weeks. Complete bed rest is
unnecessary and could lead to
complications. Physical therapy is not
indicated, and NSAIDs should be used
with caution.

A. Complete bed rest for 2 weeks


B. Markedly decreased activity until the
pain lessens, and follow-up in 1 week
C. Referral for vertebroplasty as soon as
possible
D. NSAIDs and referral for physical
therapy

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Random Board Review Questions 29
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A 70-year-old male presents to your office
for a follow-up visit for hypertension. He
was started on lisinopril (Prinivil, Zestril),
20 mg daily, 1 month ago. Laboratory tests
from his last visit, including a CBC and a
complete metabolic panel, were normal
except for a serum creatinine level of 1.5
mg/dL (N 0.6-1.5). A follow-up renal
panel obtained yesterday shows a
creatinine level of 3.2 mg/dL and a BUN
of 34 mg/dL (N 8-25).
Which one of the following is the most
likely cause of this patient's increased
creatinine level? (check one)

A. Bilateral renal artery stenosis. Classic


clinical clues that suggest a diagnosis of
renal-artery stenosis include the onset of
stage 2 hypertension (blood pressure
>160/100 mm Hg) after 50 years of age or
in the absence of a family history of
hypertension; hypertension associated with
renal insufficiency, especially if renal
function worsens after the administration
of an agent that blocks the reninangiotensin-aldosterone system;
hypertension with repeated hospital
admissions for heart failure; and drugresistant hypertension (defined as blood
pressure above the goal despite treatment
with three drugs of different classes at
optimal doses). The other conditions
mentioned do not cause a significant rise
in serum creatinine after treatment with an
ACE inhibitor.

A. Bilateral renal artery stenosis


B. Coarctation of the aorta
C. Essential hypertension
D. Hyperaldosteronism
E. Pheochromocytoma

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Random Board Review Questions 30
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A 53-year-old male presents to your office
with a several-day history of hiccups. They
are not severe, but have been interrupting
his sleep, and he is becoming exasperated.
What should be the primary focus of
treatment in this individual?
(check one)
A. Drug treatment to prevent recurrent
episodes
B. Decreasing the intensity of the muscle
contractions in the diaphragm
C. Finding the underlying pathology
causing the hiccups
D. Improving the patient's quality of sleep
E. Suppressing the current hiccup
symptoms

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C. Finding the underlying pathology


causing the hiccups. Hiccups are caused by
a respiratory reflex that originates from the
phrenic and vagus nerves, as well as the
thoracic sympathetic chain. Hiccups that
last a matter of hours are usually benign
and self-limited, and may be caused by
gastric distention. Treatments usually
focus on interrupting the reflex loop of the
hiccup, and can include mechanical means
(e.g., stimulating the pharynx with a
tongue depressor) or medical treatment,
although only chlorpromazine is FDAapproved for this indication.
If the hiccups have lasted more than a
couple of days, and especially if they are
waking the patient up at night, there may
be an underlying pathology causing the
hiccups. In one study, 66% of patients who
experienced hiccups for longer than 2 days
had an underlying physical cause.
Identifying and treating the underlying
disorder should be the focus of
management for intractable hiccups.

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Random Board Review Questions 31
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A patient who takes fluoxetine (Prozac),
40 mg twice daily, develops shivering,
tremors, and diarrhea after taking an overthe-counter cough and cold medication.
On examination he has dilated pupils and a
heart rate of 110 beats/min. His
temperature is normal.
Which one of the following medications in
combination with fluoxetine could
contribute to this patient's symptoms?
(check one)

A. Dextromethorphan. Dextromethorphan
is commonly found in cough and cold
remedies, and is associated with serotonin
syndrome. SSRIs such as fluoxetine are
also associated with serotonin syndrome,
and there are many other medications that
increase the risk for serotonin syndrome
when combined with SSRIs. The other
medications listed here are not associated
with serotonin syndrome, however.

A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)

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Random Board Review Questions 32
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While playing tennis, a 55-year-old male
tripped and fell, landing on his
outstretched hand with his elbow in slight
flexion at impact. Pronation and supination
of the forearm are painful on examination,
as are attempts to flex the elbow. There is
tenderness of the radial head without
significant swelling. A radiograph of the
elbow shows no fracture, but a positive fat
pad sign is noted.
Appropriate management would include:
(check one)

D. a posterior splint and a repeat


radiograph in 1-2 weeks. Nondisplaced
radial head fractures can be treated by the
primary care physician and do not require
referral. Conservative therapy includes
placing the elbow in a posterior splint for
5-7 days, followed by early mobilization
and a sling for comfort. Sometimes the
joint effusion may be aspirated for pain
relief and to increase mobility. One study
compared immediate mobilization with
mobilization beginning in 5 days and
found no differences at 1 and 3 months,
but early mobilization was associated with
better function and less pain 1 week after
the injury. Radiographs should be repeated
in 1-2 weeks to make sure that alignment
is appropriate.

A. a long arm cast for 2 weeks, followed


by use of a brace
B. mobilization of the elbow beginning 3
weeks after the injury
C. a posterior splint for 6 weeks
D. a posterior splint and a repeat
radiograph in 1-2 weeks

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Random Board Review Questions 33
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A 48-year-old female with type 2 diabetes
has been hospitalized for 4 days with
persistent fever. Her diabetes has been
controlled with diet and glyburide
(Micronase, DiaBeta). You saw her 2
weeks ago in the office with urinary
frequency, urgency, and dysuria. At that
time a urinalysis showed 25 WBCs/hpf,
and a urine culture subsequently grew
Escherichia coli sensitive to all antibiotics.
She was placed on
trimethoprim/sulfamethoxazole (Bactrim,
Septra) empirically, and this was
continued after the culture results were
reported.
She improved over the next week, but then
developed flank pain, fever to 39.5C
(103.1F), and nausea and vomiting. She
was hospitalized and intravenous cefazolin
(Kefzol) and gentamicin were started
while blood and urine cultures were
performed. This urine culture also grew E.
coli sensitive to the current antibiotics. Her
temperature has continued to spike to
39.5C since admission, without any
change in her symptoms.
Which one of the following would be most
appropriate at this time? (check one)
A. Add vancomycin (Vancocin) to the
regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen

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E. Order CT of the abdomen. Perinephric


abscess is an elusive diagnostic problem
that is defined as a collection of pus in the
tissue surrounding the kidney, generally in
the space enclosed by Gerota's fascia.
Mortality rates as high as 50% have been
reported, usually from failure to diagnose
the problem in a timely fashion. The
difficulty in making the diagnosis can be
attributed to the variable constellation of
symptoms and the sometimes indolent
course of this disease. The diagnosis
should be considered when a patient has
fever and persistence of flank pain.
Most perinephric infections occur as an
extension of an ascending urinary tract
infection, commonly in association with
renal calculi or urinary tract obstruction.
Patients with anatomic urinary tract
abnormalities or diabetes mellitus have an
increased risk. Clinical features may be
quite variable, and the most useful
predictive factor in distinguishing
uncomplicated pyelonephritis from
perinephric abscess is persistence of fever
for more than 4 days after initiation of
antibiotic therapy. The radiologic study of
choice is CT. This can detect perirenal
fluid, enlargement of the psoas muscle
(both are highly suggestive of the
diagnosis), and perirenal gas (which is
diagnostic). The sensitivity and specificity
of CT is significantly greater than that of
either ultrasonography or intravenous
pyelography.
Drainage, either percutaneously or
surgically, along with appropriate
antibiotic coverage reduces both morbidity
and mortality from this condition.
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Random Board Review Questions 34
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Which one of the following should be used
first for ventricular fibrillation when an
initial defibrillation attempt fails? (check
one)
A. Amiodarone (Cordarone)
B. Lidocaine (Xylocaine)
C. Adenosine (Adenocard)
D. Vasopressin (Pitressin)
E. Magnesium

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D. Vasopressin (Pitressin). For persistent


ventricular fibrillation (VF), in addition to
electrical defibrillation and CPR, patients
should be given a vasopressor, which can
be either epinephrine or vasopressin.
Vasopressin may be substituted for the
first or second dose of epinephrine.
Amiodarone should be considered for
treatment of VF unresponsive to shock
delivery, CPR, and a vasopressor.
Lidocaine is an alternative antiarrhythmic
agent, but should be used only when
amiodarone is not available. Magnesium
may terminate or prevent torsades de
pointes in patients who have a prolonged
QT interval during normal sinus rhythm.
Adenosine is used for the treatment of
narrow complex, regular tachycardias and
is not used in the treatment of ventricular
fibrillation.

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Random Board Review Questions 35
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A 14-year-old female with a history of
asthma is having daytime symptoms about
once a week and symptoms that awaken
her at night about once a month. Her
asthma does not interfere with normal
activity, and her FEV1 is >80% of
predicted.
Which one of the following is the most
appropriate treatment plan for this patient?
(check one)
A. A short-acting inhaled -agonist as
needed
B. Low-dose inhaled corticosteroids daily
C. A leukotriene receptor antagonist daily
D. Medium-dose inhaled corticosteroids
daily
E. Low-dose inhaled corticosteroids plus a
long-acting inhaled -agonist daily

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A. A short-acting inhaled -agonist as


needed. Based on this patient's reported
frequency of asthma symptoms, she should
be classified as having intermittent asthma.
The preferred first step in managing
intermittent asthma is an inhaled shortacting -agonist as needed. Daily
medication is reserved for patients with
persistent asthma (symptoms >2 days per
week for mild, daily for moderate, and
throughout the day for severe) and is
initiated in a stepwise approach, starting
with a daily low-dose inhaled
corticosteroid or leukotriene receptor
antagonist and then progressing to a
medium-dose inhaled corticosteroid or
low-dose inhaled corticosteroid plus a
long-acting inhaled -agonist.

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Random Board Review Questions 36
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A 91-year-old white male presents with a
6-month history of a painless ulcer on the
dorsum of the proximal interphalangeal
joint of the second toe. Examination
reveals a hallux valgus and a rigid hammer
toe of the second digit. His foot has mild
to moderate atrophic skin changes, and the
dorsal and posterior tibial pulses are
absent.
Appropriate treatment includes which one
of the following? (check one)

B. Custom-made shoes to protect the


hammer toe. The treatment of foot
problems in the elderly is difficult because
of systemic and local infirmities, the most
limiting being the poor vascular status of
the foot. Conservative, supportive, and
palliative therapy replace definitive
reconstructive surgical therapy. Surgical
correction of a hammer toe and
bunionectomy could be disastrous in an
elderly patient with a small ulcer and
peripheral vascular disease. The best
approach with this patient is to prescribe
custom-made shoes and a protective shield
with a central aperture of foam rubber
placed over the hammer toe. Metatarsal
pads are not useful in the treatment of
hallux valgus and a rigid hammer toe.

A. Surgical correction of the hammer toe


B. Custom-made shoes to protect the
hammer toe
C. Bunionectomy
D. A metatarsal pad
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Random Board Review Questions 37
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A patient presents with a pigmented skin
lesion that could be a melanoma. Its
largest dimension is 0.5 cm.

B. Excision with a 1-mm margin. The


diagnosis of melanoma should be made by
simple excision with clear margins. A
shave biopsy should be avoided because
determining the thickness of the lesion is
critical for staging. Wide excision with or
without node dissection is indicated for
confirmed melanoma, depending on the
findings from the initial excisional biopsy.

What should be the first step in


management? (check one)
A. A shave biopsy
B. Excision with a 1-mm margin
C. Wide excision with a 1-cm margin
D. Wide excision with a 1-cm margin
E. Excision with sentinel node dissection
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Random Board Review Questions 38
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A 60-year-old female receiving home
hospice care was taking oral morphine, 15
mg every 2 hours, to control pain. When
this was no longer effective, she was
transferred to an inpatient facility for pain
control. She required 105 mg of morphine
in a 24-hour period, so she was started on
intravenous morphine, 2 mg/hr with a
bolus of 2 mg, and was well controlled for
5 days. However, her pain has worsened
over the past 2 days.

E. Tolerance to morphine. This patient has


become tolerant to morphine. The
intravenous dose should be a third of the
oral dose, so the starting intravenous dose
was adequate. Addiction is compulsive
narcotic use. Pseudoaddiction is
inadequate narcotic dosing that mimics
addiction because of unrelieved pain.
Physical dependence is seen with abrupt
narcotic withdrawal.

Which one of the following is the most


likely cause of this patient's increased
pain? (check one)
A. An inadequate initial morphine dose
B. Addiction to morphine
C. Pseudoaddiction to morphine
D. Physical dependence on morphine
E. Tolerance to morphine

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Random Board Review Questions 39
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A 40-year-old white male presents with a
5-year history of periodic episodes of
severe right-sided headaches. During the
most recent episode the headaches
occurred most days during January and
February and lasted about 1 hour.
The most likely diagnosis is which one of
the following? (check one)

B. Cluster headache. Cluster headache is


predominantly a male disorder. The mean
age of onset is 27-30 years. Attacks often
occur in cycles and are unilateral.
Migraine headaches are more common in
women, start at an earlier age (second or
third decade), and last longer (4-24 hours).
Temporal arteritis occurs in patients above
age 50. Trigeminal neuralgia usually
occurs in paroxysms lasting 20-30
seconds.

A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia
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Random Board Review Questions 40
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Which one of the following is true
regarding hospice? (check one)
A. Hospice benefits end if the patient lives
beyond the estimated 6-month life
expectancy
B. A do-not-resuscitate (DNR) order is
required for a patient receiving Medicare
hospice benefits
C. Patients in hospice cannot receive
chemotherapy, blood transfusions, or
radiation treatments
D. Patients must be referred to hospice by
their physician
E. Any terminal patient with a life
expectancy <6 months is eligible

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E. Any terminal patient with a life


expectancy <6 months is eligible. Any
patient with a life expectancy of less than
6 months who chooses a palliative care
approach is an appropriate candidate for
hospice. There is no penalty if patients do
not die within 6 months, as long as the
disease is allowed to run its natural course.
Medicare does not require a DNR order to
enroll in hospice, but it does require that
patients seek only palliative, not curative,
treatment. Patients may receive
chemotherapy, blood transfusions, or
radiation if the goal of the treatment is to
provide symptom relief. Patients can be
referred to hospice by anyone, including
nurses, social workers, family members, or
friends.

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Random Board Review Questions 41
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A 62-year-old African-American female
undergoes a workup for pruritus.
Laboratory findings include a hematocrit
of 55.0% (N 36.0-46.0) and a hemoglobin
level of 18.5 g/dL (N 12.0-16.0).
Which one of the following additional
findings would help establish the diagnosis
of polycythemia vera? (check one)
A. A platelet count >400,000/mm3
B. An O2 saturation <90%
C. A WBC count <4500/mm (N 430010,800)3
D. An elevated uric acid level
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Random Board Review Questions 42
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Which one of the following is NOT
considered a first-line treatment for head
lice? (check one)
A. Lindane 1%
B. Malathion 0.5% (Ovide)
C. Permethrin 1% (Nix)
D. Pyrethrins 0.33%/pipernyl butoxide 4%
(RID)

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A. A platelet count >400,000/mm3.


Polycythemia vera should be suspected in
African-Americans or white females
whose hemoglobin level is >16 g/dL or
whose hematocrit is >47%. For white
males, the thresholds are 18 g/dL and 52%.
It should also be suspected in patients with
portal vein thrombosis and splenomegaly,
with or without thrombocytosis and
leukocytosis. Major criteria include an
increased red cell mass, a normal O2
saturation,and the presence
ofsplenomegaly. Minor criteria
includeelevated vitamin B 12 levels,
elevated leukocyte alkaline phosphatase, a
platelet count >400,000/mm3 and a WBC
count >12,000/mm3 . Patients with
polycythemia vera may present with gout
and an elevated uric acid level, but neither
is considered a criterion for the diagnosis.
A. Lindane 1%. Lindane's efficacy has
waned over the years and it is
inconsistently ovicidal. Because of its
neurotoxicity, lindane carries a black box
warning and is specifically recommended
only as second-line treatment by the FDA.
Pyrethroid resistance is widespread, but
permethrin is still considered to be a firstline treatment because of its favorable
safety profile. The efficacy of malathion is
attributed to its triple action with isopropyl
alcohol and terpineol, likely making this a
resistance-breaking formulation. The
probability of simultaneously developing
resistance to all three substances is small.
Malathion is both ovicidal and
pediculicidal.

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Random Board Review Questions 43
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Which one of the following insulin
regimens most closely mimics the normal
pattern of pancreatic insulin release in a
nondiabetic person? (check one)
A. 70/30 NPH/regular insulin (Humulin
70/30) twice daily
B. NPH insulin twice daily plus an insulin
sliding-scale protocol using regular insulin
C. Insulin glargine (Lantus) daily plus an
insulin sliding-scale protocol using regular
insulin
D. Insulin detemir (Levamir) daily plus
rapid-acting insulin with meals
E. Rapid-acting insulin before each meal

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D. Insulin detemir (Levamir) daily plus


rapid-acting insulin with meals. Basal
insulin provides a relatively constant level
of insulin for 24 hours, with an onset of
action in 1 hour and no peak. NPH gives
approximately 12 hours of coverage with a
peak around 6-8 hours. Regular insulin has
an onset of action of about 30 minutes and
lasts about 5-8 hours, with a peak at about
2-4 hours. New rapid-acting analogue
insulins have an onset of action within 515 minutes, peak within 30-75 minutes,
and last only about 2-3 hours after
administration. Thus, a 70/30 insulin mix
(typically 70% NPH and 30% regular)
provides coverage for 12 hours, but the
peaks of insulin release do not closely
mimic natural patterns. NPH given twice
daily along with an insulin sliding-scale
protocol using regular insulin is only
slightly closer than a 70/30 twice-daily
regimen. Rapid insulin alone does not
provide any basal insulin, and the patient
would therefore not have insulin available
during the night.

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Random Board Review Questions 44
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A 34-year-old female with a history of
bilateral tubal ligation consults you
because of excessive body and facial hair.
She has a normal body weight, no other
signs of virilization, and regular menses.
Which one of the following is the most
appropriate treatment for her mild
hirsutism? (check one)

A. Spironolactone (Aldactone).
Antiandrogens such as spironolactone,
along with oral contraceptives, are
recommended for treatment of hirsutism in
premenopausal women (SOR C). In
addition to having side effects, prednisone
is only minimally helpful for reducing
hirsutism by suppressing adrenal
androgens. Leuprolide, although better
than placebo, has many side effects and is
expensive. Metformin can be used to treat
patients with polycystic ovarian syndrome,
but this patient does not meet the criteria
for this diagnosis.

A. Spironolactone (Aldactone)
B. Leuprolide (Lupron)
C. Prednisone
D. Metformin (Glucophage)

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Random Board Review Questions 45
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A 26-month-old child presents with a 2day history of 6-8 loose stools per day and
a low-grade fever. When evaluating the
child to determine whether he is
dehydrated, which one of the following
would NOT be useful? (check one)
A. Skin turgor
B. Capillary refill time
C. Respiratory rate and pattern
D. The BUN/creatinine ratio
E. The serum bicarbonate level

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D. The BUN/creatinine ratio. The most


useful findings for identifying dehydration
are prolonged capillary refill time,
abnormal skin turgor, and abnormal
respiratory pattern (SOR C). Capillary
refill time is not affected by fever and
should be less than 2 seconds. Skin recoil
is normally instantaneous, but recoil time
increases linearly with the degree of
dehydration. The respiratory pattern
should be compared with age-specific
normal values, but will be increased and
sometimes labored, depending on the
degree of dehydration.
Unlike in adults, calculation of the
BUN/creatinine ratio is not useful in
children. Although the normal BUN level
is the same for children and adults, the
normal serum creatinine level changes
with age in children. In combination with
other clinical indicators, a low serum
bicarbonate level (<17 mmol/L) is helpful
in identifying children who are
dehydrated, and a level <13 mmol/L is
associated with an increased risk of failure
of outpatient rehydration efforts.

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Random Board Review Questions 46
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For a healthy 1-month-old, daily vitamin D
intake should be: (check one)
A. 50 IU
B. 100 IU
C. 200 IU
D. 400 IU
E. 800 IU

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Random Board Review Questions 47
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The mother of a 16-year-old male calls to
report that her son has a severe sore throat
and has been running a fever of 102F.
Which one of the following additional
findings would be most specific for
peritonsillar abscess? (check one)
A. A 1-day duration of illness
B. Ear pain
C. Difficulty opening his mouth
D. Hoarseness
E. Pain with swallowing

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D. 400 IU. It is now recommended that all


infants and children, including
adolescents, have a minimum daily intake
of 400 IU of vitamin D, beginning soon
after birth. The current recommendation
replaces the previous recommendation of a
minimum daily intake of 200 IU/day of
vitamin D supplementation beginning in
the first 2 months after birth and
continuing through adolescence. These
revised guidelines for vitamin D intake for
healthy infants, children, and adolescents
are based on evidence from new clinical
trials and the historical precedent of safely
giving 400 IU of vitamin D per day in the
pediatric and adolescent population. New
evidence supports a potential role for
vitamin D in maintaining innate immunity
and
preventing diseases such as diabetes
mellitus and cancer.
C. Difficulty opening his mouth. Trismus
is almost universally present with
peritonsillar abscess, while voice changes,
otalgia, and odynophagia may or may not
be present. Pharyngotonsillitis and
peritonsillar cellulitis may also be
associated with these complaints. Otalgia
is common with peritonsillar abscess, otitis
media, temporomandibular joint disorders,
and a variety of other conditions.
Peritonsillar abscess is rarely found in
patients who do not have at least a 3-day
history of progressive sore throat.

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Random Board Review Questions 48
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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 .

A. A central DXA scan of the lumbar


spine and hips. 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.

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

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Random Board Review Questions 49
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Which one of the following drugs inhibits
platelet function for the life of the platelet?
(check one)
A. Aspirin
B. Ibuprofen
C. Dipyridamole (Persantine)
D. Ticlopidine (Ticlid)
E. Warfarin (Coumadin)

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A. Aspirin. A number of drugs inhibit


platelet function, but aspirin is the only
effective drug that interferes with platelet
aggregation for the life of the platelet. It
does this by permanently acetylating the
platelet enzyme cyclooxygenase, thus
inhibiting prostaglandin synthesis. This
phenomenon is clinically helpful when an
antithrombotic effect is desired, but it may
require that necessary surgical procedures
be delayed. The effect of a single aspirin
on bleeding times can persist for up to 5
days. Other NSAIDs (i.e., indomethacin,
sulfinpyrazone) also inhibit platelet
activity, but their effect on prostaglandin
synthesis is reversible. The anti-platelet
effect of dipyridamole is less well
understood. Warfarin is a biochemical
antagonist of prothrombin and vitamin Kdependent coagulation factors, and
therefore has no significant effect on
platelet activity.

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Random Board Review Questions 50
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A 25-year-old female is concerned about
recurrent psychological and physical
symptoms that occur during the luteal
phase of her menstrual cycle and resolve
by the end of menstruation. She wants help
managing these symptoms, but does not
want to take additional estrogen or
progesterone.

B. Spironolactone during the luteal phase.


Randomized, controlled trials found that
luteal-phase spironolactone improved
psychological and physical symptoms of
premenstrual syndrome over 2-6 months
compared with placebo. Based on existing
evidence, the effectiveness is unknown for
cognitive-behavioral therapy, bright light
therapy, evening primrose oil, and black
cohosh.

Which one of the following management


strategies is supported by the best clinical
evidence?
(check one)
A. Cognitive-behavioral therapy
B. Spironolactone during the luteal phase
C. Bright light therapy during the luteal
phase
D. Evening primrose oil started 2-4 days
prior to the luteal phase
E. Black cohosh
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Random Board Review Questions 51
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Which one of the following is most
associated with falls in older adults?
(check one)
A. Diphenhydramine (Benadryl)
B. Atorvastatin (Lipitor)
C. Metformin (Glucophage)
D. Memantine (Namenda)
E. Theophylline (Theo-24)
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A. Diphenhydramine (Benadryl). Certain


classes of medications are frequently
associated with falls in older adults. These
classes include benzodiazepines,
antidepressants, antipsychotics,
antiepileptics, anticholinergics, sedative
hypnotics, muscle relaxants, and
cardiovascular medications.
Diphenhydramine is one of the
anticholinergic medications associated
with falls in older adults. The other drugs
listed are not in the higher-risk groups of
medications.

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Random Board Review Questions 52
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A 20-year-old nonsmoker presents to your
office with a sudden onset of chest pain.
You order a chest radiograph, which
shows a small (<15%) pneumothorax. He
is in no respiratory distress and vital signs
are normal.
Pulse oximetry shows a saturation of 98%
on room air. which one of the following
would be most appropriate initially?
(check one)

B. Analgesics and a follow-up visit in 48


hours. Practice guidelines state that a
patient without apparent lung disease who
develops a spontaneous "small"
pneumothorax (<15% of lung volume) can
be managed as an outpatient with
analgesics and follow-up within 72 hours.
CT of the lung is needed in complicated
cases, including patients with known lung
disease or recurrent pneumothoraces. A
chest tube is required only when the
pneumothorax involves >15% of lung
volume.

A. CT of the affected lung


B. Analgesics and a follow-up visit in 48
hours
C. Chest tube insertion
D. Hospital admission and a repeat chest
film in 24 hours

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Random Board Review Questions 53
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A 13-year-old male presents with a 3-week
history of left lower thigh and knee pain.
There is no history of a specific injury, and
his past medical history is negative. He has
had no fevers, night sweats, or weight loss,
and the pain does not awaken him at night.
He tried out for the basketball team but
had to quit because of the pain, which was
worse when he tried to run.
Which one of the following physical
examination findings would be
pathognomonic for slipped capital femoral
epiphysis? (check one)
A. Excessive forward passive motion of
the tibia with the knee flexed
B. Lateral displacement of the patella with
active knee flexion
C. Limited internal rotation of the flexed
hip
D. Reduced hip abduction with the hip
flexed
E. Inability to extend the hip past the
neutral position

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C. Limited internal rotation of the flexed


hip. Slipped capital femoral epiphysis
(SCFE) typically occurs in young
adolescents during the growth spurt.
Physical activity, obesity, and male gender
are predisposing factors for the
development of this condition, in which
the femoral head is displaced posteriorly
through the growth plate. There is pain
with physical activity, most commonly in
the upper thigh anteriorly, but one-third of
patients present with referred lower thigh
or knee pain, which can make accurate and
timely diagnosis more difficult. The
hallmark of SCFE on examination is
limited internal rotation of the hip.
Specific to SCFE is the even greater
limitation of internal rotation when the hip
is flexed to 90. No other pediatric
condition has this physical finding, which
makes the maneuver very useful in
children with lower extremity pain.
Orthopedic consultation is advised if
SCFE is suspected. Hip extension and
abduction are also limited in SCFE, but
these findings are nonspecific. The knee
findings in this patient are not associated
with SCFE.

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Random Board Review Questions 54
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You test a patient's muscles and find that
his maximum performance consists of the
ability to move with gravity neutralized.
This qualifies as which grade of muscle
strength, on a scale of 5? (check one)
A. 0
B. 1
C. 2
D. 3
E. 4

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C. 2. Muscle strength is scored on a scale


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

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Random Board Review Questions 55
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A 7-year-old Hispanic female has a 3-day
history of a fever of 40.0C (104.0F),
muscle aches, vomiting, anorexia, and
headache. Over the past 12 hours she has
developed a painless maculopapular rash
that includes her palms and soles but
spares her face, lips, and mouth. She has
recently returned from a week at summer
camp in Texas. Her pulse rate is 140
beats/min, and her blood pressure is 80/50
mm Hg in the right arm while lying down.
Which one of the following is the most
likely diagnosis? (check one)
A. Mucocutaneous lymph node syndrome
B. Leptospirosis
C. Rocky Mountain spotted fever
D. Scarlet fever
E. Toxic shock syndrome

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C. Rocky Mountain spotted fever. While


all of the diagnoses listed are in the
differential, the most likely is Rocky
Mountain spotted fever (RMSF) (SOR C).
It occurs throughout the United States, but
is primarily found in the South Atlantic
and south central states. It is most common
in the summer and with exposure to tall
vegetation (e.g., while camping, hiking, or
gardening), and is transmitted by ticks.
The diagnosis is based on clinical criteria
that include fever, hypotension, rash,
myalgia, vomiting, and headache
(sometimes severe). The rash associated
with RMSF usually appears 2-4 days after
the onset of fever and begins as small,
pink, blanching macules on the ankles,
wrists, or forearms that evolve into
maculopapules. It can occur anywhere on
the body, including the palms and soles,
but the face is usually spared.
Mucocutaneous lymph node syndrome is a
similar condition in children (usually <2
years old), but symptoms include changes
in the lips and oral cavity, such as
strawberry tongue, redness and cracking of
the lips, and erythema of the
oropharyngeal mucosa. Leptospirosis is
usually accompanied by severe cutaneous
hyperesthesia. The patient with scarlet
fever usually has prominent pharyngitis
and a fine, papular, erythematous rash.
Toxic shock syndrome may present in a
similar fashion, but usually in
postmenarchal females.

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Random Board Review Questions 56
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The most common presenting symptom of
obstructive sleep apnea is: (check one)
A. excessive daytime sleepiness
B. snoring
C. morning headache
D. gastroesophageal reflux
E. enuresis

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A. excessive daytime sleepiness. The most


common presenting symptom of
obstructive sleep apnea is excessive
daytime sleepiness (SOR A). Other
symptoms include snoring, unrefreshing or
restless sleep, witnessed apneas and
nocturnal choking, morning headache,
nocturia or enuresis, gastroesophageal
reflux, and reduced libido.

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Random Board Review Questions 57
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A 68-year-old African-American male
with a history of hypertension and heart
failure continues to have shortness of
breath and fatigue after walking only one
block. He has normal breath sounds, no
murmur, and no edema on examination.
His current medications include
furosemide (Lasix), 20 mg/day, and
metoprolol extended-release (Toprol-XL),
50 mg/day. He previously took lisinopril
(Prinivil, Zestril), but it was discontinued
because of angioedema. A recent
echocardiogram showed an ejection
fraction of 35%.
Which one of the following would be most
likely to improve both symptoms and
survival in this patient?
(check one)

E. Isosorbide/hydralazine (BiDil). In
patients with systolic heart failure, the
usual management includes an ACE
inhibitor and a -blocker. Since this patient
had angioedema with an ACE inhibitor, an
angiotensin receptor blocker may cause
this side effect as well. Adding metolazone
is generally not necessary unless the
patient has volume overload that does not
respond to increased doses of furosemide.
Digoxin may improve symptoms, but has
not been shown to increase survival. For
patients who cannot tolerate an ACE
inhibitor, especially African-Americans, a
combination of direct-acting vasodilators
such as isorbide and hydralazine is
preferred.Verapamil has a negative
inotropic effect and should not be used.

A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)

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Random Board Review Questions 58
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A 52-year-old male requests "everything
you've got" to help him stop smoking. You
review common barriers to quitting and
the benefits of cessation with him, and
develop a plan that includes follow-up. He
chooses to start varenicline (Chantix) to
assist with his efforts, and asks about also
using nicotine replacement.
Which one of the following would be
accurate advice?
(check one)

A. Combining these medications has not


proven to be beneficial. Varenicline works
by binding to nicotine receptors in the
brain, providing much lower stimulation
than nicotine itself would. This has the
effect of reducing the reinforcement and
reward that smoking provides to the brain.
However, this medication also blocks the
benefit a patient would receive from
nicotine replacement products. Studies
have shown that using nicotine
replacement products concurrently with
varenicline leads to an increase in nausea,
headaches, dizziness, and fatigue.

A. Combining these medications has not


proven to be beneficial
B. The addition of transdermal nicotine,
but not nicotine gum, has proven benefits
C. The combination is highly efficacious
D. Nicotine replacement doses need to be
doubled in a patient taking varenicline
E. The combination of nicotine and
varenicline is potentially lethal

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Random Board Review Questions 59
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A 40-year-old male with a 20-pack-year
history of smoking is concerned about
lung cancer. He denies any constitutional
symptoms, or breathing or weight changes.
You encourage him to quit smoking and
order which one of the following? (check
one)

A. No testing. This patient is at risk for


lung cancer, even with no symptoms. He
should be encouraged to stop smoking,
especially if he has concerns that may help
motivate him to quit. No study has
demonstrated that screening with any of
the tests listed improves survival, and no
major organization endorses lung cancer
screening.

A. No testing
B. A chest radiograph
C. Low-dose CT of the chest
D. Sputum cytology
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Random Board Review Questions 60
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You are a member of a committee at your
local hospital that has been asked to
develop measures to reduce the incidence
of postoperative methicillin-resistant
Staphylococcus aureus (MRSA)
infections. Which one of the following
would be most effective for preventing
these infections? (check one)
A. Give preoperative antibiotics to all
surgical patients to eradicate bacteria
B. Screen all admitted patients for MRSA
and use antibiotics pre- and
postoperatively in positive cases
C. Culture the nares of all hospital
employees upon hiring and on a routine
basis thereafter
D. Institute an intensive program of good
hand washing for all employees
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D. Institute an intensive program of good


hand washing for all employees.
Nosocomial infections are a significant
factor in morbidity and cost in the health
care field. Methicillinresistant
Staphylococcus aureus (MRSA) has
rapidly increased in frequency, first being
found only at tertiary centers, then local
hospitals, and now in the outpatient
setting.
In 2004, an estimated 1.5% of U.S.
residents carried MRSA in the anterior
nares of the nose. Of those who are found
to be colonized, either at the time of
hospitalization or later by a routine culture,
25% will develop a MRSA infection.
However, a recent study showed that of 93
patients who became infected with the
organism, 57% were not colonized at the
time of infection. The study also attempted
to screen all patients for MRSA on
admission, but found that even though 337
previously unknown carriers were found
(in addition to those already known to
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harbor the organism), there was not a


significant decrease in the rate of MRSA
infections during the study.
Although MRSA infections can be serious,
they comprise only 8% of nosocomial
infections in the hospital, and
concentrating prevention efforts only on
MRSA has little effect on that 8%, and no
effect on the 92% of infections caused by
other organisms.
Iatrogenic complications arise from trying
to treat MRSA carriers, including both
drug reactions and the development of
other resistant organisms. Costs related to
attempts at prophylaxis also go up.
Culturing all hospital employees has not
been proven to be of value, as employees
can pick up the organism after screening,
and also can spontaneously eradicate the
organism without treatment. The best way
to prevent complications and postoperative
infections is to aggressively advocate
universal and frequent hand washing and
room cleaning, and use good isolation
techniques and methods of preventing
infection, such as strict catheter and
intravenous tubing protocols.

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Random Board Review Questions 61
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A 35-year-old male consults you about a
vague chest pain he developed while
sitting at his desk earlier in the day. The
pain is right-sided and was sharp for a
brief time when it began, but it rapidly
subsided. There was no hemoptysis and
the pain does not seem pleuritic. His
physical examination, EKG, and oxygen
saturation are unremarkable. A chest film
shows a 10% right pneumothorax. Which
one of the following is true in this
situation? (check one)
A. He is likely to be an overweight smoker
with a chronic cough
B. Rupture of subpleural bullae would be
an unlikely cause of his problem
C. Outpatient observation with a repeat
chest radiograph in 24 hours is indicated
D. A chest tube should be placed
expeditiously
E. After treatment his probability of
recurrence is less than 15%
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Random Board Review Questions 62
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=========================
A 24-year-old African-American male
presents with a history of several weeks of
dyspnea, cough productive of bloody
streaks, and malaise. His examination is
normal except for bilateral facial nerve
palsy. A CBC and urinalysis are normal. A
chest radiograph reveals bilateral lymph
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C. Outpatient observation with a repeat


chest radiograph in 24 hours is indicated.
The majority of patients presenting with
spontaneous pneumothorax are tall, thin
individuals under 40 years of age. Most do
not have clinically apparent lung disease,
and the chest pain is sometimes minimal at
onset and may resolve within 24 hours
even if untreated. Patients with small
pneumothoraces involving less than 15%
of the hemithorax may have a normal
physical examination, although
tachycardia is occasionally noted. The
diagnosis is confirmed by chest
radiographs. Studies of recurrence have
found that an average of 30% of patients
will have a recurrence within 6 months to
2 years. The treatment of an initial
pneumothorax of less than 20% may be
monitored if a patient has few symptoms.
Follow-up should include a chest
radiograph to assess stability at 24-48
hours. Indications for treatment include
progression, delayed expansion, or the
development of symptoms. The majority
of patients with spontaneous
pneumothoraces, and perhaps almost all of
them, will have subcutaneous bullae on a
CT scan.
C. sarcoidosis. Sarcoidosis, a disease of
unknown etiology, affects young to
middle-age adults (predominantly 20-29
years ld). In the U.S. it is more common in
African-Americans. It is asymptomatic in
30%-50% of patients, and is often
diagnosed on a routine chest film. About
one-third of cases will present with fever,
malaise, weight loss, cough, and dyspnea.
The pulmonary system is the main organ
system affected, and findings may include
bilateral hilar lymphadenopathy and
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node enlargement.This presentation is


most consistent with: (check one)
A. polyarteritis nodosa
B. Goodpasture's syndrome
C. sarcoidosis
D. pulmonary embolus

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Random Board Review Questions 63
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A 4-week-old white male is brought to
your office with a 2-week history of
increasing dyspnea, cough, and poor
feeding. The child appears nontoxic and is
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discrete, noncaseating epithelial


granulomas. Facial nerve palsy is seen in
<5% of patients, and usually occurs late in
the process. Before Lyme disease was
recognized, bilateral facial nerve palsy was
almost always due to sarcoidosis.
Hemoptysis does not generally occur until
late in the course of sarcoidosis, and is
usually related to Aspergillus infection or
cavitation. Renal involvement rarely
results in significant proteinuria or
hematuria. Polyarteritis nodosa may
involve the lungs. Although pneumonic
episodes may be associated with
hemoptysis in a small percentage of
patients, the chest radiograph is more
likely to reveal granulomatous lesions
rather than patchy infiltrates.
Goodpasture's syndrome is characterized
by pulmonary hemorrhage,
glomerulonephritis, and antiglomerular
basement membrane antibodies.
Hemoptysis, pulmonary alveolar
infiltrates, dyspnea, and iron-deficiency
anemia are frequent presenting features.
Within days or weeks, the pulmonary
findings are generally followed by
hematuria, proteinuria, and the rapid loss
of renal function. Pulmonary embolus is an
acute event, and would present with
dyspnea and possibly hemoptysis,
but not hilar lymphadenopathy.
B. Chlamydia trachomatis. Chlamydial
pneumonia is usually seen in infants 3-16
weeks of age, and they frequently have
been sick for several weeks. The infant
appears nontoxic and is afebrile, but is
tachypneic with a prominent cough.
Physical examination reveals diffuse rales
with few wheezes. Conjunctivitis is
present in about 50% of cases. The chest
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afebrile. On examination you note


conjunctivitis, and a chest examination
reveals tachypnea and rales. A chest film
shows hyperinflation and diffuse
interstitial infiltrates. A WBC count
reveals eosinophilia.
What is the most likely etiologic agent?
(check one)
A. Staphylococcus species
B. Chlamydia trachomatis
C. Respiratory syncytial virus
D. Parainfluenza virus

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film shows hyperinflation and diffuse


interstitial or patchy infiltrates.
Staphylococcal pneumonia has a sudden
onset. The infant appears very ill and has a
fever. At the time of onset there may be an
expiratory wheeze simulating
bronchiolitis. Signs of abdominal distress,
tachypnea, dyspnea, and localized or
diffuse bronchopneumonia or lobar disease
may be present. The WBC count shows a
prominent leukocytosis.
Respiratory syncytial infections start with
rhinorrhea and pharyngitis, followed in 1-3
days by cough and wheezing. Auscultation
reveals diffuse rhonchi, fine rales, and
wheezes. The chest film is often normal. If
the illness progresses, cough and wheezing
increase, air hunger and intercostal
retractions develop, and evidence of
hyperexpansion of the chest is seen. In
some infants, the course of the illness may
be similar to that of pneumonia. Rash or
conjunctivitis may occur occasionally, and
fever is an inconsistent sign. The WBC
count is normal or elevated, and the
differential may be normal or shifted either
to the right or left. Chlamydial infections
may be differentiated from respiratory
syncytial infections by a history of
conjunctivitis and a subacute onset.
Coughing is prominent, but wheezing is
not. There may also be
eosinophilia. Fever is usually absent.
Parainfluenza virus infection presents with
typical cold symptoms. Eight percent of
infections affect the upper respiratory
tract. In children hospitalized for severe
respiratory illness, parainfluenza viruses
account for about 50% of the cases of
laryngotracheitis and about 15% each of
the cases of bronchitis, bronchiolitis, and
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pneumonia.
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Random Board Review Questions 64
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A 15-year-old white female who has had
regular periods since age 12 comes to your
office because of secondary amenorrhea
and a milky discharge from her breasts. A
pregnancy test is negative.
The best test for initial evaluation of the
pituitary in this patient is:
(check one)
A. plasma antidiuretic hormone
B. plasma ACTH
C. serum prolactin
D. serum FSH and LH
E. fasting growth hormone

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C. serum prolactin. Anterior pituitary


hormone overproduction is suspected on
clinical grounds and confirmed by
appropriate laboratory evaluation. The
most common secretory pituitary
adenomas are prolactinomas. They cause
galactorrhea and hypogonadism, including
amenorrhea, infertility, and impotence.
Growth hormone-secreting tumors, which
are the next most common secretory
pituitary tumors, cause acromegaly or
gigantism. Next in frequency are
corticotropic (ACTH-secreting) adenomas,
which cause cortisol excess (Cushing's
disease). Glycoprotein hormone-secreting
pituitary adenomas (secreting TSH, LH, or
FSH) are the least common. TSH-secreting
adenomas are a rare cause of
hyperthyroidism. Paradoxically, most
patients with gonadotropin-secreting
adenomas have hypogonadism.

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Random Board Review Questions 65
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A patient in the first trimester of
pregnancy has just learned that her
husband has acute hepatitis B. She feels
well, and her screening test for hepatitis B
surface antigen (HBsAg) was negative last
month. She has not been immunized
against hepatitis B.
Which one of the following would be the
most appropriate management of this
patient?
(check one)
A. No further workup or immunization at
this time, a repeat HBsAg test near term,
and treatment of the newborn if the test is
positive
B. Use of condoms for the remainder of
the pregnancy, and administration of
immunization after delivery
C. Testing for hepatitis B immunity (antiHBs), and immunization if needed
D. Administration of hepatitis B immune
globulin (HBIG) now and hepatitis B
vaccine after the first trimester
E. Administration of both HBIG and
hepatitis B vaccine now

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E. Administration of both HBIG and


hepatitis B vaccine now. Hepatitis B
immune globulin (HBIG) should be
administered as soon as possible to
patients with known exposure to hepatitis
B. Hepatitis B vaccine is a killed-virus
vaccine and can be used safely in
pregnancy, with no need to wait until after
organogenesis. This patient has been
exposed to sexual transmission for at least
6 weeks, given that the incubation period
is at least that long, so it is too late to use
condoms to prevent infection. The patient
is unlikely to be previously immune to
hepatitis B, given that she has no history
of hepatitis B infection, immunization, or
carriage. Because the patient's HBsAg is
negative, she is not the source of her
husband's infection. Full treatment for this
patient has an efficacy of only 75% so
follow-up testing is still needed.

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Random Board Review Questions 66
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A 14-year-old female sees you for followup after hypercalcemia is found on a
chemistry profile obtained during a 5-day
episode of vomiting and diarrhea. She is
now asymptomatic, but her serum calcium
level at this visit is 11.0 mg/dL (N 8.510.5). Her aunt underwent unsuccessful
parathyroid surgery for hypercalcemia a
few years ago.
Which one of the following laboratory
findings would suggest a diagnosis other
than primary hyperparathyroidism?
(check one)

A. Low 24-hour urine calcium. Low urine


24-hour calcium levels or a low urine
calcium to urine creatinine ratio is not
characteristic of hyperparathyroidism. This
finding should suggest familial
hypocalciuric hypercalcemia (SOR C).
Awareness of this condition is important to
avoid unnecessary surgery. The
parathyroid hormone level may be mildly
elevated. Parathyroid hormone is elevated
in hyperparathyroidism. Serum chloride
tends to be high normal or mildly elevated.
Alkaline phosphatase may be elevated in
more severe cases, while serum phosphate
levels tend to be low.

A. Low 24-hour urine calcium


B. Decreased serum phosphate
C. High-normal to increased serum
chloride
D. Elevated alkaline phosphatase
E. Elevated parathyroid hormone

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Random Board Review Questions 67
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A 27-year-old male with a diagnosis of
depression prefers to avoid pharmacologic
treatment. You agree to engage in a trial of
therapy in your office. During the
treatment process, you help the patient
realize that some of his perceptions and
interpretations of reality may be false and
lead to negative thoughts. Next, you help
him discover alternative thoughts that
reflect reality more closely, and to learn to
discard his previous distorted thinking. By
learning to substitute healthy thoughts for
negative thoughts, he finds his mood,
behavior, and physical reaction to different
situations are improved.
Which one of the following best
categorizes this type of therapy?
(check one)
A. Psychoanalysis
B. Biofeedback
C. Cognitive therapy
D. Group psychotherapy
E. Hypnosis therapy

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C. Cognitive therapy. This patient is


engaged in cognitive therapy, which is a
treatment process that helps patients
correct false self-beliefs that can lead to
negative moods and behaviors. Cognitive
therapy has been shown to effectively treat
patients with unipolar major depression,
and is particularly useful in patients who
do not respond to medication or who
prefer nonpharmacologic therapy.
Psychoanalysis is a process of free
association where repressed memories are
recovered. Biofeedback involves
instrumentation that gives feedback about
a patient's physiologic response to various
situations in order to bring the autonomic
nervous system under voluntary control.
Group psychotherapy is a form of
treatment in which people who are
emotionally ill meet in a group guided by a
trained therapist and help one another
effect personality change. Hypnosis
involves helping a patient enter a state of
heightened focal concentration and
receptivity that is typified by a feeling of
involuntariness or an altered state of
consciousness.

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Random Board Review Questions 68
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A 44-year-old male sees you for
evaluation of an episode of pink-tinged
urine last week. He denies any flank or
abdominal pain, as well as frequency,
urgency, and dysuria. He has no prior
history of renal or other urologic disease,
and no other significant medical problems.
He has a 24-pack-year smoking history. A
urinalysis today reveals 8-10 RBCs/hpf.
You refer him to a urologist for
cystoscopy.
Which one of the following would be the
most appropriate additional evaluation?
(check one)

D. CT urography. CT urography or
intravenous pyelography is recommended
by the American College of Radiology as
the most appropriate imaging procedure
for hematuria in all patients, with the
exception of those with generalized renal
parenchymal disease, young women with
hemorrhagic cystitis, children, and
pregnant females.

A. KUB radiography
B. Transabdominal ultrasonography
C. Voiding cystourethrography
D. CT urography
E. Magnetic resonance urography

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Random Board Review Questions 69
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A 35-year-old white male who has had
diabetes mellitus for 20 years begins
having episodes of hypoglycemia. He was
previously stable and well controlled and
has not recently changed his diet or insulin
regimen.
Which one of the following is the most
likely cause of the hypoglycemia?
(check one)

B. Renal disease. The most common cause


of hypoglycemia in a previously stable,
well-controlled diabetic patient who has
not changed his or her diet or insulin
dosage is diabetic renal disease. A
reduction in physical activity or the
appearance of insulin antibodies (unlikely
after 20 years of therapy) would increase
insulin requirements and produce
hyperglycemia. Spontaneous improvement
-cell function after 20 years would be
very rare.

A. Spontaneous improvement of -cell


function
B. Renal disease
C. Reduced physical activity
D. Insulin antibodies
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Random Board Review Questions 70
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Which one of the following is
recommended for the treatment of patients
with obsessive compulsive disorder?
(check one)
A. Cognitive-behavioral therapy
B. Psychoanalytic therapy
C. Family therapy
D. Psychodynamic psychotherapy
E. Motivational interviewing

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A. Cognitive-behavioral therapy.
Cognitive-behavioral therapy is the
recommended treatment for obsessivecompulsive disorder
(OCD).Psychoanalytic therapy has not
been shown to help treat OCD. Family
therapy can help reduce family tensions
that result from the disease.
Psychodynamic psychotherapy and
motivational interviewing may help
patients overcome their resistance to
treatment.

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Random Board Review Questions 71
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A 31-year-old African-American female
presents with the chief complaint of
bilateral galactorrhea of 3 months'
duration. She also has not menstruated for
1 year despite changing birth control pills
several times. A review of systems is
otherwise noncontributory. Except for a
milky discharge with stimulation of the
breasts, her examination is within normal
limits. Serum prolactin on two occasions is
>200 g/L (N 0-20). Which one of the
following would be most appropriate at
this point? (check one)

B. Order a brain MRI with enhancement


and emphasis on the pituitary fossa.
Galactorrhea associated with a prolactin
level >200 g/L usually indicates a
prolactinoma, and requires MRI of the
pituitary with gadolinium enhancement.
Many drugs can cause galactorrhea,
including oral contraceptives and
risperidone, but they would not elevate
serum prolactin to this level. Dopamine
agonists such as bromocriptine or
cabergoline are the preferred treatment for
most patients with hyperprolactinemia.

A. Stop her oral contraceptive and repeat


the serum prolactin level in 1 month
B. Order a brain MRI with enhancement
and emphasis on the pituitary fossa
C. Order bilateral mammography
D. Start the patient on risperidone
(Risperdal)

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Random Board Review Questions 72
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Sympathomimetic decongestants such as
pseudoephedrine and phenylephrine can be
problematic in elderly patients because
they can: (check one)
A. decrease blood pressure
B. cause bradycardia
C. worsen existing urinary obstruction
D. enhance the anticholinergic effects of
other medications
E. enhance the sedative effects of other
medications
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Random Board Review Questions 73
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In the elderly, the risk of heat wave-related
death is highest in those who (check one)
A. have COPD
B. have diabetes and are insulin-dependent
C. have a functioning fan, but not air
conditioning
D. are homebound

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C. worsen existing urinary obstruction.


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

D. are homebound. Factors associated with


a higher risk of heat-related deaths include
being confined to bed, not leaving home
daily, and being unable to care for oneself.
Living alone during a heat wave is
associated with an increased risk of death,
but this increase is not statistically
significant. Among medical conditions, the
highest risk is associated with preexisting
psychiatric illnesses, followed by
cardiovascular disease, use of psychotropic
medications, and pulmonary disease. A
lower risk of heat-related deaths has been
noted in those who have working air
conditioning, visit air-conditioned sites, or
participate in social activities. Those who
take extra showers or baths and who use
fans have a lower risk, but this difference
is not statistically significant.

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Random Board Review Questions 74
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A 5-year-old female presents with a lesion
on her forearm. It began as a red macule,
turned into a small vesicle that easily
ruptured, then dried into a 1-cm honeycolored, crusted lesion seen now. Which
one of the following would be the most
appropriate therapy? (check one)

E. Topical mupirocin (Bactroban). Topical


mupirocin is as effective as cephalexin or
amoxicillin/clavulanate in the treatment of
impetigo, which is most often caused by
Staphlococcal species. Oral penicillin V,
oral erythromycin, and topical bacitracin
are less effective than mupirocin. Topical
treatment is well suited to this localized
lesion. Topical disinfectants such as
hydrogen peroxide are no more effective
than placebo.

A. Oral penicillin V
B. Oral erythromycin
C. Topical disinfectant (e.g., hydrogen
peroxide)
D. Topical bacitracin
E. Topical mupirocin (Bactroban)

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Random Board Review Questions 75
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A 59-year-old male reports nausea,
vomiting, and progressive fatigue for the
past few months. At his last visit, 6 months
ago, his blood pressure was poorly
controlled and hydrochlorothiazide was
added to his -blocker therapy. At this
visit he appears moderately dehydrated on
examination. Laboratory testing reveals a
serum calcium level of 12.5 mg/dL (N 8.010.0), a BUN level of 36 mg/dL (N 6-20),
and a creatinine level of 2.2 mg/dL (N 0.61.1). A CBC, albumin level, and
electrolyte levels are normal. His intact
parathyroid hormone level is reported a
few days later, and is 60 pg/mL (N 10-65).
What is the most likely cause of his
hypercalcemia? (check one)
A. Renal failure
B. Hyperparathyroidism
C. Milk alkali syndrome
D. Sarcoidosis

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B. Hyperparathyroidism. Many patients


have mild hyperparathyroidism that
becomes evident only with an added
calcium load. Thiazide diuretics reduce
calcium excretion and can cause overt
symptoms in a patient whose
hyperparathyroidism would otherwise
have remained asymptomatic. The finding
of a normal parathyroid hormone (PTH)
level in a patient with hypercalcemia is
diagnostic for hyperparathyroidism, since
PTH should be suppressed in the presence
of elevated calcium. Symptomatic
hypercalcemia causes dehydration because
of both intestinal symptoms and diuresis.
Reversible renal insufficiency can result,
and can become permanent if it is longstanding and severe. Conversely, renal
failure usually causes hypocalcemia, but
can cause hypercalcemia resulting from
tertiary hyperparathyroidism. This
develops after severe hyperphosphatemia
and vitamin D deficiency eventually
produce hypersecretion of PTH. This
patient's renal insufficiency is not severe
enough to cause tertiary
hyperparathyroidism. Milk alkali
syndrome is hypercalcemia resulting from
a chronic overdose of calcium carbonate,
and is becoming more common as more
patients take calcium and vitamin D
supplements. In milk alkali syndrome, and
other causes of hypercalcemia such as
sarcoidosis, the PTH level is appropriately
suppressed.

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Random Board Review Questions 76
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Which one of the following is the most
likely cause of hearing loss in newborns?
(check one)
A. Intraventricular hemorrhage
B. Anomalies of the external ear canal
C. Congenital cholesteatoma
D. Genetic disorders
E. Infectious diseases

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D. Genetic disorders. Genetic disorders


(e.g., Waardenburg syndrome, Usher's
syndrome, Alport syndrome, and Turner's
syndrome) are responsible for more than
50% of hearing impairments in children.
Intraventricular hemorrhage is a central
cause of hearing loss, and is rare.
Conductive abnormalities such as external
canal anomalies and congenital
cholesteatoma, and sensorineural causes
other than genetic disorders (e.g.,
infectious diseases) are important but less
frequent.

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Random Board Review Questions 77
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A 3-year-old female is brought to your
office for a health maintenance
examination, and her father expresses
concern about her vision. Her visual acuity
is 20/20 bilaterally on a tumbling E visual
acuity chart. With both eyes uncovered
during a cover/uncover test, the corneal
light reflex in the right eye is medial to the
pupil when focused on a fixed point, but
the light reflex in the left eye is almost
centered in the pupil. When the left eye is
covered, the right eye moves quickly
inward to focus on the fixed point, and the
corneal light reflex is centered in the pupil.
When the left eye is uncovered, the right
eye returns to its original position. When
you cover the right eye, no left eye
movement is noted. Which one of the
following is the most likely diagnosis?
(check one)

A. Strabismus. Strabismus is an ocular


misalignment that can be diagnosed on a
cover/uncover test when the corneal light
reflex is deviated from its normal position
slightly nasal to mid-pupil. The misaligned
eye then moves to fixate on a held object
when the opposite eye is covered. The eye
drifts back to its original position when the
opposite eye is uncovered. Amblyopia is
cortical visual impairment from abnormal
eye development-most often as a result of
strabismus. Cataract is a less frequent
cause of amblyopia. Esotropia is a type of
strabismus with an inward or nasal
deviation of the eye that would be
evidenced by a corneal light reflex lateral
to its normal position. (The outward eye
deviation seen in this patient is exotropia.)
Heterophoria, or latent strabismus, does
not cause eye deviation when both eyes are
uncovered.

A. Strabismus
B. Amblyopia
C. Cataract
D. Esotropia
E. Heterophoria

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Random Board Review Questions 78
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A 26-year-old female presents with a 1year history of recurring abdominal pain
associated with intermittent diarrhea, 5-7
days per month. Her pain improves with
defecation. There has been no blood in her
stool and no weight loss. Laboratory
findings are normal, including a CBC,
chemistry profile, TSH level, and
antibodies for celiac disease. Which one of
the following would be most appropriate at
this point? (check one)
A. Colonoscopy
B. An upper GI series with small-bowel
follow-through
C. Abdominal CT with contrast
D. A gluten-free diet
E. Loperamide (Imodium)

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E. Loperamide (Imodium). This patient


has classic symptoms of irritable bowel
syndrome (IBS) and meets the Rome
criteria by having 3 days per month of
abdominal pain for the past 3 months, a
change in the frequency of stool, and
improvement with defecation. According
to current clinical guidelines IBS can be
diagnosed by history, physical
examination, and routine laboratory
testing, as long as there are no warning
signs. Warning signs include rectal
bleeding, anemia, weight loss, fever, a
family history of colon cancer, onset of
symptoms after age 50, and a major
change in symptoms. Colonoscopy, CT,
and GI contrast studies are not indicated.
A gluten-free diet would not be indicated
since the antibody tests for celiac disease
are negative. Antidiarrheal agents such as
loperamide are generally safe and effective
in the management of diarrheal symptoms
in IBS.

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Random Board Review Questions 79
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Which one of the following would be the
most effective monotherapy for alcohol
withdrawal syndrome? (check one)
A. Clonidine (Catapres)
B. Phenytoin (Dilantin)
C. Atenolol (Tenormin)
D. Phenobarbital
E. Chlordiazepoxide (Librium)

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E. Chlordiazepoxide (Librium). Alcohol


withdrawal syndrome encompasses a wide
range of symptoms involving primarily the
central nervous, cardiovascular, and
gastrointestinal systems, and is mediated
by the abrupt removal of alcohol-enhanced
GABA inhibition of excitatory glutamate
receptors in the central nervous system. It
generally is divided into three stages,
based on severity and timeline; seizures
may occur during any of these stages and
may be the first sign of withdrawal. The
ideal pharmacologic agent should provide
not only safe sedation but also protection
from seizures. Long-acting
benzodiazepines such as chlordiazepoxide
have been shown to be superior to the
other choices in numerous studies.
Clonidine and atenolol have been found to
be useful in symptom reduction but not in
seizure prevention. Phenytoin would seem
to offer protection from seizures, but
studies have not consistently shown this to
be the case. Phenobarbital, while effective,
has a very narrow therapeutic window,
making its use problematic.

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Random Board Review Questions 80
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A 70-year-old female with type 2 diabetes
mellitus is admitted to the hospital with a
4-week history of fever, anorexia, and
weight loss. Two blood cultures are
positive for Streptococcus bovis. In
addition to being treated for the infection,
she should be evaluated for which one of
the following? (check one)

E. Colorectal cancer. For unknown


reasons, Streptococcus bovis bacteremia or
endocarditis is associated with a high
incidence of occult colorectal
malignancies. It may also occur with upper
gastrointestinal cancers. Radiography or
endoscopy is indicated.

A. B-cell lymphoma
B. T-cell lymphoma
C. Multiple myeloma
D. Lung cancer
E. Colorectal cancer

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Random Board Review Questions 81
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An obviously intoxicated 50-year-old
white male is brought to the emergency
department after the car he was driving hit
a telephone pole. He has a fracture of the
femur, and is confused and uncooperative.
His pulse rate is 120 beats/min, his blood
pressure is 80/40 mm Hg, and his skin is
clammy. Initial physical examination of
his abdomen does not indicate significant
intra-abdominal injury. Which one of the
following would be best for determining
whether laparotomy is needed? (check
one)
A. CT of the abdomen
B. MRI of the abdomen
C. Upright and lateral decubitus
radiographs of the abdomen
D. Contrast duodenography
E. Peritoneal lavage

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E. Peritoneal lavage. Physical examination


of the abdomen is often unreliable for
detecting significant intra-abdominal
injury, especially in the head-injured or
intoxicated patient. In a hemodynamically
unstable patient with a high-risk
mechanism of injury and altered mental
status, peritoneal lavage is the quickest,
most reliable modality to determine
whether there is a concomitant intraabdominal injury requiring laparotomy.
CT of the abdomen and contrast
duodenography may complement lavage in
stable patients with negative or equivocal
lavage results, but in an unstable or
uncooperative patient these studies are too
time-consuming or require ill-advised
sedation. Ultrasonography may also
complement lavage in selected patients,
but its usefulness is limited in the acute
situation. MRI is extremely accurate for
the anatomic definition of structural injury,
but logistics limit its practical application
in acute abdominal trauma.

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Random Board Review Questions 82
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A 75-year-old African-American female is
diagnosed with macular degeneration. She
is being treated for type 2 diabetes
mellitus, hypothyroidism, hypertension,
hypercholesterolemia, and gout. Which
one of her conditions is associated with
macular degeneration? (check one)

C. Hypertension. Age-related macular


degeneration is the most common cause of
blindness in the older population. It occurs
more frequently in light-skinned
individuals than in dark-skinned
individuals. Risk factors include smoking
and hypertension.

A. Type 2 diabetes mellitus


B. Hypothyroidism
C. Hypertension
D. Gout
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Random Board Review Questions 83
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A 4-year-old male has a fever of 1 week's
duration. It has been at or slightly above
38 C (101 F) and has responded poorly
to antipyretics. The patient complains of
photophobia, burning in his eyes, and a
sore throat. His mother also notes that his
eyes look red, his lips are red and cracked,
and he has a "strawberry tongue." The
child's palms and soles are erythematous
and the periungual regions show
desquamation of the skin. He has
minimally painful nodes located in the
anterior cervical region, about 22 cm in
size. A Streptococcus screen is negative.
The most appropriate management at this
time would be: (check one)
A. Intramuscular benzathine penicillin G
(Bicillin L-A), 600,000 U
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C. Intravenous immune globulin and


aspirin. Kawasaki disease, or
mucocutaneous lymph node syndrome, is a
common form of vasculitis in childhood. It
is typically self-limited, with fever and
acute inflammation lasting 12 days on
average without therapy. However, if
untreated, this illness can result in heart
failure, coronary artery aneurysm,
myocardial infarction, arrhythmias, or
occlusion of peripheral arteries. It is most
common in those under the age of 5 years.
To diagnose this disease, fever must be
present for 5 days or more with no other
explanation. In addition, at least four of the
following symptoms must be present: 1)
nonexudative conjunctivitis that spares the
limbus; 2) changes in the oral membranes
such as diffuse erythema, injected or
fissured lips, or "strawberry tongue"; 3)
erythema of palms and soles, and/or edema
of the hands or feet followed by periungual
desquamation; 4) cervical adenopathy in
the anterior cervical triangle with at least
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B. Intravenous nafcillin (Nallpen)


C. Intravenous immune globulin and
aspirin
D. Prednisone, 2-3 mg/kg daily
E. A fine-needle biopsy of the lymph
nodes

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one node larger than 1.5 cm in diameter;


and, 5) an erythematous polymorphous
rash, which may be targetoid or purpuric
in 20% of cases. The disease must be
distinguished from toxic shock syndrome,
streptococcal scarlet fever, StevensJohnson syndrome, juvenile rheumatoid
arthritis, measles, adenovirus infection,
echovirus infection, and drug reactions.
Treatment significantly diminishes the risk
of complications. Current
recommendations are to hospitalize the
patient for treatment with intravenous
immune globulin. In addition, aspirin is
used for both its anti-inflammatory and
antithrombolitic effects. While prednisone
is used to treat other forms of vasculitis, it
is considered unsafe in Kawasaki disease,
as a previous study showed an
extraordinarily high rate of coronary artery
aneurysm with its use.

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Random Board Review Questions 84
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In 2001, the National Cholesterol
Education Program published updated
guidelines for cholesterol testing and
management, as recommended by its
Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in
Adults. According to these guidelines and
the 2004 Adult Treatment Panel (ATP) III
Update, the target LDL cholesterol for
patients with type 2 diabetes mellitus is:
(check one)
A. 60 mg/dL
B. 100 mg/dL
C. 130 mg/dL
D. 160 mg/dL
E. 200 mg/dL

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B. 100 mg/dL. The 2001 National


Cholesterol Education Program Adult
Treatment Panel III guidelines and the
2004 update, as well as guidelines
previously published by the American
Diabetes Association, have established a
target LDL cholesterol level of 100 mg/dL
for patients with diabetes. This target is
also applicable for individuals with known
coronary artery disease (CAD),
symptomatic carotid artery disease,
abdominal aortic aneurysm, peripheral
vascular disease, and multiple risk factors
that confer a 10-year risk for coronary
heart disease that is >20%. An LDL level
of 130 mg/dL is acceptable for other
individuals with only two risk factors for
CAD and a 10-year CAD risk <20%, and
160 mg/dL is the upper limit of
acceptability for patients with no more
than one risk factor for CAD and a 10-year
CAD risk <20%.

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Random Board Review Questions 85
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A 3-week-old white male presents with a
history of several days of projectile
vomiting after feeding, and documented
weight loss despite a good appetite. There
is a questionable history of a paternal
uncle having surgery for a similar problem
when he was an infant. Which one of the
following findings is a characteristic sign
of this disease? (check one)
A. Hypochloremic alkalosis
B. Pneumonia
C. Generalized abdominal distention
D. Currant jelly stool
E. Direct hyperbilirubinemia

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A. Hypochloremic alkalosis. Hypertrophic


pyloric stenosis is the most likely
diagnosis in this case. If it is allowed to
progress untreated, there may be signs of
malnutrition, constipation, oliguria, and
profound hypochloremic metabolic
alkalosis. The latter is a characteristic sign
of pyloric obstruction. As the child vomits
chloride and hydrogen-rich gastric
contents, hypochloremic alkalosis sets in.
Pneumonia is not a common problem with
pyloric stenosis, as it can be with
congenital tracheoesophageal fistulae for
example. After feeding, there may be a
visible peristaltic wave that progresses
across the abdomen. However, since the
point of obstruction is proximal to the
small and large intestines and affected
infants lose weight, the abdomen is usually
flat rather than distended, especially in the
malnourished infant. Currant jelly stool is
a common clinical manifestation of
intussusception. Mild jaundice with
elevated indirect bilirubin is seen in about
5% of infants with pyloric stenosis, but is
not a characteristic sign.

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Random Board Review Questions 86
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A 72-year-old white female who is
otherwise healthy complains of occasional
incontinence. She reports that this occurs
mainly at night when she awakens with an
intense desire to void, and by the time she
is able to get to the bathroom she has "wet
herself." The most likely diagnosis is:
(check one)
A. Sphincter incompetence
B. Detrusor instability
C. Detrusor hypotonia
D. Uninhibited neurogenic bladder

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B. Detrusor instability. Urinary


incontinence is very common in the
elderly female. Treatment depends entirely
on a careful history to ascertain the exact
circumstances when the patient wets
herself. One of the most common types of
incontinence results from uninhibited
contractions of the detrusor muscle. This
detrusor instability causes an intense urge
to void, which overcomes the patient's
voluntary attempt to hold the sphincter
closed; hence, the common term urge
incontinence. Other common causes of
incontinence include a weak sphincter
(sphincter incompetence), which leads to
leakage associated with ordinary activities
such as coughing or lifting (stress
incontinence). Another common cause is
overflow of urine from an abnormally
distended, hypotonic, poorly contractile
bladder (detrusor hypotonia). This is
probably more common in males with
longstanding obstruction due to prostatic
hypertrophy. A rare type of incontinence is
caused by spinal cord damage. This reflex
incontinence is due to the patient being
unable to sense the need to void.

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Random Board Review Questions 87
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A 4-week-old full-term male is brought to
your office by his parents. They report that
their child started vomiting just after his 1week visit. The parents are concerned
because they think the vomiting is
worsening, occurring after every feeding,
and "shooting across the room." You note
that the baby is afebrile, but has not gained
any weight since birth. Based on this
information, the most likely diagnosis is:
(check one)

D. Pyloric stenosis. Pyloric stenosis fits


the described scenario; it is characterized
by the early onset of worsening projectile
vomiting and poor weight gain, and occurs
most often in full-term male infants who
are otherwise healthy. Formula intolerance
causes regurgitation, as would
inappropriate feeding. Meningitis, whether
viral or bacterial, would be associated with
fever. Viral gastroenteritis is a common
cause of vomiting in older children, and is
usually associated with fever and diarrhea.

A. Formula intolerance
B. Meningitis
C. Viral gastroenteritis
D. Pyloric stenosis
E. Inappropriate feeding

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Random Board Review Questions 88
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A 68-year-old white female presents to
your office and reports that yesterday she
had a 20-minute episode of difficulty
speaking and weakness of the right side of
the face and right arm. She has never
experienced any episodes similar to this in
the past and reports her overall health to be
excellent. In fact, she tells you that she has
not seen a physician since her
hysterectomy for fibroids 20 years ago.
Her only medication is occasional
acetaminophen or ibuprofen for knee pain.
Physical examination reveals a blood
pressure of 160/90 mm Hg, an irregularly
irregular heartbeat with a rate of 90/min,
an otherwise normal cardiovascular
examination, and a completely normal
neurologic examination. Her EKG
confirms atrial fibrillation with evidence
for left ventricular hypertrophy but no Q
waves or ST elevation. You are able to
obtain an emergent CT scan of the brain
without contrast, which is negative. Which
one of the following is the most
appropriate immediate management?
(check one)

C. Anticoagulation with warfarin


(Coumadin). The patient described
presents with a history most consistent
with a recent, resolved transient ischemic
attack (TIA). This was most likely due to
an embolus related to her atrial fibrillation.
Her risk for a recurrent neurologic event
(TIA or stroke) is high. Long-term
anticoagulation with warfarin reduces this
risk. The use of antiplatelet agents such as
clopidogrel to reduce TIAs has not been
studied. Lowering blood pressure and lipid
levels can reduce risks over the long term,
but do not require immediate intervention.
Cardioversion for patients with atrial
fibrillation of uncertain or long duration
may be appropriate but should not be
attempted before several weeks of
anticoagulation in the stable patient.

A. Lowering blood pressure


B. Antiplatelet therapy with clopidogrel
(Plavix)
C. Anticoagulation with warfarin
(Coumadin)
D. Electrical or chemical cardioversion
E. An MRI scan of the brain with contrast

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Random Board Review Questions 89
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A 78-year-old white female presents with
a 3-day history of lower thoracic back
pain. She denies any antecedent fall or
trauma, and first noted the pain upon
arising. Her description of the pain
indicates that it is severe, bilateral, and
without radiation to the arms or legs. Her
past medical history is positive for
hypertension and controlled diabetes
mellitus. Her medications include
hydrochlorothiazide, enalapril (Vasotec),
metformin (Glucophage), and a general
multivitamin. She is a previous smoker but
does not drink alcohol. She underwent
menopause at age 50 and took estrogen for
"a few months" for hot flashes. Physical
examination reveals her to be in moderate
pain with a somewhat stooped posture and
mild tenderness over T12-L1. She has
negative straight-leg raising and normal
lower extremity sensation, strength, and
reflexes. Which one of the following is
true regarding this patient's likely
condition? (check one)

D. Subcutaneous or intranasal calcitonin


(Calcimar, Miacalcin) may be very helpful
for pain relief. The patient described has a
classic presentation of an osteoporotic
vertebral compression fracture. The
diagnosis should be confirmed with a plain
radiograph. Treatment is basically
symptomatic, with a period of bed rest as
short as possible (to avoid complications
of immobility), pain medication, and
bracing. Salmon calcitonin (injectable or
intranasal) is often helpful in providing
pain relief. Long-term management of
underlying osteoporosis may help prevent
future fractures.

A. An MRI or nuclear medicine bone scan


should be performed
B. Prolonged (approximately 2 weeks) bed
rest will increase the chance of complete
recovery
C. Investigation for an underlying
malignancy is indicated
D. Subcutaneous or intranasal calcitonin
(Calcimar, Miacalcin) may be very helpful
for pain relief

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Random Board Review Questions 90
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The most common stress fracture in
children involves which one of the
following bones? (check one)

B. Tibia. Tibial fractures are the most


common lower extremity stress fractures
in both children and adults, accounting for
about half of all stress fractures.

A. Calcaneus
B. Tibia
C. Fibula
D. Tarsal navicular
E. Metatarsal
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Random Board Review Questions 91
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Three members of the same family present
with a high fever and cough that began
abruptly yesterday. All three report having
fevers over 40 C (104 F), painful
coughs, moderate sore throats, and
prostration. They have loss of appetite, but
no vomiting or diarrhea. Two other family
members have similar symptoms. On
examination the patients appear ill and
flushed. There is no cervical adenopathy,
no visible pharyngeal inflammation, and
no significant findings on examination of
the chest. Which one of the following is
the most likely diagnosis? (check one)
A. Mycoplasma pneumonia
B. Influenza-like illness
C. Bacterial bronchitis
D. Upper respiratory infection
E. Legionnaires disease

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B. Influenza-like illness. Influenza has a


very abrupt onset, and a fever with a
nonproductive cough is almost always
present. Unconfirmed cases are referred to
as influenza-like illness (ILI) or suspected
influenza. Patients with confirmed cases
tend to say they have never been so ill.
Mycoplasma pneumonia can spread
among family members, but it is milder
and has a more indolent onset and a longer
incubation period. Bacterial bronchitis is
an overdiagnosed, supposed complication
of upper respiratory infections, and is not
contagious. While the phrase cold and flu
is often used, upper respiratory infections
are not so febrile or prostrating, and coryza
is the dominant syndrome sooner or later.
Legionella can have point-source
epidemics, but the incubation period is
longer, symptoms vary from mild illness
to life-threatening pneumonia, and
diarrhea is prominent in many cases.
Reference: Thibodeau KP, Viera AJ:
Atypical pathogens and challenges in
community-acquired pneumonia. Am Fam
Physician 2004;69(7):1699-1706.
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Random Board Review Questions 92
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You have hospitalized a 67-year-old obese
white female for urosepsis. She has
completed a course of intravenous
antibiotics. She has hypertension, diabetes
mellitus, and congestive heart failure. In
addition, she has renal failure which has
worsened, and she has been on
hemodialysis for 1 week. The chart lists
her medications as enalapril (Vasotec),
furosemide (Lasix), labetalol (Trandate,
Normodyne), insulin, and heparin for
flushing intravenous lines. For the past 2
days she has had nosebleeds. A CBC is
normal except for mild anemia and marked
thrombocytopenia of 28,000/mL. Which
one of the following is most likely the
cause of her thrombocytopenia? (check
one)

E. Heparin. A number of medications can


cause thrombocytopenia, but heparin is a
more likely cause than enalapril,
furosemide, labetalol, or insulin. Even the
small doses of heparin used to flush
intravenous lines can be a source of
thrombocytopenia.

A. Enalapril
B. Furosemide
C. Labetalol
D. Insulin
E. Heparin

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Random Board Review Questions 93
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When draining a felon, which one of the
following incisions is recommended?
(check one)

D. A high lateral incision. When draining a


felon, a volar longitudinal incision or a
high lateral incision is recommended.
Incisions that are not recommended are the
"fish-mouth" incision, the "hockey stick"
(or "J") incision, and the transverse palmar
incision.

A. A "fishmouth" bilateral incision


B. A "hockey stick" J-shaped incision
including the distal and lateral aspects of
the digit
C. A transverse volar incision
D. A high lateral incision
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Reproductive (Female) Board Review
Questions 01
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A 16-year-old female presents with a
complaint of pelvic cramps with her
menses over the past 2 years. She
describes her periods as heavy, and says
they occur once a month and last for 7
days, with no spotting in between. She has
never been sexually active and does not
expect this to change in the foreseeable
future. An abdominal examination is
normal. Which one of the following would
be the most appropriate next step? (check
one)
A. A pelvic examination
B. Ultrasonography
C. A TSH level
D. Naproxen prior to and during menses

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D. Naproxen prior to and during menses.


This patient is experiencing primary
dysmenorrhea, a common finding in
adolescents, with estimates of prevalence
ranging from 20% to 90%. Because
symptoms started at a rather young age
and she has pain only during menses,
endometriosis or other significant pelvic
pathology is unlikely. An infection is
doubtful, considering that she is not
sexually active and that symptoms have
been present for 2 years. In the absence of
red flags, a pelvic examination, laboratory
evaluation, and pelvic ultrasonography are
not necessary at this time. However, they
can be ordered if she does not respond to
simple treatment. NSAIDs such as
naproxen have a slight effect on platelet
function, but because they inhibit
prostaglandin synthesis they actually
decrease the volume of menstrual flow and
lessen the discomfort of pelvic cramping.
Acetaminophen would have no effect on
prostaglandins.

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Reproductive (Female) Board Review
Questions 02
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A 17-year-old white female presents with
new-onset left-sided lower abdominal
pain. Color flow Doppler ultrasonography,
in addition to pelvic ultrasonography,
would be most useful for evaluating:
(check one)

A. Adnexal torsion. Color Doppler flow


studies are useful for evaluating blood
flow to the ovary in possible cases of
adnexal or ovarian torsion. Adnexal
torsion is a surgical emergency. Pelvic
ultrasonography, preferably with a vaginal
probe, can be beneficial in the workup of
ruptured ovarian cyst, pelvic abscess, and
pelvic inflammatory disease without
abscess. The Doppler flow study is not
required with these condition.

A. Adnexal torsion
B. Pelvic abscess
C. Pelvic inflammatory disease
D. Ruptured ovarian cyst
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Reproductive (Female) Board Review
Questions 03
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A 30-year-old African-American female
presents with a vaginal discharge. On
examination the discharge is homogeneous
with a pH of 5.5, a positive whiff test, and
many clue cells. Which one of the
following findings in this patient is most
sensitive for the diagnosis of bacterial
vaginosis? (check one)

A. The pH of the discharge. Patients must


have 3 of 4 Amsel criteria to be diagnosed
with bacterial vaginosis. These include a
pH >4.5 (most sensitive), clue cells >20%
(most specific), a homogeneous discharge,
and a positive whiff test (amine odor with
addition of KOH).

A. The pH of the discharge


B. The presence of clue cells
C. The character of the discharge
D. The whiff test

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Reproductive (Female) Board Review
Questions 04
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A 31-year-old married white female
complains of vaginal discharge, odor, and
itching. Speculum examination reveals a
homogeneous yellow discharge, vulvar
and vaginal erythema, and a "strawberry"
cervix. The most likely diagnosis is:
(check one)
A. Candidal vaginitis
B. Bacterial vaginosis
C. Trichomonal vaginitis
D. Chlamydial infection
E. Herpes simplex type 2

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Reproductive (Female) Board Review
Questions 05
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The definition of post-term pregnancy is a
pregnancy that has reached: (check one)

C. Trichomonal vaginitis. Trichomonal


vaginitis usually causes a yellowish
discharge which sometimes has a frothy
appearance. Colpitis macularis (strawberry
cervix) is often present. Monilial vaginitis
classically causes a cheesy, whitish
exudate with associated vaginal itching
and burning. There may be vaginal and
vulvar erythema and edema, but colpitis
macularis is not a feature. Bacterial
vaginosis is characterized by a grayish
discharge with few other physical signs or
symptoms, if any. Chlamydia may cause a
yellowish cervical discharge and
symptoms of pelvic inflammatory disease
or, alternatively, may be totally
asymptomatic. Herpes simplex type 2
causes ulcerations on the vulva and
vaginal mucosa which are exquisitely
tender, often with marked surrounding
erythema and edema.
C. 42 weeks' gestation. Postdate and postterm pregnancy are terms that are used
interchangeably. The postdate pregnancy
is defined as a pregnancy that has reached
42 weeks of amenorrhea. This is important
because perinatal mortality doubles at 42
weeks gestational age. The diagnosis of
postdate pregnancy depends heavily on
accurate dating methods.

A. 40 weeks' gestation
B. 41 weeks' gestation
C. 42 weeks' gestation
D. 43 weeks' gestation

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Reproductive (Female) Board Review
Questions 06
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A 22-year-old gravida 2 para 1 presents to
your office with a 1-day history of vaginal
bleeding and abdominal pain. Her last
menstrual period was 10 weeks ago, and
she had a positive home pregnancy test 6
weeks ago. She denies any passage of
clots. On pelvic examination, you note
blood in the vaginal vault. The internal
cervical os is open. Which one of the
following best describes the patient's
current condition? (check one)

A. Inevitable abortion. Inevitable abortion


is defined by bleeding, an open os, and no
passage of products of conception (POCs).
Bleeding also occurs with completed
abortion, but the os is closed and there is
complete passage of POCs. Threatened
abortion also is characterized by bleeding
and a closed os, but there is no passage of
POCs. With incomplete abortion there is
bleeding and an open os, but POCs are
visualized in the os or vaginal vault. There
are no symptoms with missed abortion, but
there is no embryo or fetus on
ultrasonography.

A. Inevitable abortion
B. Completed abortion
C. Threatened abortion
D. Incomplete abortion
E. Missed abortion
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Reproductive (Female) Board Review
Questions 07
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Black cohosh is: (check one)
A. A form of herbal licorice with
gastrointestinal effects
B. A botanical medicine used to alleviate
menopausal symptoms
C. A type of toxic hallucinogenic
mushroom
D. A variety of Cannabis sativa
E. A form of dried hashish

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B. A botanical medicine used to alleviate


menopausal symptoms. Black cohosh is an
herbal preparation widely used in the
treatment of menopausal symptoms and
menstrual dysfunction. Studies have
demonstrated that this botanic medicine
appears to be effective in alleviating
menopausal symptoms. It has not been
proven effective in randomized controlled
trials and should not be used to prevent
osteoporosis. Questions as to its
stimulating effect on endometrial tissue are
as yet unanswered.

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Respiratory Board Review Questions 01
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Which one of the following is an
indication for a second dose of
pneumococcal polysaccharide vaccine
(Pneumovax 23) in children? (check one)
A. Cerebrospinal fluid leak
B. Cyanotic congenital heart disease
C. Type 1 diabetes mellitus
D. Sickle cell disease
E. Chronic bronchopulmonary dysplasia

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D. Sickle cell disease. Patients with


chronic illness, diabetes mellitus,
cerebrospinal fluid leaks, chronic
bronchopulmonary dysplasia, cyanotic
congenital heart disease, or cochlear
implants should receive one dose of
pneumococcal polysaccharide vaccine
after 2 years of age, and at least 2 months
after the last dose of pneumococcal
conjugate vaccine (Prevnar 13).
Revaccination with polysaccharide vaccine
is not recommended for these patients.
Individuals with sickle cell disease, those
with anatomic or functional asplenia,
immunocompromised persons with renal
failure or leukemia, and HIV-infected
persons should receive polysaccharide
vaccine on this schedule and should be
revaccinated at least 5 years after the first
dose.

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Respiratory Board Review Questions 03
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A 72-year-old male slipped on a rug in his
kitchen and struck his right side against a
counter. He presents several days after the
fall with a complaint of ongoing pain in
his flank. He has a history of chronic atrial
fibrillation, which is treated with warfarin
(Coumadin). His vital signs are normal. A
physical examination reveals tenderness to
palpation along the posterior-lateral chest
wall and decreased breath sounds in the
right base. Radiographs reveal two
fractured ribs on the right side and a
moderately large pleural effusion in the
right hemithorax. Laboratory test results
include a hemoglobin of 10.5 mg/dL
(baseline 11.0-12.0 mg/dL) and a
prothrombin time of 33.5 seconds with an
INR of 3.5. Which one of the following
would be the most appropriate
management at this time? (check one)

A. Evacuation of the pleural space. This


patient has been clinically stable despite
losing what appears to be a fair amount of
blood into his pleural space after fracturing
two ribs, a condition referred to as
hemothorax. The treatment of choice in
this condition is to remove the bloody
fluid and re-expand the associated lung.
This therapy is felt to decrease any
ongoing blood loss by having the lung
pleura put a direct barrier over the site that
is bleeding. It also prevents the
development of empyema or fibrosis,
which could occur if the blood were to
remain.

A. Evacuation of the pleural space


B. Prophylactic antibiotics
C. Open fixation of the ribs with control of
bleeding
D. Symptomatic treatment and close
follow-up
E. Use of a rib binder for 2-3 weeks

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Respiratory Board Review Questions 04
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In adults, which one of the following is the
most likely cause of chronic, unilateral
nasal obstruction? (check one)
A. Nasal septal deviation
B. Foreign body impaction
C. Allergic rhinitis
D. Adenoidal hypertrophy

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Special Sensory Board Review Questions
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You are the team physician for the local
high-school swim team. Over the past
week, seven members of the team have
developed both folliculitis and outer ear
infections. You suspect bacterial
contamination of the swimming pool.
Which one of the following is the most
likely cause? (check one)

A. Nasal septal deviation. The most


common cause of nasal obstruction in all
age groups is the common cold, which is
classified as mucosal disease. Anatomic
abnormalities, however, are the most
frequent cause of constant unilateral
obstruction. Of these, septal deviation is
the most common. Foreign body impaction
is an important, but infrequent, cause of
unilateral obstruction and purulent
rhinorrhea. Mucosal disease is usually
bilateral and intermittent. Adenoidal
hypertrophy is the most common tumor or
growth to cause nasal obstruction,
followed by nasal polyps, but both are less
frequent than true anatomic causes of
constant obstruction.
B. Pseudomonas aeruginosa. Athletes,
including swimmers, are susceptible to a
number of skin infections. The pH of the
external ear is normally acidic. Continued
water exposure raises the pH, creating
conditions for bacterial overgrowth, most
often caused by either Pseudomonas
aeruginosa or Staphylococcus aureus.
Swimming pool folliculitis is most often
attributed to colonization of water with P.
aeruginosa.

A. Streptococcus pneumoniae
B. Pseudomonas aeruginosa
C. Corynebacterium ulcerans
D. Staphylococcus epidermidis
E. Escherichia coli
A 2-week-old female is brought to the
office for a well child visit. The physical
examination is completely normal except
for a clunking sensation and feeling of
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A. Referral for orthopedic consultation.


Developmental dysplasia of the hip
encompasses both subluxation and
dislocation of the newborn hip, as well as
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movement when adducting the hip and


applying posterior pressure. Which one of
the following would be the most
appropriate next step? (check one)
A. Referral for orthopedic consultation
B. Reassurance that the problem resolves
spontaneously in 90% of cases, and
follow-up in 2 weeks
C. Triple diapering and follow-up in 2
weeks
D. A radiograph of the pelvis

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anatomic abnormalities. It is more


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


mother keeps him from falling by pulling
up on his right hand. An hour later the
child refuses to use his right arm and cries
when his mother tries to move it. The most
likely diagnosis is (check one)

C. subluxation of the head of the radius.


"Nursemaid's elbow" is one of the most
common injuries in children under 5 years
of age. It occurs when the child's hand is
suddenly jerked up, forcing the elbow into
extension and causing the radial head to
slip out from the annular ligament.

A. dislocation of the ulna


B. dislocation of the olecranon epiphysis
C. subluxation of the head of the radius
D. subluxation of the head of the ulna
E. anterior dislocation of the humeral head
A 2-year-old female is brought to the
emergency department with a 2-day
history of fever and increasing redness on
the left forearm. She is otherwise healthy.
On examination her temperature is 39.9C
(103.8F), pulse rate 140 beats/min, and
respiratory rate 42/min. She is irritable,
and the left forearm has a 4-cm
erythematous, warm, tender area, with a
fluctuant area centrally. Her WBC count is
21,000/mm3 (N 4300-1 3 0,800), with
14% immature bands.
In addition to incision and drainage, which
one of the following is the best initial
treatment in this patient?
(check one)

A. Intravenous vancomycin. This patient


has systemic symptoms that suggest a
severe underlying infection. Communityacquired methicillin-resistant
Staphylococcus aureus (CA-MRSA)
should be considered the cause of this type
of infection until definitive cultures are
obtained. CA-MRSA can cause aggressive
infections in children, especially in the
skin and soft tissue. Incision and drainage
of the abscess is necessary for treatment.
In a severe infection, vancomycin should
be started initially until culture and
sensitivities are available (SORB).

A. Intravenous vancomycin
B. Intravenous ampicillin/sulbactam
(Unasyn)
C. Intravenous nafcillin
D. Intravenous clindamycin (Cleocin)
E. No antibiotics

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A 2-year-old Hispanic male with a 3-day


history of nasal congestion presents with a
barking cough and hoarseness. He is
afebrile. The examination reveals
tachypnea, inspiratory and expiratory
stridor, noticeable intercostal retractions,
and good color.
Which one of the following is indicated?
(check one)
A. Albuterol syrup and the use of a
humidifier
B. Inhaled albuterol (Proventil, Ventolin)
C. Aerosolized epinephrine and
intramuscular dexamethasone
D. Visualization of the epiglottis, and
ceftriaxone (Rocephin)

A 2-year-old white female is brought to


your office by her parents, who are
concerned about the child's "flat feet." On
evaluation, the child's feet are flat with
weight-bearing, but with toe standing and
with sitting the arch appears. You would:
(check one)
A. Reassure the parents
B. Recommend orthotics
C. Recommend surgery
D. Recommend casting
E. Recommend foot-stretching exercises

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C. Aerosolized epinephrine and


intramuscular dexamethasone. This child
has a history and physical findings typical
of viral laryngotracheobronchitis, or croup.
In rare instances, this illness can be
complicated by critical upper airway
obstruction. The symptoms of cough,
respiratory stridor, and distress result from
edema of the subglottic portion of the
upper airway. Humidification of inspired
air is sometimes beneficial, but the child
should not be sent home until
improvement is demonstrated. Because
this child has stridor and intercostal
retractions, aerosolized epinephrine is
indicated, along with intramuscular
dexamethasone, and hospitalization may
be required for observation and continued
treatment. Antibiotics do not have a role in
the treatment of viral croup, and attempted
visualization of the epiglottis is not
indicated since it will increase the child's
anxiety and worsen the symptoms.
A. Reassure the parents. Flexible flat feet
as described are not pathologic unless
painful, which is uncommon. Flexibility of
the flat foot is determined by appearance
of an arch when the feet are not bearing
weight. No treatment is indicated for
painless flexible flatfoot. Spontaneous
correction is usually expected within 1
year of walking.

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A 2-year-old white male is seen for a well


child visit. His mother is concerned
because he is not yet able to walk. The
routine physical examination, including an
orthopedic evaluation, is unremarkable.
Speech and other developmental
landmarks seem normal for his age.
Which one of the following tests would be
most appropriate? (check one)
A. A TSH level
B. Random urine for aminoaciduria
C. Phenylketonuria screening
D. A serum creatine kinase level
E. Chromosome analysis

D. A serum creatine kinase level. The


diagnosis of Duchenne muscular
dystrophy, the most common
neuromuscular disorder of childhood, is
usually not made until the affected
individual presents with an established gait
abnormality at the age of 4-5 years. By
then, parents unaware of the X-linked
inheritance may have had additional
children who would also be at risk.
The disease can be diagnosed earlier by
testing for elevated creatine kinase in boys
who are slow to walk. The mean age for
walking in affected boys is 17.2 months,
whereas over 75% of developmentally
normal children in the United States walk
by 13.5 months. Massive elevation of
creatine kinase (CK) from 20 to 100 times
normal occurs in every young infant with
the disease. Early detection allows
appropriate genetic counseling regarding
future pregnancies.
Hypothyroidism and phenylketonuria
could present as delayed walking.
However, these diseases cause significant
mental retardation and would be associated
with global developmental delay.
Furthermore, these disorders are now
diagnosed in the neonatal period by
routine screening. Disorders of amino acid
metabolism present in the newborn period
with failure to thrive, poor feeding, and
lethargy. Gross chromosomal
abnormalities would usually be
incompatible with a normal physical
examination at 18 months of age.

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A 3-day-old female developed a rash 1 day


ago that has continued to progress and
spread. The infant was born at term after
an uncomplicated pregnancy and delivery
to a healthy mother following excellent
prenatal care. The infant was discharged 2
days ago in good health. She does not
appear to be irritable or in distress, and she
is afebrile and feeding well. On
examination, abnormal findings are
confined to the skin, including her face,
trunk, and proximal extremities, which
have macules, papules, and pustules that
are all 2-3 mm in diameter. Her palms and
soles are spared. A stain of a pustular
smear shows numerous eosinophils.

D. Erythema toxicum neonatorum. This


infant has a typical presentation of
erythema toxicum neonatorum.
Staphylococcal pyoderma is vesicular and
the stain of the vesicle content shows
polymorphonuclear leukocytes and
clusters of gram-positive bacteria. Because
the mother is healthy and the infant shows
no evidence of being otherwise ill,
systemic infections such as herpes are
unlikely. Acne neonatorum consists of
closed comedones on the forehead, nose,
and cheeks. Rocky Mountain spotted fever
is a tickborne disease that does not need to
be considered in a child who is not at risk.

Which one of the following is the most


likely diagnosis? (check one)
A. Staphylococcal pyoderma
B. Herpes simplex
C. Acne neonatorum
D. Erythema toxicum neonatorum
E. Rocky Mountain spotted fever

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A 3-week-old infant is brought to your


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

A 3-week-old male is brought to your


office because of a sudden onset of bilious
vomiting of several hours duration. He is
irritable and refuses to breastfeed, but
stools have been normal. He was delivered
at term after a normal pregnancy, and has
had no health problems to date. A physical
examination shows a fussy child with a
distended abdomen. Radiography of the
abdomen shows a double bubble sign.
Which one of the following is the most
likely diagnosis? (check one)
A. Infantile colic
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A. Admit to the hospital; obtain urine,


blood, and CSF cultures; and start
intravenous antibiotics. Any child younger
than 29 days old with a fever and any child
who appears toxic, regardless of age,
should undergo a complete sepsis workup
and be admitted to the hospital for
observation until culture results are known
or the source of the fever is found and
treated (SOR A). Observation only, with
close follow-up, is recommended for
nontoxic infants 3-36 months of age with a
temperature <39.0C (102.2F) (SOR B).
Children 29-90 days old who appear to be
nontoxic and have negative screening
laboratory studies, including a CBC and
urinalysis, can be sent home with
precautions and with follow-up in 24 hours
(SOR B). Testing for neonatal herpes
simplex virus infection should be
considered in patients with risk factors,
including maternal infection at the time of
delivery, use of fetal scalp electrodes,
vaginal delivery, cerebrospinal fluid
pleocytosis, or herpetic lesions. Testing
also should be considered when a child
does not respond to antibiotics (SOR C).
E. Midgut volvulus. Volvulus may present
in one of three ways: as a sudden onset of
bilious vomiting and abdominal pain in a
neonate; as a history of feeding problems
with bilious vomiting that appears to be a
bowel obstruction; or less commonly, as
failure to thrive with severe feeding
intolerance. The classic finding on
abdominal plain films is the double bubble
sign, which shows a paucity of gas (airless
abdomen) with two air bubbles, one in the
stomach and one in the duodenum.
However, the plain film can be entirely
normal. The upper gastrointestinal contrast
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B. Necrotizing enterocolitis
C. Hypertrophic pyloric stenosis
D. Intussusception
E. Midgut volvulus

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study is considered the gold standard for


diagnosing volvulus. Infantile colic usually
begins during the second week of life and
typically occurs in the evening. It is
characterized by screaming episodes and a
distended or tight abdomen. Its etiology
has yet to be determined. There are no
abnormalities on physical examination and
ancillary studies, and symptoms usually
resolve spontaneously around 12 weeks of
age. Necrotizing enterocolitis is typically
seen in the distressed neonate in the
intensive-care nursery, but it may
occasionally be seen in the healthy neonate
within the first 2 weeks of life. The child
will appear ill, with symptoms including
irritability, poor feeding, a distended
abdomen, and bloody stools. Abdominal
plain films will show pneumatosis
intestinalis, caused by gas in the intestinal
wall, which is diagnostic of the condition.
Hypertrophic pyloric stenosis is a
narrowing of the pyloric canal caused by
hypertrophy of the musculature. It usually
presents during the third to fifth weeks of
life. Projectile vomiting after feeding,
weight loss, and dehydration are common.
The vomitus is always nonbilious, because
the obstruction is proximal to the
duodenum. If a small olive-size mass
cannot be felt in the right upper or middle
quadrant, ultrasonography will confirm the
diagnosis. Intussusception is seen most
frequently between the ages of 3 months
and 5 years, with 60% of cases occurring
in the first year and a peak incidence at 611 months of age. The disorder occurs
predominantly in males. The classic triad
of intermittent colicky abdominal pain,
vomiting, and bloody, mucous stools is
encountered in only 20%-40% of cases. At
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least two of these findings will be present


in approximately 60% of patients. The
abdomen may be distended and tender, and
there may be an elongated mass in the
right upper or lower quadrants. Rectal
examination may reveal either occult
blood or frankly bloody, foul-smelling
stool, classically described as currant jelly.
An air enema using fluoroscopic guidance
is useful for both diagnosis and treatment.
A 3-year-old female is brought to your
office for evaluation of mild intoeing. The
child's patellae face forward, and her feet
point slightly inward. Which one of the
following would be most appropriate?
(check one)
A. Reassurance
B. Foot stretching exercises
C. Use of orthotics
D. Use of night splints
E. Surgery

A 3-year-old female is brought to your


office with a 3-hour history of skin lesions
that are prominent, warm, papular, and
serpiginous (see Figure 3). Which one of
the following is the most likely cause of
these lesions?
(check one)
A. Heredity
B. Physical abuse
C. Infection
D. A topical agent
E. An oral medication

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A. Reassurance. Intoeing, as described, is


usually caused by internal tibial torsion.
This problem is believed to be caused by
sleeping in the prone position, and sitting
on the feet. In 90% of cases, internal tibial
torsion gradually resolves without
intervention by the age of 8. Avoiding
prone sleeping enhances resolution of the
problem. Night splints, orthotics, and shoe
wedges are ineffective. Surgery
(osteotomy) has been associated with a
high complication rate, and is therefore not
recommended in mild cases before the age
of 8.
E. An oral medication. Acute urticaria
occurs when an allergen activates mast
cells in the skin, and is commonly caused
by oral
and parenteral drugs, food, and, less
frequently, infections. Topical agents and
physical abuse are unlikely
to present in this manner, and hereditary
angioedema is more a systemic illness than
a skin disorder.

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A 3-year-old female presents with urinary


frequency, dysuria, and fever to 39.0
degrees C (102.2 degrees F). She denies
nausea, vomiting, fever, and flank pain.
There is no prior history of urinary
infection and no family history of urinary
tract abnormalities. Urethral
catheterization reveals bacteriuria and a
urine culture reveals >100,000 colonyforming units of Escherichia coli. She is
started on appropriate antibiotic therapy.
Evaluation to rule out anatomic
abnormalities should include: (check one)
A. Renal ultrasonography only if she has
recurrent infections
B. Renal ultrasonography and voiding
cystourethrography (VCUG) only if she
has recurrent infections
C. Renal ultrasonography and cystoscopy
only if she has recurrent infections
D. Renal ultrasonography for this primary
episode of infection
E. Renal ultrasonography and VCUG for
this primary episode of infection

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E. Renal ultrasonography and VCUG for


this primary episode of infection. In the
first few months of life, the incidence of
urinary tract infection (UTI) in boys is
higher than that of girls. However, after
that time period, UTIs are much more
common in females, with the peak
incidence in the 2- to 3-year age range.
The clinical presentation of UTI in
children is similar to that of adults,
including dysuria, hematuria, frequency,
incontinence, suprapubic tenderness, and
low-grade fever. Upper tract infection is
suggested by high fever, nausea, vomiting,
flank pain, and lethargy. All children who
have a culture-documented UTI should
undergo evaluation of the anatomy of the
urinary tract. This is due to the fact that
children who are at most risk for renal
parenchymal damage are those with an
anatomic defect. In general, studies to
evaluate both the upper and lower tract are
recommended. Children under the age of 5
years with a UTI, any child with a UTI and
a fever, school-aged girls who have had
two or more UTIs, and any boy with a UTI
should have a voiding cystourethrogram
(VCUG) to evaluate for vesiculoureteral
reflux and renal ultrasonography to
evaluate the kidneys. Cystoscopy and
retrograde pyelography are rarely
indicated in the workup.

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A 3-year-old male is brought to the


emergency department by his parents, who
report seeing him swallow a handful of
adult ibuprofen tablets 20 minutes ago.
Which one of the following would be the
most appropriate initial management of
this patient? (check one)
A. Oral ipecac
B. Oral activated charcoal
C. Gastric lavage
D. Whole-bowel irrigation
E. Close observation
A 3-year-old male is brought to your office
because of ear pain. On examination you
find a round, plastic bead in the lower third
of the ear canal close to the tympanic
membrane. You restrain the child and are
unable to remove the object despite several
attempts, first using water irrigation and
then fast-acting glue on an applicator.
Which one of the following is the best
option for removal? (check one)
A. A plastic loop curette through an
otoscope
B. Referral for removal under anesthesia
C. Grasping with forceps
D. Applying acetone to dissolve the object

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B. Oral activated charcoal. A single dose


of activated charcoal is the
decontamination treatment of choice for
most medication ingestions. It should be
used within 1 hour of ingestion of a
potentially toxic amount of medication
(SOR C). Gastric lavage, cathartics, or
whole bowel irrigation is best for ingestion
of medications that are poorly absorbed by
activated charcoal (iron, lithium) or
medications in sustained-release or
enteric-coated formulations. Ipecac has no
role in home use or in the health care
setting (SOR C).
B. Referral for removal under anesthesia.
After several unsuccessful attempts to
remove an object deep in the ear canal of
an uncooperative child, it is best to refer
the patient to an otolaryngologist for
removal under anesthesia. Additional
attempts are very unlikely to succeed,
especially with the techniques listed. A
loop curette cannot be safely placed
behind a foreign body that is close to the
tympanic membrane. A round, hard object
cannot be grasped with forceps. Acetone
can be used to dissolve Styrofoam foreign
bodies, but it would not dissolve a plastic
bead.

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A 3-year-old male is brought to your office


by his parents because they are concerned
about three "spells" he has had in the past
month. In each case, the child started
crying when he was prevented by a parent
from doing something he wished to do.
While crying, he suddenly stopped
breathing and his face and lips began to
turn blue. After 30-45 seconds he resumed
crying, his color returned to normal, and
he showed no evidence of impairment. A
physical examination today is normal and
the child is developmentally appropriate
for his age. A recent hemoglobin level was
in the normal range.
Which one of the following should you do
now? (check one)
A. Teach the parents age-appropriate
disciplinary procedures to implement
when the child behaves in this manner
B. Reassure the parents that this is a
benign condition and will resolve as the
child gets older
C. Order an EEG
D. Obtain appropriate laboratory studies to
confirm the most likely diagnosis
E. Initiate treatment with valproic acid
(Depakene)

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B. Reassure the parents that this is a


benign condition and will resolve as the
child gets older. This child is experiencing
simple breath-holding spells, a relatively
common and benign condition that usually
begins in children between the ages of 6
months and 6 years. The cause is uncertain
but seems to be related to overactivity of
the autonomic nervous system in
association with emotions such as fear,
anger, and frustration. The episodes are
self-limited and may be associated with
pallor, cyanosis, and loss of conciousness
if prolonged. There may be an association
with iron deficiency anemia, but this child
had a recent normal hemoglobin level.
These events are not volitional, so
disciplinary methods are neither effective
nor warranted. While children may
experience a loss of consciousness and
even exhibit some twitching behavior, the
episodes are not seizures so neither EEG
evaluation nor anticonvulsant therapy is
indicated. No additional laboratory studies
are indicated. Parents should be reassured
that the episodes are benign and will
resolve without treatment.

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A 3-year-old male is carried into the office


by his mother. Yesterday evening he began
complaining of pain around his right hip.
Today he has a temperature of 37.6C
(99.7F), cries when bearing weight on his
right leg, and will not allow the leg to be
moved in any direction. A radiograph of
the hip is normal.
Which one of the following would be most
appropriate at this time?
(check one)
A. A CBC and an erythrocyte
sedimentation rate
B. A serum antinuclear antibody level
C. Ultrasonography of the hip
D. MRI of the hip
E. In-office aspiration of the hip

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A. A CBC and an erythrocyte


sedimentation rate. This presentation is
typical of either transient synovitis or
septic arthritis of the hip. Because the
conditions have very different treatment
regimens and outcomes, it is important to
differentiate the two. It is recommended
that after plain films, the first studies to be
performed should be a CBC and an
erythrocyte sedimentation rate (ESR).
Studies have shown that septic arthritis
should be considered highly likely in a
child who has a fever over 38.7C
(101.7F), refuses to bear weight on the
leg, has a WBC count >12,000 cells/mm ,
and has an ESR >40 mm/hr. If several or
all of these conditions exist, aspiration 3 of
the hip guided by ultrasonography or
fluoroscopy should be performed by an
experienced practitioner. MRI may be
helpful in cases that are unclear based on
standard data, or if other etiologies need to
be excluded.

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A 3-year-old male presents with a 3-day


history of fever and refusal to eat. Today
his parents noted some sores just inside his
lips. No one else in the family is ill, and he
has no significant past medical history. He
is up-to-date on his immunizations and has
no known allergies.
On examination, positive findings include
a temperature of 38.9C (102.0F) rectally,
irritability, and ulcers on the oral buccal
mucosa, soft palate, tongue, and lips. He
also has cervical lymphadenopathy. The
remainder of the physical examination is
normal. The child is alert and has no skin
lesions or meningeal signs.
Which one of the following would be the
most appropriate treatment? (check one)
A. Ceftriaxone (Rocephin) intramuscularly
B. Nystatin oral suspension
C. Amoxicillin suspension
D. Acyclovir (Zovirax) suspension
E. Methotrexate (Trexall)

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D. Acyclovir (Zovirax) suspension. The


history and physical findings in this patient
are consistent with gingivostomatitis due
to a primary or initial infection with herpes
simplex virus type 1 (HSV-1). There are
no additional findings to suggest other
diagnoses such as aphthous ulcers,
Behet's syndrome, or herpangina
(coxsackievirus).
After a primary HSV-1 infection with oral
involvement, the virus invades the neurons
and replicates in the trigeminal sensory
ganglion, leading to recurrent herpes
labialis and erythema multiforme, among
other things. Although some clinicians
might choose to use oral anesthetics for
symptomatic care, it is not a specific
therapy.
Antibiotics are not useful for the treatment
of herpetic gingivostomatitis and could
confuse the clinical picture should this
child develop erythema multiforme, which
occurs with HSV-1 infections. An orally
applied corticosteroid is not specific
treatment, but some might try it for
symptomatic relief. An
immunosuppressant is sometimes used for
the treatment of Behet's syndrome, but
this patient's findings are not consistent
with that diagnosis. Therefore, the only
specific treatment listed is acyclovir
suspension, which has been shown to lead
to earlier resolution of fever, oral lesions,
and difficulties with eating and drinking. It
also reduces viral shedding from 5 days to
1 day (SOR B).

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A 3-year-old male was treated for acute


otitis media last month. His mother brings
him in for follow-up because she believes
his hearing has not been normal since then.
He attends day care and has had several
upper respiratory infections. On
examination the tympanic membranes are
not inflamed, but the membrane is
retracted on the right side. An office
tympanogram shows a normal peak (type
A) on the left side, but a flat tracing (type
B) on the right side. Which one of the
following would be the most appropriate
recommendation? (check one)
A. Audiometry
B. Observation with follow-up
C. An antihistamine/decongestant
combination
D. Intranasal corticosteroids
E. Systemic corticosteroids

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B. Observation with follow-up. This


patient has unilateral serous otitis and is
unlikely to have delayed language from
decreased hearing on one side. The patient
should be observed for now. Hearing loss
of longer than 3 months may indicate a
need for tympanostomy tubes. Surgical
treatment has been shown to be helpful,
but should be reserved for patients with
chronic effusion. Audiometry is not
needed to make a decision about surgery at
this point. The mother's judgment is likely
correct about his current hearing loss, so a
hearing test most likely would not add any
useful information. Numerous studies have
shown that all medical treatments for
serous otitis are ineffective, including
antihistamine and decongestant therapy,
and corticosteroids by any route.

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A 3-year-old white female is brought to


the emergency department with an acute
onset of epistaxis. The child, who has a
history of good health, is brought in by her
recently-divorced mother, a registered
nurse. The mother appears relatively
unconcerned about the child's illness, but
otherwise is friendly and interacts
appropriately with the health care team
evaluating the child. The child's vital signs
are normal, but she is bleeding mildly
from both nostrils and there are areas of
ecchymosis. Laboratory Findings
Hemoglobin 12.3 g/dL (N 11.5-15.0)
Hematocrit 36% (N 32-42) WBC count
4500/mm3 (N 6000-15,000) Platelets
235,000/mm3 (N >50,000) Prothrombin
time 40.0 sec (N 11.0-15.0) Partial
thromboplastin time 30 sec (N 24-36) INR
3.9 sec (N 2.0-3.0) ALT (SGPT) 18 IU/L
(N 7-35) AST (SGOT) 16 IU/L (N 15-60)
Bilirubin 0.8 mg/dL (N 0.3-1.2) You
hospitalize the child for observation and
further testing. Her bleeding subsides in
several hours, no new skin lesions
develop, and her PT/INR decreases to 32
sec/3.0, 23 sec/2.1, and 15 sec/1.4 on
subsequent days. You suspect that the
child's condition is due to: (check one)

C. Munchausen syndrome by proxy. The


patient exhibits signs of a moderate
bleeding diathesis. Her prothrombin time
(PT) elevation, without evidence of
hepatocellular damage or hepatic
dysfunction, is highly suspicious for
warfarin ingestion. The normalization of
the PT under observation in a hospital
setting is consistent with this suspicion.
Although accidental poisoning is a
possibility, the mother's affect is highly
suspicious for Munchausen syndrome by
proxy. The fact that her mother is a healthcare worker and develops a close and
appropriate relationship with the healthcare team is consistent with this diagnosis.
Acetaminophen toxicity of this degree
would likely produce transaminase and
bilirubin elevations, as well as mental
status changes. Antiphospholipid
syndrome produces a hypercoagulable
state. Henoch-Schonlein purpura presents
with purpura, joint pain, abdominal pain,
and a normal PT. Traumatic injury would
not result in PT elevations.

A. Acetaminophen overdose
B. Antiphospholipid syndrome with lupus
anticoagulant
C. Munchausen syndrome by proxy
D. Henoch-Schnlein purpura
E. Traumatic injury (child abuse)

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A 4-month-old white male in respiratory


distress is brought to the emergency
department. On examination, heart sounds
include a grade 4/6 pansystolic murmur,
best heard at the lower left sternal border.
He is acyanotic. A chest radiograph shows
an enlarged heart and increased pulmonary
vascular markings, and an EKG shows
combined ventricular hypertrophy.
Of the following, the most likely diagnosis
is: (check one)
A. hypoplastic left heart syndrome (aortic
valve atresia)
B. transposition of the great vessels
C. ventricular septal defect
D. tetralogy of Fallot
E. patent ductus arteriosus

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C. ventricular septal defect. Ventricular


septal defect causes overload of both
ventricles, since the blood is shunted left
to right. The murmur is harsh and
holosystolic, generally heard best at the
lower left sternal border. As the volume of
the shunting increases, cardiac
enlargement and increased pulmonary
vascular markings can be seen on a chest
radiograph.
Hypoplastic left heart syndrome would be
manifested by near-obliteration of the left
ventricle on the EKG and chest
radiograph, and the infant would be
cyanotic. Transposition of the great vessels
would cause AV conduction defects and
single-sided hypertrophy on the EKG. The
chest radiograph would show a straight
shoulder on the left heart border where the
aorta was directed to the right. Tetralogy
of Fallot causes cyanosis and right
ventricular enlargement. The murmur of
patent ductus arteriosus is continuous, best
heard below the left clavicle. The EKG
shows left atrial and ventricular
enlargement.

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A 4-year-old female has had three urinary


tract infections in the past 6 months. She
complains of difficulty with urination and
on examination is noted to have labial
adhesions that have resulted in near
closing of the introitus. Which one of the
following is the most appropriate
management? (check one)
A. No treatment at this time
B. Reporting your suspicion of child abuse
to the appropriate authorities
C. Application of estrogen cream to the
site
D. Gentle insertion of progressively larger
dilators over a period of several days
E. Referral to a gynecologist for surgical
correction
A 4-year-old Hispanic female has been
discovered to have a congenital hearing
loss. Her mother is an 18-year-old migrant
farm worker who is currently at 8 weeks'
gestation with her second pregnancy. The
mother has been found to have cervical
dysplasia on her current Papanicolaou
(Pap) smear and has also tested positive
for Chlamydia. The most likely cause of
this child's hearing loss is: (check one)
A. Human parvovirus B19
B. Varicella zoster virus
C. Herpes simplex virus
D. Toxoplasmosis
E. Cytomegalovirus

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C. Application of estrogen cream to the


site. The etiology of prepubertal labial
adhesions is idiopathic. The adhesions
may be partial or complete; in some cases
only a small pinhole orifice may be seen
that allows urine to exit from the fused
labia. This problem may be asymptomatic,
but the patient may also have a pulling
sensation, difficulty with voiding,
recurrent urinary tract infections, or
vaginitis. If there is enough labial fusion to
interfere with urination, treatment should
be undertaken. The use of topical estrogen
cream twice daily at the point of the
midline fusion will usually result in
resolution of the problem.

E. Cytomegalovirus. Cytomegalovirus
(CMV) is the most common congenital
infection and occurs in up to 2.2% of
newborns. It is the leading cause of
congenital hearing loss. The virus is
transmitted by contact with infected blood,
urine, or saliva, or by sexual contact. Risk
factors for CMV include low
socioeconomic status, birth outside North
America, first pregnancy prior to age 15, a
history of cervical dysplasia, and a history
of sexually transmitted diseases. Infection
can be primary or a reactivation of a
previous infection. While the greatest risk
of infection is during the third trimester,
those occurring in the first trimester are the
most dangerous to the fetus.

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A 4-year-old is brought to the emergency


department with abdominal pain and is
noted to have 3+ proteinuria on a dipstick.
Three days later the pain has resolved
spontaneously, and a repeat urinalysis in
your office shows 2+ proteinuria with
normal findings on microscopic
examination. A metabolic panel, including
creatinine and total protein, is also normal.
Which one of the following would be most
appropriate at this point? (check one)
A. Renal ultrasonography
B. A spot first morning urine
protein/creatinine ratio
C. An antinuclear antibody and
complement panel
D. Referral to a nephrologist

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B. A spot first morning urine


protein/creatinine ratio. When proteinuria
is noted on a dipstick and the history,
examination, full urinalysis, and serum
studies suggest no obvious underlying
problem or renal insufficiency, a urine
protein/creatinine ratio is recommended.
This test correlates well with 24-hour urine
protein, which is particularly difficult to
collect in a younger patient. Renal
ultrasonography is appropriate once renal
insufficiency or nephritis is established. If
pathogenic proteinuria is confirmed, an
antinuclear antibody and/or complement
panel may be indicated. A nephrology
referral is not necessary until the presence
of kidney disease or proteinuria from a
cause other than benign postural
proteinuria is confirmed.

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A 4-year-old male is brought to your office


for evaluation of fever, coryza, and cough.
On examination, the child appears mildly
ill but in no respiratory distress. His
temperature is 37.4C (99.3F) and other
vital signs are within the normal range. An
HEENT examination is significant only for
light yellow rhinorrhea and reddened nasal
mucous membranes. Lung auscultation
reveals good air flow with a few coarse
upper airway sounds. While performing
the examination you note multiple red
welts and superficial abrasions scattered
on the chest and upper back. When you
question the parents, they tell you the
marks are where "the sickness is leaving
his body," and were produced by rubbing
the skin with a coin.
This traditional healing custom is practiced
principally by people from which
geographic region? (check one)

B. Southeast Asia. Coin rubbing is a


traditional healing custom practiced
primarily in east Asian countries such as
Cambodia, Korea, China, and Vietnam.
The belief is that one's illness must be
drawn out of the body, and the red marks
produced by rubbing the skin with a coin
are evidence of the body's "release" of the
illness. These marks may be confused with
abuse, trauma from some other source, or
an unusual manifestation of the illness
itself.

A. Sub-Saharan Africa
B. Southeast Asia
C. The Middle East
D. Caribbean islands
E. Andean South America

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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 honeycolored 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)

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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.

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A 4-year-old white female is brought to


your office by her mother, who reports that
the child recently developed a foulsmelling vaginal discharge. After an
appropriate history and general
examination, you determine that a genital
examination is necessary. Which one of
the following positions is most likely to
allow for visualization of the child's vagina
and cervix without instrumentation?
(check one)
A. Supine in the mother's lap
B. The left lateral decubitus position on an
examination table
C. Trendelenburg's position on an
examination table
D. The knee-chest position on an
examination table
E. Supine with the knees spread apart on
an examination table

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D. The knee-chest position on an


examination table. The knee-chest position
has been found to allow for visualization
of the vagina and cervix of a prepubertal
child after 2 years of age without
instrumentation. The vagina is filled with
air when the child is in the knee-chest
position, facilitating inspection. An
assistant holds the child's buttocks apart
and the child is asked to relax her
abdominal muscles and take a few deep
breaths. With these preliminary steps, the
vaginal orifice opens and the short vaginal
canal fills with air. A bright light will help
to illuminate the prepubertal child's vagina
and cervix. Inspection of genitalia (where
examination of the vaginal canal and
cervix are not indicated) during a general
physical examination need not be in the
knee-chest position. In the young child
(usually less than 2 years of age),
examination is best done with the child
lying supine in the mother's lap. For the
older prepubertal child, examination is
best done with the child lying supine with
the knees spread apart on the examination
table. The other positions listed are not
helpful or recommended when examining
the genital area of a prepubertal child.

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A 4-year-old white male is brought to your


office because he has had a low-grade
fever and decreased oral intake over the
past few days. On examination you note
shallow oral ulcerations confined to the
posterior pharynx. Which one of the
following is the most likely diagnosis?
(check one)
A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola infantum
E. Rubella

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A. Herpangina. Herpangina is a febrile


disease caused by coxsackieviruses and
echoviruses. Vesicles and subsequent
ulcers develop in the posterior pharyngeal
area (SOR C). Herpes infection causes a
gingivostomatitis that involves the anterior
mouth. Mononucleosis may be associated
with petechiae of the soft palate, but does
not usually cause pharyngeal lesions. The
exanthem in roseola usually coincides with
defervescence. Mucosal involvement is not
noted. Rubella may cause an enanthem of
pinpoint petechiae involving the soft palate
(Forschheimer spots), but not the pharynx.

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A 4-year-old white male is brought to your


office in late August. His mother tells you
that over the past few days he has
developed a rash on his hands and sores in
his mouth. On examination you note a
vesicular exanthem on his hands, with
lesions ranging from 3 to 6 mm in
diameter. The oral lesions are shallow,
whitish, 4- to 8-mm ulcerations distributed
randomly over the hard palate, buccal
mucosa, gingiva, tongue, lips, and
pharynx. Except for a temperature of
37.4C (99.3F), the remainder of the
examination is normal. The most likely
diagnosis is (check one)
A. herpangina
B. hand, foot, and mouth disease
C. aphthous stomatitis
D. herpetic gingivostomatitis
E. streptococcal pharyngitis

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B. hand, foot, and mouth disease. Hand,


foot, and mouth disease is a mild infection
occurring in young children, and is caused
by coxsackievirus A16, or occasionally by
other strains of coxsackie- or enterovirus.
In addition to the oral lesions, vesicular
lesions may occur on the feet and
nonvesicular lesions may occur on the
buttocks. A low-grade fever may also
develop. Herpangina is also caused by
coxsackieviruses, but it is a more severe
illness characterized by severe sore throat
and vesiculo-ulcerative lesions limited to
the tonsillar pillars, soft palate, and uvula,
and occasionally the posterior oropharynx.
Temperatures can range to as high as 41C
(106F). The etiology of aphthous
stomatitis is multifactorial, and it may be
due to a number of conditions. Systemic
signs, such as fever, are generally absent.
Lesions are randomly distributed. Herpetic
gingivostomatitis also causes randomly
distributed oral ulcers, but it is a more
severe illness, regularly accompanied by a
higher fever, and is extremely painful.
Streptococcal pharyngitis is rarely
accompanied by ulceration except in
agranulocytic patients.

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A 5-month-old female is brought in with a


1-day history of an axillary temperature of
100.6F and mild irritability. Findings are
normal on examination except for a runny
nose and a moderately distorted, immobile,
red right eardrum. There is no history of
recent illness or otitis in the past.
The most appropriate management would
be: (check one)
A. azithromycin (Zithromax) for 5 days
B. amoxicillin for 10 days
C. amoxicillin for 5 days
D. oral decongestants
E. observation and a repeat examination in
2 weeks

B. amoxicillin for 10 days. The treatment


for otitis media is evolving.
Recommendations by the American
Academy of Family Physicians and the
American Academy of Pediatrics advocate
a 10-day course of antibiotics for children
under the age of 2 years if the diagnosis is
certain. If the diagnosis is not certain and
the illness is not severe, there is an option
of observation with follow-up. For
children over the age of 2 years, the
recommendation is still to treat if the
diagnosis is certain, but there is an option
of observation and follow-up if the illness
is not severe and follow-up can be
guaranteed.
Amoxicillin is the first-line therapy; the
recommended dosage is 80-90 mg/kg/day
in two divided doses, which increases the
concentration of amoxicillin in the middle
ear fluid to help with resistant
Pneumococcus.
Azithromycin, because of a broader
spectrum and potential for causing
resistance, is not considered the treatment
of first choice. Treatment regimens
ranging from 5 to 7 days are appropriate
for selected children over the age of 5
years.
Oral decongestants and antihistamines are
not recommended for children with acute
otitis media.

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A 5-month-old infant has had several


episodes of wheezing, not clearly related
to colds. The pregnancy and delivery were
normal; the infant received phototherapy
for 1 day for hyperbilirubinemia. He had
an episode of otitis media 1 month ago.
There is no chronic runny nose or strong
family history of asthma. He spits up small
amounts of formula several times a day,
but otherwise appears well. His growth
curve is normal. An examination is
unremarkable except for mild wheezing.
Which one of the following is the most
likely diagnosis?
(check one)

B. Gastroesophageal reflux.
Gastroesophageal reflux is a common
cause of wheezing in infants. At 5 months
of age, most infants no longer spit up
several times a day, and this is a major
clue that this child's wheezing may be
from the reflux. In addition, there is no
family history of asthma and the wheezing
is not related to infections.Cystic fibrosis
is more likely to present with recurrent
infections and failure to thrive than with
intermittent wheezing.

A. Benign reactive airway disease of


infancy
B. Gastroesophageal reflux
C. Unresolved respiratory syncytial virus
infection
D. Early asthma
E. Cystic fibrosis

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A 5-year-old African-American male


presents with behavior problems noted in
the first 3 months of kindergarten. The
mother explains that the child does not pay
attention and often naps in class. He
averages 10 hours of sleep nightly and is
heard snoring frequently. The mother has a
history of attention-deficit disorder and
takes atomoxetine (Strattera). The boy's
examination is within normal limits except
for his being in the 25th percentile for
weight and having 3+ tonsillar
enlargement. The most reasonable plan at
this point would include which one of the
following? (check one)
A. An electroencephalogram
B. Polysomnography
C. Atomoxetine
D. Methylphenidate (Ritalin)
A 5-year-old female is seen for a
kindergarten physical and is noted to be
below the 3rd percentile for height. A
review of her chart shows that her height
curve has progressively fallen further
below the 3rd percentile over the past year.
She was previously at the 50th percentile
for height. The physical examination is
otherwise normal, but your workup shows
that her bone age is delayed.
Of the following conditions, which one is
the most likely cause of her short stature?
(check one)

B. Polysomnography. Obstructive sleep


apnea is increasingly recognized in
children. The peak incidence is in the
preschool-age range of 2-5 years when
adenotonsillar tissue is greatest in relation
to airway size. It is associated with obesity
in older children. Common clinical
manifestations include snoring with sleep
interruptions and respiratory pauses.
Polysomnography is the gold standard for
the diagnosis. Although the child has
inattention, excessive drowsiness is not
seen in attention-deficit/hyperactivity
disorder (ADHD) and medications for that
condition are not indicated. None of his
symptoms suggests a seizure disorder, so
an EEG would not be helpful.

B. Growth hormone deficiency. This


patient has delayed bone age coupled with
a reduced growth velocity, which suggests
an underlying systemic cause. Growth
hormone deficiency is one possible cause
for this. Although bone age can be delayed
with constitutional growth delay, after 24
months of age growth curves are parallel
to the 3rd percentile. Bone age would be
normal with genetic short stature. Patients
with Turner syndrome or skeletal dysplasia
have dysmorphic features, and bone age
would be normal.

A. Constitutional growth delay


B. Growth hormone deficiency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia

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A 5-year-old male fell while playing and


complained that his wrist hurt. The next
day he is brought to your office because he
refuses to use his arm.
Which one of the following best describes
the condition seen in the radiographs
shown in Figure 9?
(check one)
A. A normal appearance
B. A radial fracture
C. An ulnar fracture
D. A radioulnar fracture
E. Indeterminate result
A 5-year-old male is scheduled for elective
hernia repair at 11:00 a.m. Which one of
the following would be the most
appropriate recommendation? (check one)
A. No solid food for 8 hours prior to
surgery and clear liquids until 2 hours
prior to surgery
B. No solid food 4 hours prior to surgery
and clear liquids until 2 hours prior to
surgery
C. No solid food after midnight and
nothing by mouth 8 hours prior to surgery
D. Nothing by mouth 2 hours prior to
surgery
E. Nothing by mouth 8 hours prior to
surgery

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B. A radial fracture. Even though they are


the most common fracture in this age
group, radial fractures can be missed
byclinicians. The bend in the cortex of the
distal radius indicates the fracture.
Sometimes referred to as a buckle or torus
fracture, it will heal with almost any
choice of treatment. Most clinicians opt for
casting to reduce the chance of reinjury
during the first few weeks of healing, but
the parents' preferences in this regard are
important. Some pediatric long-bone
fractures involve growth plates, and the
results can be indeterminate, requiring
either more advanced imaging or
comparison views of the opposite limb.
A. No solid food for 8 hours prior to
surgery and clear liquids until 2 hours
prior to surgery. Recent American Society
of Anesthesiologists guidelines
recommend the following restrictions on
diet prior to surgery for pediatric patients:
8 hours for solid food, 6 hours for formula,
4 hours for breast milk, and 2 hours for
clear liquids. These changes have resulted
in decreased numbers of canceled cases
and pediatric patients who are less irritable
preoperatively and less dehydrated at the
time of anesthesia induction.

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A 5-year-old white male has an itchy


lesion on his right foot. He often plays
barefoot in a city park that is subject to
frequent flooding. The lesion is located
dorsally between the web of his right third
and fourth toes, and extends toward the
ankle. It measures approximately 3 cm in
length, is erythematous, and has a
serpiginous track. The remainder of his
examination is within normal limits.
Which one of the following is the most
likely cause of these findings? (check one)
A. Dog or cat hookworm (Ancylostoma
species)
B. Dog or other canid tapeworm
(Echinococcus granulosus)
C. Cat protozoa (Toxoplasma gondii)
D. Dog or cat roundworm (Toxocara canis
or T. mystax)

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A. Dog or cat hookworm (Ancylostoma


species). This patient has cutaneous larva
migrans, a common condition caused by
dog and cat hookworms. Fecal matter
deposited on soil or sand may contain
hookworm eggs that hatch and release
larvae, which are infective if they
penetrate the skin. Walking barefoot on
contaminated ground can lead to infection.
Echinococcosis (hydatid disease) is caused
by the cestodes (tapeworms) Echinococcus
granulosus and Echinococcus
multilocularis, found in dogs and other
canids. It infects humans who ingest eggs
that are shed in the animals feces and
results in slow-growing cysts in the liver
or lungs, and occasionally in the brain,
bones, or heart. Toxoplasmosis is caused
by the protozoa Toxoplasma gondii, found
in cat feces. Humans can contract it from
litter boxes or feces-contaminated soil, or
by consuming infected undercooked meat.
It can be asymptomatic, or it may cause
cervical lymphadenopathy, a
mononucleosis-like illness; it can also lead
to a serious congenital infection if the
mother is infected during pregnancy,
especially during the first trimester.
Toxocariasis due to Toxocara canis and
Toxocara cati causes visceral or ocular
larva migrans in children who ingest soil
contaminated with animal feces that
contains parasite eggs, often found in areas
such as playgrounds and sandboxes.

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A 6-month-old Hispanic female has had


itching and irritability for 4-5 weeks.
There is a family history of atopy and
asthma. Physical examination reveals an
excoriated dry rash bilaterally over the
antecubital and popliteal fossae, as well as
some involvement of the face. In addition
to maintenance therapy with an emollient,
which one of the following topical
medications would be appropriate first-line
treatment for flare-ups in this patient?
(check one)
A. A calcineurin inhibitor such as
pimecrolimus (Elidel)
B. An anesthetic
C. An antihistamine
D. An antibiotic
E. A corticosteroid

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E. A corticosteroid. This child has atopic


dermatitis (eczema). It is manifested by a
pruritic rash on the face and/or extensor
surfaces of the arms and/or legs, especially
in children. There often is a family history
of atopy or allergies. In addition to the
regular use of emollients, the mainstay of
maintenance therapy, topical
corticosteroids have been shown to be the
best first-line treatment for flare-ups of
atopic dermatitis. Topical calcineurin
inhibitors should be second-line treatment
for flare-ups, but are not recommended for
use in children under 2 years of age.
Antibiotics should be reserved for the
treatment of acutely infected lesions.
There is no evidence to support the use of
topical anesthetics or analgesics in the
treatment of this disorder.

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A 6-month-old white male is brought to


your office because he has "blisters" in his
diaper area. On examination, you find
large bullae filled with cloudy yellow
fluid. Some of the blisters have ruptured
and the bases are covered with a thin crust.
Which one of the following is most
appropriate in the management of this
condition? (check one)
A. Rinsing diapers with a vinegar solution
B. A topical antifungal agent
C. Penicillin
D. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)

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D. Trimethoprim/sulfamethoxazole
(Bactrim, Septra). Bullous impetigo is a
localized skin infection characterized by
large bullae; it is caused by phage group II
Staphylococcus aureus. Cultures of fluid
from an intact blister will reveal the
causative agent. The lesions are caused by
exfolatin, a local toxin produced by the S.
aureus, and develop on intact skin.
Complications are rare, but cellulitis
occurs in <10% of cases. Strains of
Staphylococcus associated with impetigo
in the U.S. have little or no nephritogenic
potential.
Systemic therapy should be used in
patients with widespread lesions. With the
emergence of MRSA,
trimethoprim/sulfamethoxazole and
clindamycin are options for outpatient
therapy. Intravenous vancomycin can be
used to treat hospitalized patients with
more severe infections.

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A 6-year-old male is brought in for


evaluation by his mother, who is
concerned that he may have asthma. She
reports that he coughs about 3 days out of
the week and has a nighttime cough
approximately 1 night per week. There is a
family history of eczema and allergic
rhinitis. Which one of the following would
be the preferred initial treatment for this
patient? (check one)
A. A leukotriene receptor antagonist such
as montelukast (Singulair)
B. A low-dose inhaled corticosteroid such
as budesonide (Pulmicort Turbuhaler)
C. A long-acting beta-agonist such as
salmeterol (Serevent)
D. A mast-cell stabilizer such as cromolyn
sodium (Intal)

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B. A low-dose inhaled corticosteroid such


as budesonide (Pulmicort Turbuhaler). The
National Asthma Education and
Prevention Program (NAEPP) updated its
recommendations for the treatment of
asthma in 2002. Treatment is based on
asthma classification. This child meets the
criteria for mild persistent asthma:
symptoms more than 2 times per week but
less than once a day, symptoms less than 2
nights per month, peak expiratory flow
(PEF) or FEV1 >80% of predicted, and a
PEF variability of 20%-30%. Asthma
controller medications are recommended
for all patients with persistent asthma, and
the preferred long-term controller
treatment in mild persistent asthma is a
low-dose inhaled corticosteroid.
Cromolyn, leukotriene modifiers,
nedocromil, and sustained-release
theophylline are alternatives, but are not
preferred initial agents. Quick-acting,
quick-relief agents such as short-acting
beta-agonists are appropriate for prompt
reversal of acute airflow obstruction.

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A 6-year-old white male visits your office


with chief complaints of a recent onset of
fever, bilateral knee and ankle pain,
colicky abdominal pain, and rash. On
examination, his temperature is 38.3
degrees C (101.0 degrees F), and there is a
prominent palpable reddish-brown rash on
the buttocks and thighs. There is pain on
motion of his knees and ankles, and mild
diffuse abdominal tenderness. The stool is
positive for occult blood. Laboratory
Findings Hemoglobin 11.0 g/dL (N 11.513.5) Hematocrit 33% (N 34-40) WBCs
14,500/mm3 (N 5500-15,000); 85% segs,
15% lymphs Platelets 345,000/mm3 (N
150,000-400,000) Prothrombin time 12 sec
(N 11-15) Which one of the following is
the most likely diagnosis? (check one)
A. Systemic onset juvenile rheumatoid
arthritis
B. Rocky Mountain spotted fever
C. Henoch-Schonlein purpura
D. Disseminated anthrax
E. Acute iron ingestion

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C. Henoch-Schonlein purpura. HenochSchonlein purpura typically follows an


upper respiratory tract infection, and
presents with low-grade fever, fatigue,
arthralgia, and colicky abdominal pain.
The hallmark of the disease is the rash,
which begins as pink maculopapules,
progresses to petechiae or purpura, which
are clinically palpable, and changes in
color from red to dusty brown before
fading. Arthritis, usually involving the
knees and ankles, is present in two-thirds
of cases, and gastrointestinal tract
involvement results in heme-positive
stools in 50% of cases. Laboratory
findings are not specific or diagnostic, and
include indications of mild to moderate
thrombocytosis, leukocytosis, and anemia,
and an elevated erythrocyte sedimentation
rate. Treatment is typically symptomatic
and supportive, although corticosteroids
are indicated in the rare patient with lifethreatening gastrointestinal or central
nervous system manifestations. Systemic
juvenile-onset rheumatoid arthritis usually
presents with an evanescent salmon-pink
rash. Rocky Mountain spotted fever does
not present with arthritis and the rash
begins distally on the legs. Iron ingestion
does not typically cause a rash, fever, or
arthritis. Disseminated anthrax does not
present with a rash and joint symptoms.

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A 7-year-old African-American male is


brought to your office with a 1-day history
of purulent, crusted eyelashes in the
morning, and red eye. There is no history
of visual change, foreign body, or injury.
The child is otherwise in good health and
has normal developmental milestones. No
fever or respiratory distress is noted. A
clinical diagnosis of bacterial
conjunctivitis is made. The mother is
anxious to keep the child in school. Which
one of the following would be the most
appropriate time for the child to return to
school? (check one)

A. Once treatment is started. Once therapy


is initiated, children with bacterial
conjunctivitis should be allowed to remain
in school. Careful hand hygiene is
important, however, and behavior must be
appropriate to maintain adequate hygiene.
No specific length of treatment or
evidence of clinical response is required
before returning to school. Reference:
Pickering LK (ed): Red Book: 2006
Report of the Committee on Infectious
Diseases, ed 27. American Academy of
Pediatrics, 2006, p 149.

A. Once treatment is started


B. When there is no crusting or drainage in
the morning
C. After 1 week of treatment
D. When the absence of fever for 24 hours
is documented
E. When there is resolution of conjunctival
erythema
A 7-year-old female is brought to your
clinic by her mother, who has concerns
about her behavior. For the last 2 months,
the patient has resisted going to school.
Each school morning she complains of not
feeling well and asks to stay home. When
forcibly taken to school she cries and begs
to go home. Once at home she is playful
and engages in normal activities. She also
resists attending her usual swimming
lessons in the evenings. She has frequent
nightmares in which one of her parents
dies.
After a thorough history and physical
examination rule out an underlying
medical condition, you diagnose the
patient with: (check one)
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A. separation anxiety disorder. This patient


suffers from separation anxiety disorder,
which is unique to pediatric patients and is
characterized by excessive anxiety
regarding separation from the home or
from people the child is attached to, such
as family members or other caregivers.
The anxiety is beyond what is
developmentally appropriate for the child's
age. Patients may even suffer distress from
anticipation of the separation. Other
characteristics include persistent worry
about harm occurring to major attachment
figures, worry about an event that may
separate the patient from caregivers,
reluctance to attend school due to the
separation it implies, fear of being alone,
recurring nightmares with themes of
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A. separation anxiety disorder


B. generalized anxiety disorder
C. acute stress disorder
D. panic disorder with agoraphobia
E. social phobia

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separation, and physical complaints when


faced with separation. Children diagnosed
with separation anxiety disorder must be
under 18 years of age and have had
symptoms for at least 4 weeks.
Social phobia is a persistent fear of a
specific object or situation. Exposure to
the object provokes an immediate anxiety
response such as a panic attack. To meet
the criteria for social phobia, patients must
suffer symptoms for at least 6 months.
Generalized anxiety disorder is
characterized as excessive anxiety and
worry regarding a number of events or
activities. Physical symptoms include
restlessness, irritability, or sleep
disturbance. Symptoms must be present
for at least 6 months.
Acute stress disorder occurs after a
traumatic event that the individual
considers life threatening. Patients
experience dissociative symptoms,
flashbacks, and increased arousal.
Symptoms are present for at least 2 days,
with a maximum of 4 weeks. Beyond 4
weeks, a diagnosis of posttraumatic stress
disorder is made. Panic disorder with
agoraphobia is characterized by recurrent
panic attacks with a fear of being in
situations in which the patient cannot
escape or may be embarrassed by doing
so. Symptoms must be present for 1 month
for the diagnosis to be made (SOR C).

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A 7-year-old female with a history of


asthma is brought to your office for a
routine follow-up visit. She has a history
of exercise-induced asthma, but also has
had exacerbations in the past that were
unrelated to exercise. In the past month,
she has premedicated herself with
albuterol (Proventil, Ventolin) with a
spacer before recess 5 days/week as usual.
She has also needed her albuterol to treat
symptoms (wheezing and/or shortness of
breath) once or twice per week and had
one exacerbation requiring medical
treatment in the past year. She has had no
nighttime symptoms. Albuterol as needed
is her only medication.
After reinforcing asthma education, which
one of the following would be most
appropriate? (check one)
A. Referral to an asthma specialist
B. Addition of a low-dose inhaled
corticosteroid
C. Addition of a long-acting -agonist
D. Elimination of premedication with
albuterol, restricting use to an as-needed
basis
E. No changes to her regimen
A 7-year-old male complains of left
shoulder pain after a bicycle accident. The
neurovascular evaluation is normal. A
radiograph is shown in Figure 4.

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E. No changes to her regimen. This


patient's asthma is well-controlled
according to the 2007 NHLBI asthma
guidelines. The "rule of twos" is useful in
assessing asthma control: in children under
the age of 12, asthma is NOT wellcontrolled if they have had symptoms or
used a -agonist for symptom relief more
than twice per week, had two or more
nocturnal awakenings due to asthma
symptoms in the past month, or had two or
more exacerbations requiring systemic
corticosteroids in the past year. For
individuals over 12 years of age, there
must be more than two nocturnal
awakenings per month to classify their
asthma as not well controlled.
Exercise-induced asthma is considered
separately. A -agonist used as
premedication before exercise is not a
factor when assessing asthma control.
Since this patient does not exceed the rule
of twos, her asthma is categorized as wellcontrolled and no changes to her therapy
are indicated. Asthma education should be
reinforced at every visit.

...

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09/11/2014

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A 7-year-old male is hospitalized after


sustaining abdominal trauma in an
accident. The child is conscious. His pulse
rate is 150 beats/min, his systolic blood
pressure is palpated at 60 mm Hg, and his
respiratory rate is 40/min. His hemoglobin
level is 4.0 g/dL because of trauma-related
blood loss. His clinical condition is
deteriorating despite an infusion of
intravenous volume expanders, but the
parents are Jehovah's Witnesses and refuse
to consent to a blood transfusion because
of their religious convictions. Your
prognosis is that without a blood
transfusion the patient will die. According
to medical-legal precedent, which one of
the following is correct? (check one)
A. The patient should receive the
transfusion regardless of the parents'
wishes
B. The patient can be transfused regardless
of the parents' wishes once he becomes
asystolic
C. The parents may refuse the transfusion
if they are in agreement
D. The parents may refuse the transfusion
if the patient identifies himself as a
Jehovah's Witness
E. The parents may refuse the transfusion
if there is a legally executed advance
directive

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A. The patient should receive the


transfusion regardless of the parents'
wishes. The refusal to accept any medical
intervention, including life-saving blood
transfusions, has been well established for
adults who have the ability to definitively
communicate their wishes. Also, parents
have the power to give or withhold consent
to medical treatment on behalf of their
children. However, Western courts have
deemed that parents cannot refuse
emergency, life-saving treatment to
children based on these principles: (1) the
child's interests and those of the state
outweigh parental rights to refuse medical
treatment; (2) parental rights do not give
parents life and death authority over their
children; and (3) parents do not have an
absolute right to refuse medical treatment
for their children, if that refusal is regarded
as unreasonable.

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09/11/2014

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A 7-year-old male presents with a 3-day


history of sore throat, hoarseness, fever to
100 degrees (38 degrees C), and cough.
Examination reveals injection of his
tonsils, no exudates, and no abnormal
breath sounds. Which one of the following
would be most appropriate? (check one)
A. Recommend symptomatic treatment
B. Perform a rapid antigen test for
streptococcal pharyngitis
C. Treat empirically for streptococcal
pharyngitis
D. Perform a throat culture for
streptococcal pharyngitis
E. Perform an office test for
mononucleosis

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A. Recommend symptomatic treatment.


Pharyngitis is a common complaint, and
usually has a viral cause. The key factors
in diagnosing streptococcal pharyngitis are
a fever over 100.4 degrees F, tonsillar
exudates, anterior cervical
lymphadenopathy, and absence of cough.
Age plays a role also, with those <15 years
of age more likely to have streptococcal
infection, and those 10-25 years of age
more likely to have mononucleosis. The
scenario described is consistent with a
viral infection, with no risk factors to
make streptococcal infection likely;
therefore, this patient should be offered
symptomatic treatment for likely viral
infection. Testing for other infections is
not indicated unless the patient worsens or
does not improve.

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09/11/2014

Primary Care -- AAFP flashcards | Quizlet

A 7-year-old male presents with a fever of


38.5C (101.3F), a sore throat, tonsillar
inflammation, and tender anterior cervical
adenopathy. He does not have a cough or a
runny nose. His younger sister was treated
for streptococcal pharyngitis last week and
his mother would like him to be treated for
streptococcal infection.
Which one of the following is true
concerning this situation?
(check one)
A. Empiric antibiotic treatment for
streptococcal pharyngitis is warranted.
B. The chance of this patient having a
positive rapid antigen detection test for
Streptococcus is <50%.
C. There is a generalized consensus among
the various national guidelines for
management of pharyngitis.
D. The patient should have a tonsillectomy
when he recovers from this infection.
E. The family dog should be treated for
streptococcal infection.

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A. Empiric antibiotic treatment for


streptococcal pharyngitis is warranted..
The patient has a score of 5 under the
Modified Centor scoring system for
management of sore throat. Patients with a
score 4 are at highest risk (at least 50%)
of having group A -hemolytic
streptococcal (GABHS) pharyngitis, and
empiric treatment with antibiotics is
warranted. Various national and
international organizations disagree about
the best way to manage pharyngitis, with
no consensus as to when or how to test for
GABHS and who should receive
treatment. The minimal benefit seen with
tonsillectomy in reducing the incidence of
recurrent GABHS pharyngitis does not
justify the risks or cost of surgery.
Treatment of pets for the prevention of
GABHS infection has proven ineffective.

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09/11/2014

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A 7-year-old male with recurrent sinusitis


has difficulty breathing through his nose.
He has had chronic diarrhea and his weight
is at the 5th percentile. Nasal polyps are
noted on examination, in the form of
grayish pale masses in both nares. No
nasal purulence or odor is present. Which
one of the following tests should you
order? (check one)
A. A serum angiotensin-converting
enzyme level
B. A serum alpha1-antitrypsin level
C. A serum ceruloplasmin level
D. An erythrocyte sedimentation rate
E. A sweat chloride test

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E. A sweat chloride test. This child has


chronic diarrhea, recurrent sinusitis, and
nasal polyps, and is underweight. Nasal
polyps tend to occur more often in adult
males, with the prevalence increasing in
both sexes after age 50. Any child 12 years
or younger who presents with nasal polyps
should be suspected of having cystic
fibrosis until proven otherwise. A sweat
chloride test, along with a history and
clinical examination, is necessary to
evaluate this possibility. Nasal polyps are
found in 1% of the normal population, but
a full 18% of those with cystic fibrosis are
afflicted. There is no association of polyps
with Wilson's disease, sarcoidosis, or
emphysema, so serum ceruloplasmin,
angiotensin-converting enzyme, and
alpha1-antitrypsin levels would not be
useful. An erythrocyte sedimentation rate
likewise would yield limited information.

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09/11/2014

Primary Care -- AAFP flashcards | Quizlet

An 8-year-old female is brought to your


office because she has begun to limp. She
has had a fever of 38.8C (101.8F) and
says that it hurts to bear weight on her
right leg. She has no history of trauma.
On examination, she walks with an
antalgic gait and hesitates to bear weight
on the leg. Range of motion of the right
hip is limited in all directions and is
painful. Her sacroiliac joint is not tender,
and the psoas sign is negative. Laboratory
testing reveals an erythrocyte
sedimentation rate of 55 mm/hr (N 0-10), a
WBC count of 15,500/mm 3 (N 450013,500), and a C-reactiveprotein level of
2.5 mg/dL (N 0.5-1.0).
Which one of the following will provide
the most useful diagnostic information to
further evaluate this patient's problem?
(check one)
A. MRI
B. CT
C. A bone scan
D. Ultrasonography
E. Plain-film radiography

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D. Ultrasonography. This child meets the


criteria for possible septic arthritis. In this
case ultrasonography is recommended
over other imaging procedures. It is highly
sensitive for detecting effusion of the hip
joint. If an effusion is present, urgent
ultrasound-guided aspiration should be
performed. Bone scintigraphy is excellent
for evaluating a limping child when the
history, physical examination, and
radiographic and sonographic findings fail
to localize the pathology. CT is indicated
when cortical bone must be visualized.
MRI provides excellent visualization of
joints, soft tissues, cartilage, and
medullary bone. It is especially useful for
confirming osteomyelitis, delineating the
extent of malignancies, identifying stress
fractures, and diagnosing early LeggCalv-Perthes disease. Plain film
radiography is often obtained as an initial
imaging modality in any child with a limp.
However, films may be normal in patients
with septic arthritis, providing a falsenegative result.

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09/11/2014

Primary Care -- AAFP flashcards | Quizlet

An 8-year-old female is brought to your


office with a 3-day history of bilateral
knee pain. She has had no associated upper
respiratory symptoms. On examination she
is afebrile. Her knees have full range of
motion and no effusion, but she has a
purpuric papular rash on both lower
extremities.
Which one of the following is the most
likely cause of her symptoms? (check one)
A. Henoch-Schnlein purpura
B. Rocky Mountain spotted fever
C. Juvenile rheumatoid arthritis
D. Lyme disease
E. Rheumatic fever

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A. Henoch-Schnlein purpura. The


combination of arthritis with a typical
palpable purpuric rash is consistent with a
diagnosis of Henoch-Schnlein purpura.
This most often occurs in children from 2
to 8 years old. Arthritis is present in about
two-thirds of those affected.
Gastrointestinal and renal involvement are
also common.
Rocky Mountain spotted fever presents
with a rash, but arthralgias are not typical.
These patients are usually sick with a fever
and headache. Juvenile rheumatoid
arthritis is associated with a salmon-pink
maculopapular rash, but not purpura. The
rash associated with Lyme disease is
erythema migrans, which is a bull's-eye
lesion at the site of a tick bite. The rash
associated with rheumatic fever is
erythema marginatum, which is a pink,
raised, macular rash with sharply
demarcated borders.

151/879

09/11/2014

Primary Care -- AAFP flashcards | Quizlet

An 8-year-old male is brought to your


office for evaluation of recurrent
headaches. His mother explains that the
headaches occur at least twice a week and
often require him to miss school. The
patient says he sometimes feels nauseated
and that being in a dark room helps. His
mother states that she had migraines as a
child. The child's only other medical issue
is constipation. A head CT ordered by
another physician was negative.
Which one of the following would be best
for preventing these episodes? (check one)

D. Propranolol (Inderal). This patient most


likely is suffering from recurrent migraine
headaches; at the described frequency and
intensity, he meets the criteria for
prophylactic medication. Ibuprofen or
acetaminophen could still be used as
rescue medications, but a daily agent is
indicated and propranolol is the best
choice for this patient (SOR B).
Sumatriptan is not approved for children
under the age of 12 years. Carbamazepine
has significant side effects and requires
monitoring. Amitriptyline is a commonly
used agent, but it could worsen his
constipation.

A. Sumatriptan (Imitrex)
B. Ibuprofen
C. Carbamazepine (Tegretol)
D. Propranolol (Inderal)
E. Amitriptyline
An 8-year-old male presents to your office
2 days after returning from a trip to
Mexico with his family. He developed
watery, nonbloody diarrhea on the day of
departure. He has mild abdominal
cramping, but no fever or vomiting. His
mother had similar symptoms, which were
milder and resolved with over-the-counter
treatments.
Which one of the following would be most
appropriate to treat this patient's
condition?
(check one)
A. Metronidazole (Flagyl)
B. Ciprofloxacin (Cipro)
C. Azithromycin (Zithromax)
D. Mebendazole
E. Metoclopramide (Reglan)

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C. Azithromycin (Zithromax). Traveler's


diarrhea commonly occurs in travelers to
Mexico and developing countries. It is
usually caused by bacterial organisms such
as Escherichia coli, Campylobacter,
Shigella, and Salmonella. Viral and
parasitic organisms are less common
causes, unless the diarrhea persists for 2
weeks. Appropriate medications include
antidiarrheal agents such as loperamide,
bismuth subsalicylate, and antibiotics.
Fluoroquinolones are effective in adults,
but should not be used in an 8-year-old.
Azithromycin isgenerally effective and
safe in children. Metronidazole,
mebendazole, and metoclopramide would
not be likely to successfully treat bacterial
traveler's diarrhera.

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09/11/2014

Primary Care -- AAFP flashcards | Quizlet

An 8-year-old male presents with cervical


lymphadenitis. He has a kitten at home and
you are concerned about cat-scratch
disease. Which one of the following
antibiotics is most appropriate for
treatment of Bartonella henselae infection?
(check one)
A. Azithromycin (Zithromax)
B. Ceftriaxone (Rocephin)
C. Amoxicillin/clavulanate (Augmentin)
D. Doxycycline
E. Clindamycin (Cleocin)
An 8-year-old white male presents with a
4-day history of erythematous cheeks,
giving him a "slapped-cheek" appearance.
Examination of the extremities reveals a
mildly pruritic, reticulated, erythematous,
maculopapular rash (see Figure 1). He is
afebrile and no other constitutional
symptoms are present.

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A. Azithromycin (Zithromax).
Azithromycin has been shown to reduce
the duration of lymphadenopathy in catscratch disease (SOR B). Other antibiotics
that have been used include rifampin,
ciprofloxacin,
trimethoprim/sulfamethoxazole, and
gentamicin. Ceftriaxone,
amoxicillin/clavulanate, doxycycline, and
clindamycin are not effective in the
treatment of Bartonella infection.

...

153/879

09/11/2014

Primary Care -- AAFP flashcards | Quizlet

A 9-month-old male is brought to your


office by his mother because of concerns
about his eating. She states that he throws
tantrums while sitting in his high chair,
dumps food on the floor, and refuses to
eat. She has resorted to feeding him
cookies, crackers, and juice, which are all
he will eat. A complete physical
examination, including a growth chart of
weight, length, and head circumference, is
normal. Which one of the following would
be the most appropriate recommendation?
(check one)
A. Use disciplinary measures to force the
child to eat a healthy breakfast, lunch, and
dinner
B. Leave the child in the high chair until
he has eaten all of the healthy meal
presented
C. Play feeding games to encourage
consumption of healthy meals or snacks
D. Skip the next meal if the child refuses
to eat
E. Provide healthy foods for all meals and
snacks, and end the meal if the child
refuses to eat

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E. Provide healthy foods for all meals and


snacks, and end the meal if the child
refuses to eat. It is estimated that 3%-10%
of infants and toddlers refuse to eat
according to their caregivers. Unlike other
feeding problems such as colic, this
problem tends to persist without
intervention. It is recommended that
caregivers establish food rules, such as
healthy scheduled meals and snacks, and
apply them consistently. Parents should
control what, when, and where children
are being fed, whereas children should
control how much they eat at any given
time in accordance with physiologic
signals of hunger and fullness. No food or
drinks other than water should be offered
between meals or snacks. Food should not
be offered as a reward or present. Parents
can be reassured that a normal child will
learn to eat enough to prevent starvation. If
malnutrition does occur, a search for a
physical or mental abnormality should be
sought.

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09/11/2014

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A 9-month-old male is seen for a routine


well-baby examination. There have been
no health problems and developmental
milestones are normal. Review of the
growth chart shows that length, weight,
and head circumference have continued to
remain at the 75th percentile. The
examination is normal with the exception
of the anterior fontanelle being closed.
Proper management at this time would
include: (check one)
A. A CT scan of the head
B. MRI of the head
C. A CBC, a metabolic profile, and thyroid
studies
D. Referral to a neurologist
E. Serial measurement of head
circumference

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E. Serial measurement of head


circumference. The anterior fontanelle in
the newborn is normally 0.6-3.6 cm, with
the mean size being 2.1 cm. It may
actually enlarge the first few months, but
the medial age of closure is 13.8 months.
The anterior fontanelle closes at 3 months
in 1% of cases, and by 1 year, 38% are
closed. While early closure of the anterior
fontanelle may be normal, the head
circumference must be carefully
monitored. The patient needs to be
monitored for craniosynostosis (premature
closure of one or more sutures) and for
abnormal brain development. When
craniosynostosis is suspected, a skull
radiograph is useful for initial evaluation.
If craniosynostosis is seen on the film, a
CT scan should be obtained.

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09/11/2014

Primary Care -- AAFP flashcards | Quizlet

A 9-month-old white male is brought to


your office for a well-child visit. You note
that the child's weight gain has been flat
over the last several months. He has fallen
from the 75th percentile to the 15th for
weight, and his percentile for length is
beginning to decline as well. The mother
states that the child began having diarrhea
as soon as she began giving him various
grain cereals and baby foods 5 months
ago. The remainder of a review of systems
and a social and family history is
unremarkable. Physical examination
reveals an undernourished infant with mild
abdominal distention. A check of the
infant's hemoglobin shows a microcytic
anemia with a low serum ferritin level.
Which one of the following is the most
likely diagnosis? (check one)

B. Celiac sprue. Celiac sprue is a condition


of acquired malabsorption that resolves
when the patient is exposed to a glutenfree diet. Gluten is a substance found in
wheat, rye, and barley, but not in corn or
rice products. Children with this sensitivity
will develop inflammation and destruction
of the microvilli in the small intestine as a
result of an immune response to gluten.
Patients with celiac sprue often present as
this child has, between 4 and 24 months of
age with impaired growth, diarrhea, and
abdominal distention. An iron deficiency
anemia can occur with impairment of iron
absorption from the small intestine. Lesser
cases of malabsorption are common, and
this condition often goes unrecognized into
adolescence or adulthood. Serologic tests,
and ultimately a biopsy of the small
intestine, can confirm the diagnosis.

A. Thalassemia minor
B. Celiac sprue
C. Cystic fibrosis
D. Congenital megacolon (Hirschsprung's
disease)
E. Inborn error of metabolism

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09/11/2014

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A 10-week-old term male infant is brought


to your office with a 2-day history of
difficulty breathing. He has been healthy
since birth, with the exception of a 3-day
episode of wheezing and rhinorrhea 3
weeks ago. Your initial examination shows
an alert infant with increased work of
breathing, rhinorrhea, and wheezing. His
oxygen saturation is 93% and his
temperature is 38.4C (101.1F).
Which one of the following would be most
appropriate at this point? (check one)
A. Antigen testing or another rapid assay
B. A baseline chest radiograph
C. A trial of nebulized albuterol
(AccuNeb)
D. Advising the parents that the child can
safely be returned to day care tomorrow

C. A trial of nebulized albuterol


(AccuNeb). The American Academy of
Pediatrics guideline on the diagnosis and
management of bronchiolitis recommends
against the use of laboratory or
radiographic studies to make the diagnosis,
although additional testing may be
appropriate if there is no improvement.
Bronchiolitis can be caused by a number
of different viruses, alone or in
combination, and the knowledge gained
from virologic testing rarely influences
management decisions or outcomes for the
vast majority of children.
While the guideline does not support
routine use of bronchodilators in the
management of bronchiolitis, it does allow
for a trial of bronchodilators as an option
in selected cases, and continuation of the
treatment if the patient shows objective
improvement in respiratory status.
Bronchodilators have not been shown to
affect the course of bronchiolitis with
respect to outcomes.
The guideline places considerable
emphasis on hygienic practices, including
the use of alcohol-based hand sanitizers
before and after contact with the patient or
inanimate objects in the immediate
vicinity. Education of the family about
hygienic practices is recommended as
well. Returning the child to day care the
next day is potentially harmful.

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09/11/2014

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An 11-year-old female has been diagnosed


with "functional abdominal pain" by a
pediatric gastroenterologist. Her mother
brings her to see you because of concerns
that another diagnosis may have been
overlooked despite a very thorough and
completely normal evaluation for organic
causes.
Which one of the following would you
recommend? (check one)
A. A trial of inpatient hospital admission
B. Increased testing and levels of referral
until a true diagnosis is reached
C. Removing the child from school and
activities whenever symptoms occur
D. Medications to eradicate symptoms
E. Stress reduction and participation in
usual activities as much as possible

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E. Stress reduction and participation in


usual activities as much as possible. The
diagnosis of functional abdominal pain is
made when no structural, infectious,
inflammatory, or biochemical cause for the
pain can be found. It is the most common
cause of recurrent abdominal pain in
children 4-16 years of age. The use of
medications may be helpful in reducing
(but rarely eradicating) functional
symptoms, and remaining open to the
possibility of a previously unrecognized
organic disorder is appropriate. However,
continuing to focus on organic causes,
invasive tests, or physician visits can
actually perpetuate a child's complaints
and distress.
It is estimated that approximately
30%-50% of children with functional
abdominal pain will have resolution of
their symptoms within 2 weeks of
diagnosis. Recommendations for
managing this problem include focusing
on participation in normal age-appropriate
activities, reducing stress and addressing
emotional distress, and teaching the family
to cope with the symptoms in a way that
prevents secondary gain on the part of the
child.

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09/11/2014

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A 12-month-old white female whom you


have seen regularly for all of her scheduled
well child care is found to have a
hemoglobin level of 9.0 g/dL (N for age
10.5-13.5). She started whole milk at 9
months of age. She appears healthy
otherwise and has no family history of
anemia. A CBC reveals a mild microcytic,
hypochromic anemia with RBC
poikilocytosis, but is otherwise normal.
The RBC distribution width is also
elevated.

D. prescribe oral iron. Iron deficiency is


almost certainly the diagnosis in this child.
The patient's response to a therapeutic trial
of iron would be most helpful in
establishing the diagnosis. Additional tests
might be necessary if there is no response.

Of the following, the most appropriate


next step would be to: (check one)
A. order tests for serum iron and total ironbinding capacity
B. order a serum ferritin level
C. order hemoglobin electrophoresis
D. prescribe oral iron
E. perform stool guaiac testing

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09/11/2014

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A 12-year-old female is brought to your


office with an 8-day history of sore throat
and fever, along with migratory aching
joint pain. She is otherwise healthy and
has no history of travel, tick exposure, or
prior systemic illness. A physical
examination is notable for exudative
pharyngitis; a blanching, sharply
demarcated macular rash over her trunk;
and a III/VI systolic ejection murmur.
Joint and neurologic examinations are
normal. A rapid strep test is positive and
her C-reactive protein level is elevated.
Of the following, the most likely diagnosis
is: (check one)
A. juvenile rheumatoid arthritis
B. infective endocarditis
C. Kawasaki syndrome
D. acute rheumatic fever
E. Lyme disease

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D. acute rheumatic fever. Acute rheumatic


fever is very common in developing
nations. It was previously rare in the U.S.,
but had a resurgence in the mid-1980s. It is
most common in children ages 5-15 years.
The diagnosis is based on the Jones
criteria. Two major criteria, or one major
criterion and two minor criteria, plus
evidence of a preceding streptococcal
infection, indicate a high probability of the
disease.
Major criteria include carditis, migratory
polyarthritis, erythema marginatum,
chorea, and subcutaneous nodules. Minor
criteria include fever, arthralgia, an
elevated erythrocyte sedimentation rate or
C-reactive protein (CRP) level, and a
prolonged pulse rate interval on EKG. The
differential diagnosis is extensive and
there is no single laboratory test to confirm
the diagnosis. This patient meets one
major criterion (erythema marginatum
rash) and three minor criteria (fever,
elevated CRP levels, and arthralgia).
Echocardiography should be performed if
the patient has cardiac symptoms or an
abnormal cardiac examination, to rule out
rheumatic carditis.

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09/11/2014

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A 12-year-old Hispanic female develops


fever, knee pain with swelling, diffuse
abdominal pain, and a palpable purpuric
rash. A CBC and platelet count are normal.
Her long-term prognosis depends on the
severity of involvement of the: (check one)
A. gastrointestinal tract
B. heart
C. liver
D. kidneys
E. lungs

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D. kidneys. This patient has HenochSchnlein purpura. This condition is


associated with a palpable purpuric rash,
without thrombocytopenia. Other
diagnostic criteria include bowel angina
(diffuse abdominal pain or bowel
ischemia), age 20, renal involvement, and
a biopsy showing predominant
immunoglobulin A deposition. The longterm prognosis depends on the severity of
renal involvement. Almost all children
with Henoch-Schnlein purpura have a
spontaneous resolution, but 5% may
develop end-stage renal disease.
Therefore, patients with renal involvement
require careful monitoring (SOR A).

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09/11/2014

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A 12-year-old Hispanic female is brought


to your office because of the recent onset
of a white vaginal discharge. She is
otherwise asymptomatic and has never
menstruated. She denies sexual activity
and a general examination reveals no
abnormalities. You note the presence of
breast buds and scant pubic hair.
Microscopic examination of the vaginal
discharge shows sheets of vaginal
epithelial cells. Which one of the
following is most likely in this setting?
(check one)
A. Pinworm (Enterobius vermicularis)
infestation
B. Sexual abuse
C. Vaginal foreign body
D. Trichomoniasis
E. Physiologic secretions

A 12-year-old male is brought to your


office with an animal bite. After talking
with the patient, you learn that he was
bitten on his left hand as he attempted to
pet a stray cat a little over 24 hours ago.
He says that the bite was very painful, and
that it bled for a few minutes. His parents
cared for the bite by rinsing it and
covering it with a bandage. His chart
indicates that he received a tetanus shot
last year.
On examination, the patient is afebrile
with stable vital signs. The site is warm
and tender to light palpation, with
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E. Physiologic secretions. This child is


entering puberty. In the 6- to 12-month
period before menarche, girls often
develop a physiologic vaginal discharge
secondary to the increase in circulating
estrogens. The gray-white discharge is
non-irritating. When physiologic discharge
is examined with the microscope, sheets of
vaginal epithelial cells are seen. The only
treatment necessary is reassurance of both
parents and child that this is a normal
process that will subside with time. The
other conditions listed are pathologic and
have other associated symptoms and
findings not seen in this case. Pinworms
normally cause perianal and vulvar
pruritus and irritation. The findings in
sexual abuse range from an inflamed
vulvovaginal area, to evidence of sexually
transmitted diseases, to evidence of local
trauma. Trichomoniasis would cause
vulvovaginal irritation and microscopic
examination of the discharge would show
Trichomonas organisms. A vaginal foreign
body would usually present with a foul
and/or bloody vaginal discharge.
D. Pasteurella multocida. Pasteurella
species are isolated from up to 50% of dog
bite wounds and up to 75% of cat bite
wounds, and the hand is considered a highrisk area for infection (SOR A). Although
much more rare, Capnocytophaga
canimorsus, a fastidious gram-negative
rod, can cause bacteremia and fatal sepsis
after animal bites, especially in asplenic
patients or those with underlying hepatic
disease. Anaerobes isolated from dog and
cat bite wounds include Bacteroides,
Fusobacterium, Porphyromonas,
Prevotella, Propionibacterium and
Peptostreptococcus.
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surrounding erythema measuring


approximately 3 cm in diameter.
Which one of the following is the most
likely infectious agent in this situation?
(check one)
A. Candida albicans
B. Capnocytophaga canimorsus
C. Methicillin-resistant Staphylococcus
aureus (MRSA)
D. Pasteurella multocida
E. Streptococcus pneumoniae

In addition to animal oral flora, human


skin flora are also important pathogens,
but are less commonly isolated. These can
include streptococci and staphylococci,
including methicillin-resistant
Staphylococcus aureus (MRSA). Coverage
for MRSA may be especially important if
the patient has risk factors for colonization
with community-acquired MRSA. Pets can
also become colonized with MRSA and
transmit it via bites and scratches.
Cat bites that become infected with
Pasteurella multocida can be complicated
by cellulitis, which may form around the
wound within 24 hours and is often
accompanied by redness, tenderness, and
warmth. The use of prophylactic
antibiotics is associated with a statistically
significant reduction in the rate of
infection in hand bites (SOR A). If
infection develops and is left untreated, the
most common complications are
tenosynovitis and abscess formation;
however, local complications can include
septic arthritis and osteomyelitis. Fever,
regional adenopathy, and lymphangitis are
also seen.

A 12-year-old male middle-school wrestler


comes to your office complaining of a
recurrent painful rash on his arm. There
appear to be several dry vesicles. The most
likely diagnosis is which one of the
following? (check one)
A. Molluscum contagiosum
B. Human papillomavirus
C. Herpes gladiatorum
D. Tinea corporis
E. Mat burn
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C. Herpes gladiatorum. The most common


infection transmitted person-to-person in
wrestlers is herpes gladiatorum caused by
the herpes simplex virus. Molluscum
contagiosum causes keratinized plugs.
Human papillomavirus causes warts. Tinea
corporis is ringworm, which is manifested
by round to oval raised areas with central
clearing. Mat burn is an abrasion.

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A 12-year-old male presents with left hip


pain. He is overweight and recently started
playing tennis to lose weight. He says the
pain started gradually after his last tennis
game, but he does not recall any injury. He
is walking with a limp. On examination he
is afebrile and has limited internal rotation
of the left hip.
What is the most likely cause of the hip
pain? (check one)
A. Septic arthritis
B. Juvenile rheumatoid arthritis
C. Transient synovitis
D. Slipped capital femoral epiphysis
E. Legg-Calv-Perthes disease
A 12-year-old male uses a short-acting
bronchodilator three times per week to
control his asthma. Lately he has been
waking up about twice a week due to his
symptoms.
Which one of the following medications
would be most appropriate?
(check one)
A. Inhaled medium-dose corticosteroids
B. A scheduled short-acting bronchodilator
C. A scheduled long-acting bronchodilator
D. A leukotriene inhibitor

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D. Slipped capital femoral epiphysis.


Slipped capital femoral epiphysis is the
most common hip disorder in this patient's
age group. It usually occurs between the
ages of 8 and 15 and is more common in
boys and overweight or obese children. It
presents with limping and pain, and
limited internal rotation of the hip is noted
on physical examination.
Septic arthritis would typically present
with a fever. Juvenile rheumatoid arthritis,
transient synovitis, and Legg-CalvPerthes disease are more common in
younger children.

A. Inhaled medium-dose corticosteroids.


This patient has moderate persistent
asthma. Although many parents are
concerned about corticosteroid use in
children with open growth plates, inhaled
corticosteroids have not been proven to
prematurely close growth plates, and are
the most effective treatment with the least
side effects. Scheduled use of a shortacting
bronchodilator has been shown to cause
tachyphylaxis, and is not recommended.
The same is true for long-acting
bronchodilators. Leukotriene use may be
beneficial, but compared to those using
inhaled corticosteroids, patients using
leukotrienes are 65% more likely to have
an exacerbation requiring systemic
corticosteroids.

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A 12-year-old male who lives on a farm


presents with lesions on his toes (shown in
Figure 7). Which one of the following
items from the patient's history is relevant
to the diagnosis?
(check one)
A. Recent tooth extraction and gingival
surgery
B. A family history of systemic lupus
erythematosus
C. Recurrent fevers for the past 2 weeks
D. Exposure to cold temperatures
E. Vaccination of the sheep he is raising
for a 4-H project
A 12-year-old white male asthmatic has an
acute episode of wheezing. You diagnose
an acute asthma attack and prescribe an
inhaled 2-adrenergic agonist. After 2
hours of treatment, he continues to
experience wheezing and shortness of
breath.
Which one of the following is the most
appropriate addition to acute outpatient
management?
(check one)
A. Oral theophylline (Theo-Dur)
B. Oral corticosteroids
C. An oral -adrenergic agonist
D. Inhaled cromolyn (Intal)
E. Inhaled corticosteroids

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D. Exposure to cold temperatures. This


patient has pernio, or chilblains, which is a
localized inflammatory lesion of the skin,
usually found
in the extremities following exposure to
nonfreezing cold temperatures. It is
generally a benign condition,
and is not associated with any systemic
diseases. These lesions are red-purple
plaques with deep swelling,
and are accompanied by itching or
burning. They are not associated with
infections or connective tissue
disease.
B. Oral corticosteroids. The treatment of
choice for occasional acute symptoms of
asthma is an inhaled 2-adrenergic agonist
such as albuterol, terbutaline, or pirbuterol.
If symptoms do not respond to -agonists,
they should be treated with a short course
of systemic corticosteroids. Theophylline
has limited usefulness for treatment of
acute symptoms in patients with
intermittent asthma; it is a less potent
bronchodilator than subcutaneous or
inhaled adrenergic drugs, and therapeutic
serum concentrations can cause transient
adverse effects such as nausea and central
nervous system stimulation in patients
who have not been taking the drug
continuously. Cromolyn can decrease
airway hyperreactivity, but has no
bronchodilating activity and is useful only
for prophylaxis. Inhaled corticosteroids
should be used to suppress the symptoms
of chronic persistent 2 asthma. Oral 2selective agonists are less effective and
have a slower onset of action than the
same drugs given by inhalation.
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A 12-year-old white male is brought to


your office after accidentally cutting his
left hand with a pocketknife. On
examination you find a deep 2-cm
laceration at the base of the thenar
eminence. To test for motor injury to the
median nerve you would have the patient:
(check one)
A. Extend the thumb and fingers
B. Oppose the thumb and little finger
C. Flex the wrist
D. Abduct the thumb and index finger
A 13-year-old male is found to have
hypertrophic cardiomyopathy. His father
also had hypertrophic cardiomyopathy,
and died suddenly at age 38 following a
game of tennis. The boy's mother asks you
for advice regarding his condition. What
advice should you give her? (check one)
A. He may participate in noncontact sports
B. He should receive lifelong treatment
with beta-blockers
C. His condition usually decreases lifespan
D. His hypertrophy will regress with age
E. His siblings should undergo
echocardiography

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B. Oppose the thumb and little finger. The


ability to touch the tip of the thumb to the
tip of the little finger indicates normal
motor function of the median nerve. The
radial nerve controls extension of the
thumb and fingers. The median nerve
partially controls flexion of the wrist, but
the site of innervation is proximal to the
wound site at the base of the thumb.
Abduction of the thumb is a function of
the radial nerve. Finger abduction is a
function of the ulnar nerve.
E. His siblings should undergo
echocardiography. Hypertrophic
cardiomyopathy is an autosomal dominant
condition and close relatives of affected
individuals should be screened. The
hypertrophy usually stays the same or
worsens with age. This patient should not
participate in strenuous sports, even those
considered noncontact. Beta-blockers have
not been shown to alter the progress of the
disease. The mortality rate is believed to
be about 1%, with some series estimating
5%. Thus, in most cases lifespan is
normal.

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A 13-year-old white female reports a 6month history of intermittent abdominal


cramping, with each episode becoming
progressively worse. Based on her history,
there is no obvious relationship to eating,
voiding, or defecating. She reports that she
has not yet begun menstruating and is not
sexually active. Her weight has been
stable. She appears to be in mild emotional
distress about being "the last girl in her
class to have a period." She is in no
physical discomfort and her vital signs are
normal. Secondary sexual characteristics
appear to be developing normally. She is
in the 57th percentile for height and the
65th percentile for weight. A complete
physical examination confirms your
presumptive diagnosis. The therapeutic
procedure of choice would be: (check one)

C. Hymenotomy. The key to making a


diagnosis of imperforate hymen, aside
from the obvious finding on physical
examination, lies in the systematic
drawing of inferences. One can speculate
that this patient's recurrent crescendo
abdominal cramping represented six
menstrual sheddings, with no egress from
the body. Her delay in menarche, despite
normal growth parameters, offers another
clue that structural amenorrhea is present.
Amounts of retained blood vary among
patients; up to 3000 mL have been
reported. A large volume can accumulate
without causing any permanent damage,
and subsequent fertility is usually normal.
Hymenotomy will relieve the pressure, and
normal menses should ensue.

A. Appendectomy
B. Colonoscopy
C. Hymenotomy
D. Cystoscopy
E. Paracentesis

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A 14-year-old African-American female


presents for a routine evaluation. On
examination, you note a rubbery, welldefined, nontender breast mass
approximately 2 cm in diameter. The
patient denies any history of breast
tenderness, nipple discharge, or skin
changes. The most likely diagnosis is:
(check one)
A. Fibrocystic breast disease
B. Fibroadenoma
C. Benign breast cyst
D. Cystosarcoma phyllodes
E. Intraductal papilloma

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B. Fibroadenoma. Most breast masses in


adolescent girls are benign. Fibroadenoma
is the most common, accounting for
approximately two-thirds of all adolescent
breast masses. It is characterized by a slow
growing, nontender, rubbery, well-defined
mass, most commonly located in the
upper, outer quadrant. Size varies, and is
most commonly in the range of 2-3 cm.
Fibrocystic disease is found in older
adolescents and is characterized by
bilateral nodularity and cyclic tenderness.
Benign breast cysts are characterized by a
spongy, tender mass with symptoms
exacerbated by menses. Cysts are
frequently multiple, and spontaneous
regression occurs in 50% of patients.
Cystosarcoma phyllodes is a rare tumor
with malignant potential, although most
are benign. It presents as a firm, rubbery
mass that may enlarge rapidly. Skin
necrosis is usually associated with the
tumor. Intraductal papillomas are usually
benign but do have malignant potential.
They are commonly subareolar and are
associated with nipple discharge. These
tumors are rare in the adolescent
population.

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A 14-year-old female is brought to your


office by her mother because of a 3-month
history of irritability, hypersomnia, decline
in school performance, and lack of interest
in her previous extracurricular activities.
The mother is also your patient, and you
know that she has a history of depression
and has recently separated from her
husband. After an appropriate workup, you
diagnose depression in the daughter.
For initial therapy you recommend: (check
one)
A. amitriptyline
B. methylphenidate (Ritalin)
C. divalproex sodium (Depakote)
D. cognitive-behavioral therapy
A 14-year-old female is brought to your
office by her parents because of concerns
regarding her low food intake, excessive
exercise, and weight loss. Her weight is
less than 75% of ideal for her height.
Which one of the following sets of
additional findings would indicate that the
patient suffers from severe anorexia
nervosa?
(check one)

D. cognitive-behavioral therapy. This


patient has multiple risk factors for
depression: the hormonal changes of
puberty, a family history of depression,
and psychosocial stressors. Cognitivebehavioral therapy is effective in treating
mild to moderate depression in children
and adolescents (SOR A). SSRIs are an
adjunctive treatment reserved for treatment
of severe depression, and have limited
evidence for effectiveness in children and
adolescents.
Amitriptyline should not be used because
of its limited effectiveness and adverse
effects (SOR A). Methylphenidate is used
for treating attention deficit disorder, not
depression. Divalproex sodium is used to
treat bipolar disorder.
E. Hypotension, bradycardia, and
hypothermia. Characteristic vital signs in
patients with severe anorexia nervosa
include hypotension, bradycardia, and
hypothermia. Criteria for hospital
admission include a heart rate <40
beats/min, blood pressure <80/50 mm Hg,
and temperature <36C (97F). Increased
cardiac vagal hyperactivity is thought to
cause the bradycardia.

A. Hypertension, tachycardia, and


hyperthermia
B. Hypertension, tachycardia, and
hypothermia
C. Hypotension, tachycardia, and
hypothermia
D. Hypotension, bradycardia, and
hyperthermia
E. Hypotension, bradycardia, and
hypothermia

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A 14-year-old male is brought to your


office by his mother to establish care. The
patient has been diagnosed with asthma,
but has not been on any medications for
the past year. When questioned, he reports
that his asthmatic symptoms occur daily
and more than one night per week. On
examination, he is found to have a peak
expiratory flow of 75%. Based on these
findings, the most accurate classification
of this patient's asthma is: (check one)
A. Mild intermittent
B. Mild persistent
C. Moderate persistent
D. Severe persistent

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C. Moderate persistent. The National


Asthma Education and Prevention
Program (NAEPP) classifies asthma into
four categories. Mild intermittent asthma
is characterized by daytime symptoms
occurring no more than 2 days per week
and nighttime symptoms no more than 2
nights per month. The peak expiratory
flow (PEF) or forced expiratory volume in
1 second (FEV1) is 80% or more of
predicted. Mild persistent asthma is
characterized by daytime symptoms more
than 2 days per week, but less than once a
day, and nighttime symptoms more than 2
nights per month. PEF or FEV1 is 80% or
more of predicted. Moderate persistent
asthma is characterized by daytime
symptoms daily and nighttime symptoms
more than 1 night per week. PEF or FEV1
is 60%-80% of predicted. Severe persistent
asthma is characterized by continuous
daytime symptoms and frequent nighttime
symptoms. PEF or FEV1 is 60% or less of
predicted.

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A 15 and a half year-old female is brought


to your office by her mother. They are
concerned because she has not started her
periods. She has been healthy, and has
grown several inches in the last year. Her
height is now 152 cm (60 in) and she
weighs 44 kg (98 lb). She started to
develop breast buds about a year ago and
has scant pubic hair. She denies sexual
activity. The mother's menarche occurred
at age 15. Which one of the following is
true in this case? (check one)
A. The patient has delayed puberty and
should have her hormone levels evaluated
B. The patient will likely start her periods
within a year
C. Oral contraceptives will be needed to
trigger menarche
D. A pregnancy test should be performed
E. The daughter's age of menarche is
unrelated to her mother's age of menarche

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B. The patient will likely start her periods


within a year. The changes associated with
puberty occur in an orderly sequence over
a definite time frame. Any deviation from
this sequence or time frame should be
regarded as abnormal. In girls, pubertal
development typically requires 4.5 years.
Although generally the first sign of
puberty is accelerated growth, breast
budding is usually the first recognized
pubertal change, followed by the presence
of pubic hair, peak growth velocity, and
menarche. Girls must have adequate
nutrition and reach a critical body weight
and body fat percentage before menarche
occurs. There is a concordance in the age
of menarche in mother-daughter pairs and
between sisters. Delayed or interrupted
puberty is defined as failure to develop any
secondary sex characteristics by age 13, to
have menarche by age 16, or to have
menarche 5 or more years after the onset
of pubertal development.

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A 15-month-old male is brought to the


emergency department following a
generalized tonic-clonic seizure at home.
The parents report that the seizure lasted 5
minutes, with confusion for the next 15
minutes. This is the child's first seizure.
There is no family history of seizures. His
medical history is normal except for a 1day history of a URI. While initially
lethargic in the emergency department, the
child is now awake and playful, with a
temperature of 39.5 degrees C (103.2
degrees F) and a normal examination.
Appropriate diagnostic tests are
performed, including a blood glucose
level, which is 96 mg/dL. Which one of
the following would be most appropriate
to administer at this point? (check one)

C. Acetaminophen orally. This child has


had a simple febrile seizure, the most
common seizure disorder of childhood.
Treatment includes finding a source for the
fever; this should include a lumbar
puncture if meningitis is suspected. The
most common infections associated with
febrile seizures include viral upper
respiratory infections, otitis media, and
roseola. Antipyretics are the first-line
treatment. Antibiotics are indicated only
for appropriate treatment of underlying
infections. Phenytoin and carbamazepine
are ineffective for febrile seizures.
Phenobarbital is sometimes used for
prevention of recurrent febrile seizures,
but is not indicated as an initial therapy.
Only 30%-50% of children with an initial
febrile seizure will have recurrent seizures.

A. Phenytoin (Dilantin) intravenously


B. Ceftriaxone (Rocephin) intravenously
C. Acetaminophen orally
D. Carbamazepine (Tegretol) orally
E. Phenobarbital orally

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A 15-month-old male is brought to your


office 3 hours after the onset of an
increased respiratory rate and wheezing.
He has an occasional cough and no
rhinorrhea. His immunizations are up to
date and he attends day care regularly. His
temperature is 38.2C (100.8F),
respiratory rate 42/min, and pulse rate 118
beats/min.
The child is sitting quietly on his mother's
lap. His oxygen saturation is 94% on room
air. On examination you note inspiratory
crackles in the left lower lung field. The
child appears to be well hydrated and the
remainder of the examination, including an
HEENT examination, is normal.
Nebulized albuterol (AccuNeb) is
administered and no improvement is
noted.
Which one of the following would be most
appropriate in the management of this
patient? (check one)

E. Oral high-dose amoxicillin (90


mg/kg/day), with close outpatient followup. The diagnosis of community-acquired
pneumonia is mostly based on the history
and physical examination. Pneumonia
should be suspected in any child with
fever, cyanosis, and any abnormal
respiratory finding in the history or
physical examination. Children under 2
years of age who are in day care are at
higher risk for developing communityacquired pneumonia. Laboratory tests are
rarely helpful in differentiating viral versus
bacterial etiologies and should not be
routinely performed. Outpatient antibiotics
are appropriate if the child does not have a
toxic appearance, hypoxemia, signs of
respiratory distress, or dehydration.
Streptococcus pneumoniae is one of the
most common etiologies in this age group,
and high-dose amoxicillin is the drug of
choice.

A. Laboratory evaluation
B. Inpatient monitoring, with no
antibiotics at this time
C. Hospitalization and intravenous
ceftriaxone (Rocephin)
D. Close outpatient follow-up, with no
antibiotics at this time
E. Oral high-dose amoxicillin (90
mg/kg/day), with close outpatient followup

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A 15-year-old African-American male


presents to the emergency department with
a chief complaint of fever, abdominal pain,
nausea, and anorexia. In addition to the
usual laboratory evaluation, which one of
the following imaging modalities would be
most helpful for confirming a diagnosis of
appendicitis? (check one)
A. Plain flat plate and upright radiographs
of the abdomen
B. An air contrast barium enema
C. Abdominal ultrasonography
D. A spiral CT scan of the abdomen
E. MRI of the abdomen

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D. A spiral CT scan of the abdomen. A


retrospective review of 650 patients with
suspected appendicitis showed a
sensitivity of 97% and a specificity of 98%
for spiral CT. In patients in whom the
clinical diagnosis was uncertain,
sensitivity was 92% and specificity was
85%. Two prospective studies comparing
ultrasonography with spiral CT have
favored spiral CT. Ultrasonography is used
in women who are pregnant and women in
whom there is a high degree of suspicion
of gynecologic disease. Abdominal
radiography has low specificity and
sensitivity for the diagnosis of acute
appendicitis. Air contrast barium enema
also has low accuracy. Limitations of MRI
include increased cost, decreased
availability, and increased examination
time compared to CT.

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A 15-year-old male presents for a routine


evaluation. He has no complaints. He has a
BMI of 30 kg/m2, which places him in the
97th percentile for his age. The remainder
of his examination is normal; however, a
random blood glucose level is 162 mg/dL.
Which one of the following would be the
most appropriate next step for this patient?
(check one)
A. Obtain a fasting blood glucose level
B. Start metformin (Glucophage), 500 mg
daily, and follow up in 4 weeks
C. Order a hemoglobin A1c level
D. Advise the patient to start a weight-loss
program and follow up in 4 weeks

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A. Obtain a fasting blood glucose level.


This patient should have further testing for
diabetes mellitus. Current
recommendations for diagnosing diabetes
mellitus are based on either a fasting
glucose level or a 2-hour 75-g oral glucose
tolerance test. A casual blood glucose level
>200 mg/dL is also diagnostic of diabetes
mellitus in patients with symptoms of
hyperglycemia. If unequivocal
hyperglycemia is not present, the diagnosis
must be confirmed by testing on another
day. Metformin can be used to treat
diabetes mellitus in adolescents, but it is
not recommended for prevention in this
age group. A diagnosis of diabetes mellitus
should be established prior to starting
metformin. Current recommendations for
treating adolescents with type 2 diabetes
mellitus include weight loss through
dietary modification and exercise.

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A 15-year-old white male is being


evaluated after a fall down one flight of
stairs. He was transported by the local
rescue squad with his cervical spine
immobilized. He walked briefly at the
scene and did not lose consciousness. His
only complaint is a mild, generalized
headache. One episode of vomiting
occurred shortly after the accident. No
weakness or numbness has been noted.
Vital signs, mental status, and neurologic
findings are normal. Radiologic evaluation
of the cervical spine is remarkable only for
an air-fluid level in the sphenoid sinus.
Which one of the following abnormalities
is most likely to be associated with this
radiologic finding? (check one)

A. A basilar skull fracture. A posttraumatic air-fluid level in the sphenoid


sinus is associated with basilar skull
fractures. This finding is frequently noted
on cervical spine films. Orbital floor
fractures may be associated with double
vision, fluid in the maxillary sinus, an airfluid level in the maxillary sinus, and
diplopia. Epidural hematomas are more
frequently associated with skull fractures
in the area of the meningeal artery.
Zygomatic arch fractures are more visible
on Towne's view. Characteristic swelling
and lateral orbital bruising are typically
present. Mandible fractures may be
associated with dental misalignment or
bleeding. Panoramic views are often
diagnostic.

A. A basilar skull fracture


B. An orbital floor fracture
C. An epidural hematoma
D. A zygomatic arch fracture
E. A mandible fracture
A 16-year-old female cross-country runner
has pain around both ankles. On
examination, pain is elicited on foot
inversion and there is decreased motion of
the hind foot and peroneal tightness. A
rigid flat foot also is observed.
Which one of the following is the most
likely diagnosis?
(check one)
A. Non-ossification of the os trigonum
B. Sever's apophysitis
C. Plantar fasciitis
D. Navicular stress fracture
E. Tarsal coalition
A 16-year-old high-school football player
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E. Tarsal coalition. Tarsal coalition is the


fusion of two or more tarsal bones. It
occurs in mid-to late adolescence and is
bilateral in 50% of those affected. Pain
occurs around the ankle, and there is
decreased range of motion of the hindfoot
and pain on foot inversion on examination.
Os trigonum results from non-ossification
of cartilage. It usually is unilateral and
causes palpable tenderness of the heel.
Sever's apophysitis is inflammation of the
calcaneal apophysis, and causes pain in the
heel. Plantar fasciitis causes tenderness
over the anteromedial heel. Navicular
stress fractures are tender over the
dorsomedial navicular.
C. Anterior cruciate ligament tear.
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plants his left foot to make a cut and feels


his left leg give way. He feels a pop in the
knee, followed by acute pain. He is
evaluated on the field, and examination
with the knee flexed 20 reveals that the
tibia can be displaced farther anteriorly
than with the uninvolved knee.
Which one of the following conditions is
most likely?
(check one)
A. Patellar tendon rupture
B. Posterior cruciate ligament tear
C. Anterior cruciate ligament tear
D. Tibial plateau fracture
E. Patellar dislocation

Anterior cruciate ligament (ACL) tears are


the most common ligament injury
requiring surgery. Females have a
significantly higher rate of ACL tears, with
the majority of tears in both men and
women occurring without physical contact.
In addition to the immediate problems,
there is a significant increase in premature
osteoarthritis of the knee. Approximately
50% of patients with this injury develop
osteoarthritis in 10-20 years. Findings that
help make the diagnosis of ACL tear
include a noncontact mechanism of injury,
an audible popping sound, early swelling
of the joint, and the inability to participate
in the game after the injury. Many patients
can walk normally and can perform such
straight-plane activities as climbing stairs,
biking, or jogging.
Physical examination using the Lachman
test or pivot shift test can be used to
further assess whether the ligament is torn.
MRI can be used to confirm the diagnosis,
although it is not needed if the diagnosis is
clear from the history and examination.
The other conditions listed are also sportsrelated knee injuries, but have different
mechanisms of injury or physical findings.
Patients with patellar tendon rupture are
unable to fully extend their knee and
examination shows a palpable defect in the
patellar ligament and a high-riding patella.
While the mechanism of injury in patients
with posterior cruciate ligament tears may
be similar to that of ACL injury, the
examination would show posterior rather
than anterior displacement of the tibia
when the knee is flexed at 90 (the
posterior drawer sign). The mechanism of
injury of tibial plateau fractures in a

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healthy young male generally involves a


highenergy collision causing a valgus
force with axial loading. Patients with
patellar dislocations have symptoms
similar to those of an ACL injury,
including an audible crack or pop and the
feeling of the knee giving way after a
twisting motion. Immediately following
the injury, however, examination would
show an obvious deformity, but the patella
may spontaneously relocate prior to the
on-field exam. There would be no
instability on the Lachman maneuver.
A 16-year-old male accompanied by his
mother presents to your outpatient clinic
with concerns about his short stature and
"boyish" looks. He is a sophomore in high
school but is frequently mistaken for
someone much younger. Radiographs
reveal a bone age of 14.7 years.
Which one of the following would suggest
the need for further evaluation?
(check one)
A. A family history of delayed growth
B. Height below the fifth percentile for age
C. Weight below the fifth percentile for
age
D. Prepubescent testicular size

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D. Prepubescent testicular size. Most cases


of short stature are due to constitutional
growth delay, a term which implies that
the child is normal but delayed in his
development. A hallmark of this condition
is being below the fifth percentile for
height for most of childhood. Usually
these children are thin and have a family
history of delayed development. Bone age
would be expected to be at least 2.5
standard deviations below the mean for
agematched peers of the same chronologic
age. However, most experts agree that if
no signs of puberty are seen by 14 years of
age (no breast development in girls, no
testicular enlargement in boys), then
further workup for a more serious
condition should be sought. Other
indications for evaluation would be no
menarche in a girl by 16 years of age and
underdeveloped genitalia in a boy 5 years
after his first pubertal changes.

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A 16-year-old male is brought to your


office by his mother for "stomachaches."
On review of systems, he also complains
of headaches, occasional bedwetting, and
trouble sleeping. His examination is within
normal limits. His mother says that he is
often in the nurse's office at school, and
doesn't seem to have any friends. After
some questions from you, he admits to
being called names and teased at school.
Which one of the following would be most
appropriate? (check one)
A. Explain that he must try to conform to
be more popular
B. Explain that these symptoms are a
stress reaction and will lessen with time
C. Explore whether his school counselor
has a process to address this problem
D. Order a TSH level

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C. Explore whether his school counselor


has a process to address this problem.
Childhood bullying has potentially serious
implications for bullies and their targets.
The target children are typically quiet and
sensitive, and may be perceived to be
weak and different. Children who say they
are being bullied must be believed and
reassured that they have done the right
thing in acknowledging the problem.
Parents should be advised to discuss the
situation with school personnel. Bullying
is extremely difficult to resolve.
Confronting bullies and expecting victims
to conform are not successful approaches.
The presenting symptoms are not
temporary, and in fact can progress to
serious issues such as suicide, substance
abuse, and victim-to-bully transformation.
These are not signs or symptoms of
thyroid disease. The Olweus Bullying
Program developed in Norway is a well
documented, effective program for
reducing bullying among elementary and
junior-high-school students by altering
social norms and by changing school
responses to bullying incidents, including
efforts to protect and support victims.
Students who have been bullied regularly
are most likely to carry weapons to school,
be in frequent fights, and eventually be
injured.

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A 16-year-old male is brought to your


office by his mother for "stomachaches."
On the review of systems he also
complains of headaches, occasional
bedwetting, and trouble sleeping. His
examination is within normal limits. His
mother says that he is often in the nurse's
office at school, and doesn't seem to have
any friends. When you discuss these
problems with him, he admits to being
teased and called names at school.
Which one of the following would be most
appropriate? (check one)
A. Explain that he must try to conform to
be more popular
B. Explain that these symptoms are a
stress reaction and will lessen with time
C. Explore whether his school counselor
has a process to address this problem
D. Order a TSH level

C. Explore whether his school counselor


has a process to address this problem.
Childhood bullying has potentially serious
implications for bullies and their targets.
The target children are typically quiet and
sensitive, and may be perceived to be
weak and different. Children who say they
are being bullied must be believed and
reassured that they have done the right
thing in acknowledging the problem.
Parents should be advised to discuss the
situation with school personnel.
Bullying is extremely difficult to resolve.
Confronting bullies and expecting victims
to conform are not successful approaches.
The presenting symptoms are not
temporary, and in fact can progress to
more serious problems such as suicide,
substance abuse, and victim-to-bully
transformation. These are not signs or
symptoms of thyroid disease.
The Olweus Bullying Prevention Program
developed in Norway is a well
documented, effective program for
reducing bullying among elementary and
middle-school students by altering social
norms and by changing school responses
to bullying incidents, including efforts to
protect and support victims. Students who
have been bullied regularly are more likely
to carry weapons to school, be in frequent
fights, and eventually be injured.

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A 16-year-old sexually active nulliparous


white female complains of pelvic pain and
vaginal discharge. On examination she is
found to have a temperature of 39.8
degrees C (102.0 degrees F), pain with
movement of the cervix, and tenderness
and a mass in the right adnexa. According
to CDC guidelines, which one of the
following treatments would be
appropriate? (check one)
A. Outpatient treatment with penicillin G
procaine (Wycillin) intramuscularly;
probenecid (Benemid) orally; plus
doxycycline (Vibramycin) orally for 14
days and reexamination in 3 days
B. Outpatient treatment with ceftriaxone
(Rocephin) intramuscularly; probenecid
orally; plus doxycycline twice a day for 14
days and reexamination in 1 week
C. Outpatient treatment with cefoxitin
(Mefoxin) intramuscularly; plus
doxycycline twice a day for 14 days and
reexamination in 10 days
D. Hospitalization for treatment with
cefoxitin intravenously and doxycycline
orally or intravenously, then doxycycline
orally twice a day to complete 14 days of
treatment

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D. Hospitalization for treatment with


cefoxitin intravenously and doxycycline
orally or intravenously, then doxycycline
orally twice a day to complete 14 days of
treatment. Patients with PID and tuboovarian abscess and high fever should be
hospitalized and treated for at least 24
hours with intravenous antibiotics.
Amoxicillin and penicillin G procaine are
no longer recommended because of the
increasing prevalence of penicillinaseproducing and chromosomally-mediated
resistant Neisseria gonorrhoeae. If
cefoxitin is used intramuscularly for
outpatient treatment, it should be
combined with probenecid. If ceftriaxone
is used for outpatient treatment,
probenecid is not required. Reexamination
should be done within 3 days of initiation
of therapy.

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A 16-year-old white male is seen for a


preparticipation sports examination. His
height is 183 cm (72 in), his weight is 64
kg (141 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
A 17-year-old female sees you for a
preparticipation evaluation. She has run 5
miles a day for the last 6 months, and has
lost 6 lb over the past 2 months. Her last
menstrual period was 3 months ago. Other
than the fact that she appears to be slightly
underweight, her examination is normal.
To fit the criteria for the female athlete
triad, she must have which one of the
following? (check one)
A. A formal diagnosis of an eating
disorder
B. Amenorrhea for 1 year
C. A Z-score on bone-density testing of
-2.5 or less
D. Withdrawal bleeding after progesterone
administration
E. A history of a stress fracture resulting
from minimal trauma

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D. Aortic insufficiency. This adolescent


has findings of Marfan syndrome. It is
associated with arachnodactly, arm span
greater than height, a high arched palate,
kyphosis, lenticular dislocation, mitral
valve prolapse, myopia, and pectus
excavatum. 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.
E. A history of a stress fracture resulting
from minimal trauma. The initial
definition of the female athlete triad was
amenorrhea, osteoporosis, and disordered
eating. The American College of Sports
Medicine modified this in 2007,
emphasizing that the triad components
occur on a continuum rather than as
individual pathologic conditions. The
definitions have therefore expanded.
Disordered eating is no longer defined as
the formal diagnosis of an eating disorder.
Energy availability,defined as dietary
energy intake minus exercise energy
expenditures, is now considered a risk
factor for the triad, as dietary restrictions
and substantial energy expenditures
disrupt pituitary and ovarian function.
Primary amenorrhea is defined as lack of
menstruation by age 15 in females with
secondary sex characteristics. Secondary
amenorrhea is the absence of three or more
menstrual cycles in a young woman
previously experiencing menses. For those
with secondary amenorrhea, a pregnancy
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test should be performed. If this is not


conclusive, a progesterone challenge test
may be performed. If there is withdrawal
bleeding, the cause would be anovulation.
Those who do not experience withdrawal
bleeding have hypothalamic amenorrhea,
and fit one criterion for the triad.
Athletes who have amenorrhea for 6
months, disordered eating, and/or a history
of a stress fracture resulting from minimal
trauma should have a bone density test.
Low bone mineral density for age is the
term used to describe at-risk female
athletes with a Z-score of -1 to -2.
Osteoporosis is defined as having clinical
risk factors for experiencing a fracture,
along with a Z-score <-2.
A 17-year-old soccer player presents for a
preparticipation examination. His family
history is significant for the sudden death
of his 12-year-old sister while playing
basketball, and for his mother and
maternal grandmother having recurrent
syncopal episodes.
His medical history and examination are
completely normal. Prior to approving his
participation in sports, which one of the
following is recommended? (check one)

A. A resting EKG. A family history of


sudden death and recurrent syncope is
highly suspicious for genetic long-QT
syndrome. It is best diagnosed with a
resting EKG that shows a QTc >460 msec
in females and >440 msec in males. This
syndrome especially places young people
at risk for sudden death. Management may
include -blockers, an implantable
cardioverter-defibrillator, and no
participation in competitive sports.

A. A resting EKG
B. A stress EKG
C. An echocardiogram
D. Pulmonary function testing
E. No further evaluation

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A 17-year-old white female at 20 weeks


gestation presents with a 2-day history of
painful vesicular lesions on her labia. This
is the first time she has ever had this
problem. Her last sexual contact was 10
days ago. She has also had a low-grade
fever, malaise, headache, and mild, diffuse
abdominal pain. On examination she has
vesicles and erythematous papules on the
labia bilaterally. A few firm, tender
inguinal nodes are also noted.
Which one of the following tests is most
sensitive for confirming the diagnosis?
(check one)
A. A Papanicolaou smear of the lesions
B. Amniocentesis
C. Serologic studies
D. Viral polymerase chain reaction (PCR)
testing
E. A Tzanck test

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D. Viral polymerase chain reaction (PCR)


testing. Diagnosis and appropriate
treatment of genital herpes during
pregnancy is particularly important
because of the high mortality in neonates
who contract herpes during delivery and
then develop disseminated infection. In
those who survive, there is a very high risk
of serious neurologic sequelae.
HSV is acquired by deposition of the virus
on a break in the skin or mucous
membranes during close physical contact
with an infected person. Neonatal infection
most commonly results from transmission
via the birth canal, although transplacental
transmission can occur. The risk of HSV
infection in the neonate is higher during an
episode of primary genital herpes than
during a recurrent episode.
DNA polymerase chain reaction testing is
95% sensitive as long as an ulcer is
present, and has a specificity of 90%. The
diagnosis is established by culturing the
virus from an infected lesion. A Tzanck
prep and Papanicolaou smear can detect
cellular changes, but both have low
sensitivity. Serologic diagnosis is mainly
an epidemiologic tool and has limited
clinical usefulness. Cultures of the virus by
amniocentesis have shown both falsepositive and false-negative results.

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A 17-year-old white female has a history


of anorexia nervosa, and weight loss has
recently been a problem. The patient is an
academically successful high-school
student who lives with her parents and a
younger sibling. Her BMI is 17.4 kg/m2 .
Her serum electrolyte levels and an EKG
are normal.

A. Family-based treatment. Family-based


treatment for the adolescent with anorexia
nervosa has been found to provide superior
results when compared with individual
adolescent-focused therapy (SOR B).
Antidepressants have not been successful.
They may be indicated for coexisting
conditions, but this is more common with
bulimia.

Which one of the following interventions


is most likely to be successful? (check
one)
A. Family-based treatment
B. Adolescent-focused individual therapy
C. Fluoxetine (Prozac)
D. Phenelzine (Nardil)
E. Desipramine (Norpramin)
A 17-year-old white female visits you for a
physical examination prior to entering
college. During the review of systems her
only complaint is cyclic lower abdominal
cramps around the onset of menstruation.
She reports that pain has been present to
some degree with most of her periods
since about 6 months after menarche. The
pain is often severe enough for her to miss
school. Each episode lasts 24-48 hours and
is somewhat relieved by rest and
acetaminophen. Her menstrual history is
otherwise normal. She denies ever being
sexually active and tells you that she has
received little empathy from her mother,
who had similar symptoms as an
adolescent that improved after her first
pregnancy. Pelvic and rectal examinations
are within normal limits. Which one of the
following management choices would be
appropriate at this time? (check one)
A. Referral for hysterosalpingography
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E. Naproxen sodium (Anaprox). The


patient's history is typical of primary
dysmenorrhea, defined as severe cramping
pain in the lower abdomen that occurs
during menses; it may also occur prior to
the onset of menses in the absence of
associated pelvic pathology. Although
many women complain of pain beginning
with the first cycle, symptoms usually
begin at the onset of ovulation around 6-12
months after menarche. Symptoms
typically last 48 hours or less, but
sometimes may last up to 72 hours. It is
common to find daughters with
dysmenorrhea whose mothers had the
same symptoms. Additionally, the
symptoms of primary dysmenorrhea often
resolve after the first pregnancy. In this
patient, who has no history suggesting an
emotional disorder, there is no need for
psychological counseling at this time.
Further evaluation could include
ultrasonography to rule out causes of
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B. Referral for psychological counseling


C. Danazol (Danocrine)
D. Acetaminophen/hydrocodone (Vicodin
HP)
E. Naproxen sodium (Anaprox)

dysmenorrhea such as uterine


leiomyomata, adnexal masses, and
endometrial polyps. However, a trial of
symptomatic therapy is most reasonable
before other invasive studies, such as a
laparoscopic examination or a
hysterosalpingogram, are ordered. It is not
reasonable to begin danazol without a
diagnosis of endometriosis, which is by
definition secondary dysmenorrhea. Since
neither inhibits prostaglandin synthetase,
acetaminophen (which she had already
tried without complete relief) combined
with a narcotic is not an appropriate
management strategy. Multiple placebocontrolled studies have shown that
NSAIDs such as naproxen, at the onset of
symptoms, provide significant relief of
primary dysmenorrhea compared to
placebo.

An 18-month-old white male has been


brought into your office multiple times
over the past year with a reported fever of
over 101 degrees F (38 degrees C). The
child's reported temperatures at home have
usually been higher than those measured at
the time of the office visit. The remainder
of the history is usually unremarkable. The
child has a sibling who is in good health,
but another sibling died several years ago
for unknown reasons. On two occasions
you diagnosed acute otitis media and acute
bronchitis. However, at most visits the
child has not had any abnormal physical
findings. Repeated laboratory studies have
been within normal limits, including
complete blood counts, erythrocyte
sedimentation rates, blood cultures, chest
radiographs, and urinalyses. Almost
always, the mother has reported little
reduction in fever with age-appropriate

C. The child is afebrile while staying at the


day-care center. This is a characteristic
presentation of factitious disorder by
proxy, or what is commonly known as
Munchausen syndrome by proxy. Warning
signs for this disorder include the episodes
of illness beginning only when the child is,
or has recently been, with the parent; the
parent taking the child to numerous
caregivers, resulting in multiple diagnostic
evaluations but neither cure nor definitive
diagnosis; the other parent (usually the
father) being notably uninvolved despite
the ostensible health crises; the parent not
being assured by normal test results and
continually advocating for painful or risky
diagnostic tests for the child; the child
persistently failing to tolerate or respond to
usual medical therapies; and another child
in the family having an unexplained illness
or childhood death.

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doses of acetaminophen or ibuprofen. At


the last office visit the child's temperature
was measured at 40.6 degrees C (105.1
degrees F). Although the examination was
once again unrevealing, it was decided to
hospitalize the child for close observation
and evaluation by an infectious disease
consultant. Closed-circuit television
observation in the hospital showed the
mother putting the thermometer into hot
water before a nurse came to record the
patient's temperature. During the
hospitalization you make a diagnosis.
Which one of the following is a strong
indicator of the suspected final diagnosis?
(check one)
A. The child has seen no other health-care
provider but you
B. Both parents have been involved with
each office visit
C. The child is afebrile while staying at the
day-care center
D. The parents have resisted having
painful or risky diagnostic tests performed
on the child

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An 18-year-old female basketball player


comes to your office the day after
sustaining an inversion injury to her ankle.
She says she treated the injury overnight
with rest, ice, compression, and elevation.
You examine her and diagnose a moderate
to severe lateral ankle sprain. In addition
to rehabilitative exercises, you advise
(check one)
A. a short-term cast
B. a posterior splint that allows no flexion
or extension
C. a semi-rigid stirrup brace (Air-Stirrup,
"Aircast")
D. an elastic bandage
E. no external brace or support
An 18-year-old male comes to your office
because of the recent onset of recurrent,
unpredictable episodes of palpitations,
sweating, dyspnea, gastrointestinal
distress, dizziness, and paresthesias. His
physical examination is unremarkable
except for moderate obesity. Laboratory
findings, including a CBC, blood
chemistry profile, and thyroid-stimulating
hormone (TSH) level, reveal no
abnormalities.
The most likely diagnosis is: (check one)
A. mitral valve prolapse
B. paroxysmal supraventricular
tachycardia
C. pheochromocytoma
D. generalized anxiety disorder
E. panic disorder
An 18-year-old male presents with a sore
throat, adenopathy, and fatigue. He has no
evidence of airway compromise. A
heterophil antibody test is positive for
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C. a semi-rigid stirrup brace (Air-Stirrup,


"Aircast"). In acute ankle sprains,
functional treatment with a semi-rigid
brace that allows flexion and axtension, or
a soft lace-up brace is recommended over
immobilization. Casting or posterior
splinting is no longer recommended.
Elastic bandaging does not offer the same
lateral and medial support. External ankle
support has been shown to improve
proprioception.

E. panic disorder. Panic disorder typically


presents with the symptoms described, in
late adolescence or early adulthood. The
attacks are sporadic and last 10-60
minutes. Generalized anxiety disorder is
more common, and common symptoms
include restlessness, fatigue, muscle
tension, irritability, difficulty
concentrating, and sleep disturbance.
Patients with mitral valve prolapse usually
have an abnormal cardiac examination.
Pheochromocytoma is associated with
headache and hypertension, and usually
occurs in thin patients. Paroxysmal
supraventricular tachycardia is usually not
associated with gastrointestinal distress or
paresthesias.

E. Avoidance of contact sports. Infectious


mononucleosis presents most commonly
with a sore throat, fatigue, myalgias, and
lymphadenopathy, and is most prevalent
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infectious mononucleosis.
Appropriate management includes which
one of the following? (check one)
A. A corticosteroid
B. An antihistamine
C. An antiviral agent
D. Strict bed rest
E. Avoidance of contact sports

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between 10 and 30 years of age. Both an


atypical lymphocytosis and a positive
heterophil antibody test support the
diagnosis, although false-negative
heterophil testing is common early in the
disease course. The cornerstone of
treatment for mononucleosis is supportive,
including hydration, NSAIDs, and throat
sprays or lozenges.
In general, corticosteroids do not have a
significant effect on the clinical course of
infectious mononucleosis, and they should
not be used routinely unless the patient has
evidence of acute airway obstruction.
Antihistamines are also not recommended
as routine treatment for mononucleosis.
The use of acyclovir has shown no
consistent or significant benefit, and
antiviral drugs are not recommended.
There is also no evidence to support bed
rest as an effective management strategy
for mononucleosis. Given the evidence
from other disease states, bed rest may
actually be harmful.
Although most patients will not have a
palpably enlarged spleen on examination,
it is likely that all, or nearly all, patients
with mononucleosis have splenomegaly.
This was demonstrated in a small study in
which 100% of patients hospitalized for
mononucleosis had an enlarged spleen by
ultrasound examination, whereas only 17%
of patients with splenomegaly have a
palpable spleen. Patients should be advised
to avoid contact- or collision-type
activities for 3-4 weeks because of the
increased risk of rupture.

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An 18-year-old male seen in your office is


found to be overweight and to have
acanthosis nigricans. Both of his parents
have a history of diabetes mellitus. His
fasting plasma glucose level is 111 mg/dL
(N <100). Which one of the following is
the correct diagnosis? (check one)
A. Prediabetes
B. Type 1 diabetes mellitus
C. Type 2 diabetes mellitus
D. Maturity-onset diabetes of the young

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A. Prediabetes. This patient has


prediabetes, which is defined as having a
fasting plasma glucose level of 101-125
mg/dL. These patients are at high risk for
developing diabetes mellitus later in life.
Prediabetes is associated with metabolic
syndrome, and weight loss, exercise, and
certain pharmacologic agents have been
shown to prevent or delay the subsequent
development of diabetes mellitus. Diabetes
mellitus is diagnosed in three ways:
symptoms of diabetes (polyuria,
polydipsia, unexplained weight loss) plus a
random plasma glucose level 200 mg/dL;
a fasting plasma glucose level 126
mg/dL; or a glucose level 200 mg/dL on
a 2-hour 75-g oral glucose tolerance test. It
is important to note that in the absence of
unequivocal hyperglycemia the diagnosis
must be confirmed by repeat testing on a
subsequent day. Once the diagnosis of
diabetes is confirmed, further testing is
needed to differentiate between type 1,
type 2, and maturity-onset diabetes of
youth.

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An 18-year-old primigravida at 38 weeks'


gestation complains of a headache. Her
blood pressure is 130/92 mm Hg. The fetal
heart rate is 140 beats/min. A urine
dipstick shows 2+ protein. Laboratory
Findings Hemoglobin 10.8 g/dL (N 12.016.0) Hematocrit 32.4% (N 36.0-46.0)
Platelets 110,000/mm3 (N 150,000400,000) WBCs 14,900/mm3 (N 400010,000) Creatinine 0.5 mg/dL (N 0.8-1.3)
AST (SGOT) 31 U/L (N 0-37) ALT
(SGPT) 60 U/L (N 0-65) LDH 240 U/L (N
100-190) Bilirubin 1.9 mg/dL (N 0.0-1.0)
A non stress test is reactive and the
amniotic fluid index is 9.4 (N 8.0-20.0).
The patient is admitted for further testing.
After 24 hours repeat testing shows the
following: Hemoglobin 9.8 g/dL
Hematocrit 30.2% Platelets 92,000/mm3
WBCs 15,200/mm3 Creatinine 0.6 mg/dL
AST (SGOT) 72 U/L ALT (SGPT) 98 U/L
LDH 620 U/L Bilirubin 2.4 mg/dL 24hour urine protein 2400 mg Which one of
the following would be the most
appropriate course of action at this point?
(check one)

D. Induction of labor with oxytocin


(Pitocin) if the cervix is favorable. This
patient has hemolysis, elevated liver
enzymes, and low platelets (HELLP)
syndrome and needs to be delivered. There
is no reason to delay delivery in a term
pregnancy. HELLP syndrome is a form of
severe preeclampsia. If the patient has a
favorable cervical examination, labor
induction with oxytocin is appropriate. If
the cervix is unfavorable, cesarean
delivery should be considered to expedite
delivery.

A. Continued monitoring, repeating the


24-hour urine collection, and repeating the
laboratory studies tomorrow
B. Immediate delivery by cesarean section
C. Discharge to home on bed rest, with
close follow-up
D. Induction of labor with oxytocin
(Pitocin) if the cervix is favorable

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An 18-year-old single white female at 30


weeks' gestation presents to the hospital
with uterine contractions 10 minutes apart.
Her previous pregnancy 18 months ago
resulted in a preterm birth at 29 weeks'
gestation. The most accurate test to
determine whether this patient will need
hospitalization and tocolysis would be:
(check one)
A. Serum corticotropin-releasing hormone
B. Maternal serum alpha-fetoprotein
C. Serum human chorionic gonadotropin
(hCG)
D. Salivary estriol concentration
E. Vaginal fetal fibronectin
An 18-year-old white female presents with
small, localized warts on the vulva and
lower vaginal mucosa. She wants to avoid
injections and surgical treatment if
possible. Which one of the following is an
acceptable topical agent for treating these
vaginal lesions? (check one)
A. Trichloroacetic acid
B. Podofilox gel (Condylox)
C. Imiquimod cream (Aldara)
D. Interferon
E. Podophyllin 25% solution in alcohol
(Podocon-25, Podofin)

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E. Vaginal fetal fibronectin. Of the


biochemical markers listed, the most
clinically useful test to differentiate
women who are at high risk for impending
preterm delivery from those who are not is
the fetal fibronectin in cervical or vaginal
secretions. In symptomatic women, this is
most accurate in predicting spontaneous
preterm delivery within 7-10 days. It is
less accurate in those who are
asymptomatic. If the fetal fibronectin is
negative, it may be possible to avoid
interventions such as hospitalization,
tocolysis, and corticosteroid
administration.
A. Trichloroacetic acid. Trichloroacetic
acid is acceptable for use on vaginal
mucosa. It is also acceptable for use when
pregnancy is a possibility. Professional
application is necessary. Podofilox and
podophyllin in alcohol are not safe for use
on mucosa. Imiquimod cream is also not
approved for mucosal use. Interferon
requires injection.

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A 19-year-old college freshman consults


you at the request of her cross-country
coach because she has not had a period in
2 of the last 3 months. She notes that her
current training regimen is much more
intense than in high school last year. She
has an appropriate body image and denies
caloric restriction. A pregnancy test at the
student health center was negative. On
examination she is lean and highly trained.
Her examination is otherwise normal.
Which one of the following would be the
most appropriate recommendation for this
patient?
(check one)
A. Estrogen supplementation
B. Cyclic oral contraceptive pills
C. Increased caloric intake
D. Bisphosphonate therapy
E. Discontinuation of elite-level athletics

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C. Increased caloric intake. This patient


has exercise-related oligomenorrhea, but
does not have the eating disorder that
characterizes the female athlete triad.
Menstrual problems in athletes do
correlate with bone density loss and
impaired recovery from exercise.
Additionally, menstrual irregularity of
varying severity is extremely common in
female distance runners, perhaps affecting
as many as 60%. Hormonal manipulation
has not been shown to affect bone density,
though it may produce withdrawal
bleeding. Bisphosphonate therapy has been
shown to be ineffective, and is not
recommended in women of child-bearing
age.
The main issue in well-nourished female
athletes seems to be that energy intake is
not increased to match energy
expenditures at high levels of training.
Unlike those with the female athlete triad,
there is little evidence that athletes without
eating disorders suffer substantial harm
from exercise-induced menstrual
problems. Ending an athletic career for this
reason alone is not justified.

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A 19-year-old college student comes to


your office with her mother. The mother
reports that her daughter has frequently
been observed engaging in binge eating
followed by induced vomiting. She has
also admitted to using laxatives to prevent
weight gain.
Which one of the following laboratory
abnormalities is most likely to be found in
this patient?
(check one)

A. Hypokalemia. The patient described is


likely suffering from bulimia. These
patients use vomiting, laxatives, or
diuretics to prevent weight gain after binge
eating. This often causes a loss of
potassium, leading to weakness, cardiac
arrhythmias, and respiratory difficulty.
The levels of other electrolytes are not as
dramatically affected.

A. Hypokalemia
B. Hypoglycemia
C. Hyponatremia
D. Hypercalcemia
E. Hypermagnesemia

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A 19-year-old college student comes to


your office with significant pain in his
right great toe that is making it difficult for
him to walk. He has never had this
problem before.
When you examine him you find increased
swelling with marked erythema and
seropurulent drainage and ulceration of the
medial nail fold. The toe is very tender to
touch, particularly when pressure is
applied to the tip of the toe. The most
appropriate initial management would be:
(check one)
A. oral antibiotics that cover common skin
flora, for 5-7 days
B. soaking the toe in warm, soapy water
for 10-20 minutes twice daily, followed by
application of a topical antibiotic, with a
return visit in 3-5 days
C. elevation of the nail with a wisp of
cotton
D. partial avulsion of the medial nail plate
and phenolization of the matrix at this visit
E. partial avulsion of both the medial and
lateral nail plates at this visit

A 19-year-old female high-school student


is brought to your office by a friend who is
concerned about the patient having cut her
wrists. The patient denies that she was
trying to kill herself, and states that she did
this because she "just got so angry" at her
boyfriend when she caught him sending a
text message to another woman. She
denies having a depressed mood or
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D. partial avulsion of the medial nail plate


and phenolization of the matrix at this
visit. This ingrown nail meets the criteria
for moderate severity: increased swelling,
seropurulent drainage, infection, and
ulceration of the nail fold. In these cases,
antibiotics before or after phenolization of
the matrix do not decrease healing time,
postoperative morbidity, or recurrence
rates (SOR B). A conservative approach,
elevating the nail edge with a wisp of
cotton or a gutter splint, is reasonable in
patients with a mild to moderate ingrown
toenail who do not have significant pain,
substantial erythema, or purulent drainage.
Either immediate partial nail avulsion
followed by phenolization, or direct
surgical excision of the nail matrix is
effective for the treatment of ingrown nails
(SOR B). Pretreatment with soaking and
antibiotics has not been demonstrated to
add therapeutic benefit or to speed
resolution. Several studies demonstrate
that once the ingrown portion of the nail is
removed and matricectomy is performed,
the localized infection will resolve without
the need for antibiotic therapy. Bilateral
partial matricectomy maintains the
functional role of the nail plate (although it
narrows the nail plate) and should be
considered in patients with a severe
ingrown toenail or to manage recurrences.
E. Psychotherapy. This patient displays
most of the criteria for borderline
personality disorder. This is a maladaptive
personality type that is present from a
young age, with a strong genetic
predisposition. It is estimated to be present
in 1% of the general population and
involves equal numbers of men and
women; women seek care more often,
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anhedonia, and blames her fluctuating


mood on everyone who "keeps abandoning
her," making her feel like she's "nothing."
She admits that she has difficulty
controlling her anger. Her sleep quality
and pattern appear normal, as does her
appetite. She denies hallucinations or
delusions. The wounds on her wrists
appear superficial and there is evidence of
previous cutting behavior on her forearms.
Her vital signs are stable.
Which one of the following would be most
beneficial for this patient? (check one)
A. Clonazepam (Klonopin)
B. Fluoxetine (Prozac)
C. Quetiapine (Seroquel)
D. Inpatient psychiatric admission
E. Psychotherapy

however, leading to a disproportionate


number of women being identified by
medical providers.
Borderline personality disorder is defined
by high emotional lability, intense anger,
unstable relationships, frantic efforts to
avoid a feeling of abandonment, and an
internal sense of emptiness. Nearly every
patient with this disorder engages in selfinjurious behavior (cutting, suicidal
gestures and attempts), and about 1 in 10
patients eventually succeeds in committing
suicide. However, 90% of patients
improve despite having made numerous
suicide threats. Suicidal gestures and
attempts peak when patients are in their
early 20s, but completed suicide is most
common after age 30 and usually occurs in
patients who fail to recover after many
attempts at treatment. In contrast, suicidal
actions such as impulsive overdoses or
superficial cutting, most often seen in
younger patients, do not usually carry a
high short-term risk, and serve to
communicate distress.
Inpatient hospitalization may be an
appropriate treatment option if the person
is experiencing extreme difficulties in
living and daily functioning, and
pharmacotherapy may offer a mild degree
of symptom relief. While these modalities
have a role in certain patients,
psychotherapy is considered the mainstay
of therapy, especially in a relatively stable
patient such as the one described.

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A 19-year-old female runner has a 1-week


history of constant groin pain. There is
limited hip motion on flexion and internal
rotation of the right hip. Radiographs of
the hip and pelvis are normal. Which one
of the following is the most likely
diagnosis? (check one)
A. Iliotibial band syndrome
B. Stress fracture of the right femoral neck
C. Osteitis pubis
D. Pelvic inflammatory disease

A 19-year-old white female presents for an


initial family planning evaluation.
Specifically, she is interested in oral
contraception. She is not presently
sexually active, but has a steady boyfriend.
She has no contraindications to oral
contraceptive use. She has mild acne
vulgaris. You discuss possible side effects
and benefits of combined oral
contraceptives, including improvement of
her acne. Which one of the following is
also associated with oral contraceptive
use? (check one)
A. Increased risk of ovarian cancer
B. Decreased risk of ovarian cysts
C. Increased risk for ectopic pregnancy
D. Increased incidence of dysmenorrhea

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B. Stress fracture of the right femoral


neck. Stress fractures of the femoral neck
are most commonly seen in military
recruits and runners. They present with
persistent groin pain, and limited hip
flexion and internal rotation. Radiographs
may be normal early. Iliotibial band
syndrome also occurs in runners and
presents with stinging pain over the lateral
femoral epicondyle. Osteitis pubis occurs
in distance runners and presents with pain
in the anterior pelvic area and tenderness
over the symphysis pubis. Pelvic
inflammatory disease is associated with
abdominal pain and fever.
B. Decreased risk of ovarian cysts.
Women who take combination oral
contraceptives have a reduced risk of both
ovarian and endometrial cancer. This
benefit is detectable within a year of use
and appears to persist for years after
discontinuation. Other benefits include a
reduction in dysfunctional uterine bleeding
and dysmenorrhea; a lower incidence of
ovarian cysts, ectopic pregnancy and
benign breast disease; and an increase in
hemoglobin concentration. Many women
also benefit from the convenience of
menstrual regularity. All combination oral
contraceptives raise sex hormone-binding
globulin and decrease free testosterone
concentrations, which can lead to
improvement in acne.

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A 19-year-old white male with a history of


fever, fatigue, weight loss, and mild
diarrhea of 2 months' duration is found to
have a palpable mass in the right lower
quadrant of the abdomen. The most likely
diagnosis is: (check one)
A. Crohn's disease (regional enteritis)
B. Ulcerative colitis
C. Amebic colitis
D. Diverticulitis
E. Lymphoma

A 20-month-old male presents with a


history of a fever up to 38.5C (101.3F),
pulling at both ears, drainage from his
right ear, and a poor appetite following
several days of nasal congestion. This is
his first episode of acute illness, and he has
no history of drug allergies.
The fever is confirmed on examination and
the child is found to be fussy but can be
distracted. He is eating adequately and
shows no signs of dehydration. Positive
findings include mild nasal congestion, a
purulent discharge from the right auditory
canal, and a red, bulging, immobile
tympanic membrane in the left auditory
canal.
Which one of the following would be firstline treatment for this patient? (check one)

A. Crohn's disease (regional enteritis).


When Crohn's disease affects primarily the
distal small intestine (regional enteritis), a
most characteristic clinical pattern
emerges. A young person, usually in the
second or third decade, will present with a
period of episodic abdominal pain, largely
postprandial and often periumbilical,
occasionally with low-grade fever and
mild diarrhea. Anorexia, nausea, and
vomiting may also be present. Weight loss
is frequent. Some patients may be aware of
tenderness in the right lower quadrant and
even of a palpable mass in that region.
C. Amoxicillin. This patient has acute
bilateral otitis media, with presumed
tympanic membrane perforation, and
qualifies by any criterion for treatment
with antibiotics. Amoxicillin, 80-90
mg/kg/day, should be the first-line
antibiotic for most children with acute
otitis media (SOR B). The other
medications listed are either ineffective
because of resistance (e.g., penicillin), are
second-line treatments (e.g.,
amoxicillin/clavulanate), or should be used
in patients with a penicillin allergy or in
other special situations.

A. Ceftriaxone (Rocephin)
B. Amoxicillin/clavulanate (Augmentin)
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Penicillin VK

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A 20-year-old college wrestler is seen for


an examination prior to the wrestling
season. He tells you that some friends have
told him he should start taking
dehydroepiandrosterone (DHEA), and he
asks for your advice.
Which one of the following is true about
the effects of this drug?
(check one)
A. It enhances performance but not muscle
strength
B. It enhances muscle strength but not
performance
C. It enhances both performance and
muscle strength
D. It does not enhance either performance
or muscle strength
A 20-year-old female is seen for follow-up
6 weeks after delivery. Her pregnancy was
complicated by preeclampsia. Her
examination is unremarkable. This patient
will be at increased risk for which one of
the following in midlife? (check one)
A. Breast cancer
B. Diabetes mellitus
C. Hypothyroidism
D. Kidney disease
E. Hypertension

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D. It does not enhance either performance


or muscle strength.
Dehydroepiandrosterone (DHEA) is illegal
under the Anabolic Steroid Control Act of
2004, and is prohibited by the NCAA and
the International Olympic Committee.
Like androstenedione, DHEA is a
precursor to testosterone, but neither of
these substances has been shown to
enhance either performance or strength. In
fact, they increase serum estrogen and
luteinizing hormone levels.

E. Hypertension. Preeclampsia affects as


many as 5% of first pregnancies and is
manifested as hypertension, proteinuria,
edema, and rapid weight gain after 20
weeks gestation. Very young mothers and
those over age 35 have a higher risk.
Patients who have had preeclampsia have
a fourfold increased risk of hypertension
and a twofold increased risk of ischemic
heart disease, stroke, and venous
thromboembolism. There does not appear
to be an association between preeclampsia
and cancer, breast cancer in particular.

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A 20-year-old female long-distance runner


presents with a 3-month history of
amenorrhea. A pregnancy test is negative,
and other blood work is normal. She has
no other medical problems and takes no
medications. With respect to her
amenorrhea, you advise her (check one)
A. to increase her caloric intake
B. that this is a normal response to training
C. to begin an estrogen-containing oral
contraceptive
D. to stop running

A 20-year-old female presents with a


sudden onset of fever, chills, and headache
of 2 days duration, and now has a pink
blanching rash. The rash covers most of
her body, including the palms of her hands
and the soles of her feet, but not including
her face. She recently returned from a
camping trip, but has had no recent contact
with anyone who has been ill. Which one
of the following would be the most
appropriate treatment for this patient's
symptoms? (check one)

A. to increase her caloric intake.


Amenorrhea is an indicator of inadequate
calorie intake, which may be related to
either reduced food consumption or
increased energy use. This is not a normal
response to training, and may be the first
indication of a potential developing
problem. Young athletes may develop a
combination of conditions, including
eating disorders, amenorrhea, and
osteoporosis (the female athlete triad).
Amenorrhea usually responds to increased
calorie intake or a decrease in exercise
intensity. It is not necessary for patients
such as this one to stop running entirely,
however.
A. Doxycycline, 100 mg twice daily for 10
days. This is a classic description of
rickettsial illness (in the United States this
would most likely be Rocky Mountain
Spotted Fever): a history of outdoor
activity, the sudden onset of fever, chills,
and rash on the palms of the hands and the
soles of the feet. Penicillin, cephalexin,
and azithromycin do not cover rickettsia.
Reassurance would be inappropriate
because this condition can be life
threatening and should always be treated.

A. Doxycycline, 100 mg twice daily for 10


days
B. Azithromycin (Zithromax), 500 mg
daily for 3 days
C. Cephalexin (Keflex), 500 mg twice
daily for 10 days
D. Penicillin VK, 500 mg twice daily for
10 days
E. Reassurance

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A 20-year-old male presents with a


complaint of pain in his right testis. The
onset of pain has been gradual and has
been associated with dysuria and urinary
frequency. The patient has no medical
problems and is sexually active. On
examination he has some swelling and
mild tenderness of the testis. The area
posterior to the testis is swollen and very
tender. He has a normal cremasteric reflex,
and the pain improves with elevation of
the testicle.
Which one of the following would be the
most appropriate management of this
patient?
(check one)
A. Surgical evaluation
B. Doppler ultrasonography
C. Ceftriaxone (Rocephin) and
doxycycline
D. Levofloxacin (Levaquin)
E. Ciprofloxacin (Cipro)

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C. Ceftriaxone (Rocephin) and


doxycycline. This patient has epididymitis.
In males 14-35 years of age, the most
common causes are Neisseria gonorrhoeae
and Chlamydia trachomatis. The
recommended treatment in this age group
is ceftriaxone, 250 mg intramuscularly,
and doxycycline, 100 mg twice daily for
10 days (SOR C). A single 1-g dose of
azithromycin may be substituted for
doxycycline. In those under age 14 or over
age 35, the infection is usually caused by
one of the common urinary tract
pathogens, and levofloxacin, 500 mg once
daily for 10 days, would be the appropriate
treatment (SOR C).
If there is concern about testicular torsion,
urgent surgical evaluation and
ultrasonography are appropriate. Testicular
torsion is most common between 12 and
18 years of age but can occur at any age. It
usually presents with an acute onset of
severe pain and typically does not have
associated urinary symptoms. On
examination there may be a high-riding
transversely oriented testis with an
abnormal cremasteric reflex and pain with
testicular evaluation. Color Doppler
ultrasonography will show a normalappearing testis with decreased blood
flow.

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A 20-year-old patient comes to the


emergency department complaining of
shortness of breath. On examination his
heart rate is 180 beats/min, and his blood
pressure is 122/68 mm Hg. An EKG
reveals a narrow complex tachycardia with
a regular rhythm.
Which one of the following would be the
most appropriate initial treatment? (check
one)

C. Adenosine (Adenocard). After vagal


maneuvers are attempted in a stable patient
with supraventricular tachycardia, the
patient should be given a 6-mg dose of
adenosine by rapid intravenous push. If
conversion does not occur, a 12-mg dose
should be given. This dose may be
repeated once. If the patient is unstable,
immediate synchronized cardioversion
should be administered.

A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion

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A 20-year-old single white female who is a


patient of yours was raped in her
apartment at 7:00 a.m. today. She is
brought to your office at 9:00 a.m. for
assessment and treatment. Despite having
occasional intercourse with her boyfriend,
she has never used any type of
contraceptive. They last had intercourse
approximately 1 week ago, and the
boyfriend has been out of town on
business since then. The patient has a
history of irregular periods, and her last
normal period was approximately 2 and a
half weeks ago. You note live sperm on a
wet mount. In addition to many other
issues that must be addressed at this visit,
the patient asks about emergency
contraception. Which one of the following
would be accurate advice to the patient
regarding this topic? (check one)
A. Emergency contraception does not
interfere with an established, postimplantation pregnancy
B. The estrogen/progestin combination
regimen appears to be more effective than
the levonorgestrel-only regimen
C. To be most effective, each dose of the
2-dose regimen should be administered at
least 72 hours apart
D. Fetal malformations have been reported
as a result of the unsuccessful use of the
high-dose emergency contraceptive
regimen

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A. Emergency contraception does not


interfere with an established, postimplantation pregnancy. An FDA
Advisory Committee has recommended
over-the-counter marketing of Plan B, an
emergency contraceptive package that
contains two 0.75-mg tablets of
levonorgestrel to be taken 12 hours apart.
Plan B is one of the two FDA-approved
products for this indication. The Preven
emergency contraceptive kit includes four
tablets, each containing 0.25 mg of
levonorgestrel and 50 g of ethinyl
estradiol; these are taken two at a time 12
hours apart. In a randomized, controlled
trial comparing the single versus combined
estrogen/progestin, the single-drug
regimen was shown to be more effective.
Pregnancy occurred in 11 of 976 women
(1.1%) given levonorgestrel alone, and in
31 of 979 (3.2%) given ethinyl estradiol
plus levonorgestrel. The proportion of
pregnancies prevented, compared to the
expected number without treatment, was
85% with levonorgestrel and 57% with the
combination. In both regimens, the interval
between individual doses is 12 hours. In
this case, emergency contraception may be
appropriate in the face of a possible
pregnancy from previous consensual
intercourse. Emergency contraception has
not been found to interfere with an
established post-implantation pregnancy.
Furthermore, no fetal malformations have
been reported as a result of the
unsuccessful use of high-dose oral
contraceptives for emergency
contraception.

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A 20-year-old white female presents with


painful and frequent urination that has had
a gradual onset over the past week. She
has never had a urinary tract infection.
There is no associated hematuria, flank
pain, suprapubic pain, or fever. She says
she has not noted any itching or vaginal
discharge. A midstream urine specimen
taken earlier in the week showed
significant pyuria but a culture was
reported as no growth. She has taken an
antibiotic for 2 days without relief. Her
only other medication is an oral
contraceptive agent. Which one of the
following is the most likely infectious
agent? (check one)
A. Escherichia coli
B. Chlamydia trachomatis
C. Candida albicans
D. Staphylococcus saprophyticus

B. Chlamydia trachomatis. Women who


present with symptoms of acute dysuria,
frequency, and pyuria do not always have
bacterial cystitis. In fact, up to 30% will
show either no growth or insignificant
bacterial growth on a midstream urine
culture. Most commonly these patients
represent cases of sexually transmitted
urethritis caused by Chlamydia
trachomatis, Neisseria gonorrhoeae, or
herpes simplex virus.
In this case, the gradual onset, absence of
hematuria, and week-long duration of
symptoms suggest a sexually transmitted
disease. A history of a new sexual partner
or a finding of mucopurulent cervicitis
would confirm the diagnosis. Empiric
treatment with a tetracycline and a search
for other sexually transmitted diseases
would then be indicated.
Another possible diagnosis is urinary tract
infection with Escherichia coli or
Staphylococcus species; however, the
onset of these infections is usually abrupt
and accompanied by other signs, such as
suprapubic pain or hematuria. Candida is
unlikely because there is no accompanying
discharge or itching, and the patient's
symptoms predate the use of antibiotics.

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A 20-year-old white male presents to your


office after a fall on an outstretched hand
while skateboarding. He has pain at the
anatomic snuffbox with no abrasion.
Radiographs are negative. Which one of
the following would be the most
appropriate management? (check one)
A. A long arm cast for 8 weeks
B. A thumb spica splint and follow-up
radiographs in 2 weeks
C. A sugar tong splint and follow-up
radiographs in 2 weeks
D. An Ace bandage and follow-up
radiographs in 2 weeks
E. An Ace bandage and follow-up in 2
weeks if the patient is still experiencing
pain

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B. A thumb spica splint and follow-up


radiographs in 2 weeks. This is a classic
presentation of a possible scaphoid
fracture. This fracture is important to
diagnose and treat appropriately because
of a high rate of non-union. If radiographs
are negative, the patient should be placed
in a thumb spica splint and have repeat
radiographs in 2 weeks, because initial
studies may be negative. An Ace bandage
or a sugar tong splint would be
inappropriate because they do not
immobilize the thumb. A long arm cast for
8 weeks would immobilize the thumb, but
could lead to loss of function, and may
overtreat the injury if it is not truly a
scaphoid fracture.

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A 21-year-old female complains of


bulging veins in her right shoulder region,
along with swelling and a "tingling"
sensation in her right arm that has
developed over the past 2 days. There
were no unusual events other than her
regular workouts with her swim team.
Ultrasonography confirms an upper
extremity deep-vein thrombosis of her
right axillary vein.
Which one of the following would be the
most appropriate treatment? (check one)
A. Intravenous heparin for 72 hours,
followed by oral warfarin (Coumadin) for
3 months
B. Low molecular weight heparin
(LMWH) subcutaneously for 5 days only
C. LMWH subcutaneously for at least 5
days, followed by oral warfarin for 3
months
D. LMWH subcutaneously for at least 5
days, followed by oral warfarin
indefinitely
E. Oral warfarin for 3 months

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C. LMWH subcutaneously for at least 5


days, followed by oral warfarin for 3
months. Upper extremity deep-vein
thrombosis (UE-DVT) accounts for 4% of
all cases of DVT. Catheter-related
thromboses make up the majority of these
cases. Occult cancer, use of oral
contraceptives, and inheritable
thrombophilia are other common
explanations. Another proposed risk factor
is the repetitive compression of the
axillary-subclavian vein in athletes or
laborers, which is the most likely cause of
this patient's UE-DVT.
Taken as a whole, UE-DVT is generally
associated with fewer venous
complications, including less chance for
thromboembolism, postphlebitic
syndrome, and recurrence compared to
lower-extremity deep-vein thrombosis
(LE-DVT). However, the rates of these
complications are still high enough that
most experts recommend treatment
identical to that of LE-DVT. Specifically,
heparin should be given for 5 days, and an
oral vitamin-K antagonist for at least 3
months.

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A 21-year-old married Hispanic female


who is using no method of contraception
presents to your office for evaluation of
vaginal spotting 6 weeks after her last
menstrual period. Her periods have
previously been regular. She has had one
previous episode of pelvic inflammatory
disease. A home pregnancy test is positive.
Which one of the following is true in this
situation? (check one)
A. Serum hCG levels should double every
2-3 days if the pregnancy is viable
B. Painless bleeding excludes the
diagnosis of ectopic pregnancy
C. Laparoscopy should be performed to
exclude ectopic pregnancy
D. A serum progesterone level >25 ng/mL
indicates that ectopic pregnancy is likely

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A. Serum hCG levels should double every


2-3 days if the pregnancy is viable. Early
diagnosis of ectopic pregnancy requires a
high index of suspicion. Risk factors
include previous ectopic pregnancy, tubal
sterilization, pelvic inflammatory disease,
IUD use, and in utero exposure to
diethylstilbestrol. The classic triad of
missed menses, pain, and bleeding may
not always be present. In early pregnancies
of less than 5 weeks' gestation, serial hCG
levels are helpful. Serum hCG levels
double every 1.4-2 days. In a healthy
pregnancy the level is expected to increase
by at least 66% in 48 hours. Combining
serial hCG levels with transvaginal
ultrasonography is the best combination
for evaluation of first-trimester problems.
Serum hCG levels correlate well with
sonographic landmarks. At 5 weeks'
gestation in a normal pregnancy, serum
hCG is >1000 mIU/mL and a gestational
sac can be visualized in the uterus. Serum
hCG is >2500 mIU/mL at 6 weeks and a
yolk sac can be seen within the gestational
sac. An hCG level of 5000 mIU/mL is
compatible with visualization of a fetal
pole. When the level is 17,000 mIU/mL,
cardiac activity can be detected.
Progesterone levels are also predictive of
fetal outcome. A single level of 25 ng/mL
or higher indicates a healthy pregnancy
and excludes ectopic pregnancy with a
sensitivity of 98%. If the level is <5
ng/mL, the pregnancy is nonviable.
Assessment of fetal well-being is difficult
if levels are in the intermediate range of 525 ng/mL.

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A 21-year-old primigravida at 28 weeks


gestation complains of the recent onset of
itching. On examination she has no
obvious rash. The pruritus started on her
palms and soles and spread to the rest of
her body. Laboratory evaluation reveals
elevated serum bile acids and mildly
elevated bilirubin and liver enzymes.
The most effective treatment for this
condition is:
(check one)

E. ursodiol (Actigall). This patient's


symptoms and laboratory values are most
consistent with intrahepatic cholestasis of
pregnancy. Ursodiol has been shown to be
highly effective in controlling the pruritus
and decreased liver function (SOR A) and
is safe for mother and fetus. Topical
antipruritics and oral antihistamines are
not very effective. Cholestyramine may be
effective in mild or moderate intrahepatic
cholestasis, but is less effective and safe
than ursodiol.

A. triamcinolone (Kenalog) cream


B. cholestyramine (Questran)
C. diphenhydramine (Benadryl)
D. doxylamine succinate
E. ursodiol (Actigall)
A 21-year-old sexually active female
presents with acute pelvic pain of several
days' duration. A pelvic examination
reveals right-sided tenderness and a
general fullness in that area. In addition to
laboratory testing, you decide to order an
imaging study.
Which one of the following is the best
choice at this time? (check one)
A. Transabdominal ultrasonography
B. Transvaginal ultrasonography
C. Contrast CT of the abdomen and pelvis
D. Hysteroscopy
E. Hysterosalpingography

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B. Transvaginal ultrasonography. The best


initial imaging study for acute pelvic pain
in women is transvaginal ultrasonography
(SOR C). This provides the greatest level
of detail regarding the uterus and adnexae,
superior to transcutaneous
ultrasonography. CT of the
abdomen/pelvis and
hysterosalpingography may be indicated
eventually in some patients with pelvic
pain, but they are not the initial studies of
choice. Hysteroscopy is not routinely used
in the evaluation of pelvic pain.

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A 22-year-old competitive cross-country


skier presents with a complaint of not
being able to perform as well as she
expects. She has been training hard, but
says she seems to get short of breath more
quickly than she should. She also coughs
frequently while exercising. A review of
systems is otherwise negative. Her family
history is negative for cardiac or
pulmonary diseases. Her physical
examination is completely normal, and
pulmonary function tests obtained before
and after bronchodilator use are normal.
After you discuss your findings with the
patient, she acknowledges that her
expectations may be too high, but can
think of no other cause for her problem.
Which one of the following would be the
next reasonable step? (check one)
A. An echocardiogram to look for
cardiomyopathy or valvular dysfunction
B. Counseling regarding competition
stress and athlete burnout syndrome
C. A sports medicine consultation to
evaluate her training regimen
D. A trial of inhaled albuterol (Proventil)
for exercise-induced bronchospasm

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D. A trial of inhaled albuterol (Proventil)


for exercise-induced bronchospasm.
Exercise-induced bronchoconstriction
(EIB) is a very common and
underdiagnosed condition in athletes. It is
defined as a 10% lowering of FEV1 when
challenged with exercise. The exercise
required to cause bronchoconstriction is 58 minutes at 80% of maximal oxygen
consumption. EIB is much more common
in high-ventilation sports, such as track
and cross-country skiing. It is also more
common in winter sports, because of the
inspiration of cold, dry air. In some studies
the incidence among cross-country skiers
is as high as 50%, and 40% of those who
have positive tests for bronchospasm are
unaware of the problem. A physical
examination, as well as pulmonary
function tests at rest and before and after
bronchodilators, will be normal unless
there is underlying asthma. Among
athletes with EIB, 10% will not have
asthma. Bronchoprovocative testing can be
ordered, but if it is not available a trial
with an albuterol inhaler is reasonable.
Cardiomyopathy or valvular dysfunction
not found during the physical examination
is possible, but much less likely.
Psychological stresses are also a possible
etiology, but should not receive undue
attention, especially when simple
questioning is not productive and more
likely diagnoses have not been ruled out.
Poor training methods are also possible,
but in a competitive athlete this is not the
most likely cause.

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09/11/2014

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A 22-year-old female presents with lower


right leg pain. She reports that it hurts
when she presses her shin. She has been
training for a marathon over the past 4
months and has increased her running
frequency and distance. She now runs
almost every day and is averaging
approximately 40 miles per week. She has
little pain while at rest, but the pain
intensifies with weight bearing and
ambulation. She initially thought the pain
was from shin splints, but it has intensified
this week and she has had to shorten her
usual running distances due to worsening
pain.
On examination you note tenderness to
palpation over the anterior aspect of her
mid-tibia. She also has trace edema
localized to the area of tenderness.
Which one of the following imaging
studies should be performed first? (check
one)
A. Plain radiographs
B. CT
C. MRI
D. Ultrasonography
E. Bone scintigraphy

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A. Plain radiographs. The findings in this


patient are consistent with a stress fracture.
Plain radiographs should be the initial
imaging modality because of availability
and low cost (SOR C). These are usually
negative initially, but are more likely to be
positive over time. If the initial films are
negative and the diagnosis is not urgently
needed, a second plain radiograph can be
performed in 2-3 weeks.
Although CT is useful for evaluation of
bone pathology, it is not commonly used
as even second-line imaging for stress
fractures, due to lower sensitivity and
higher radiation exposure than other
modalities. Triple-phase bone scintigraphy
has a high sensitivity and was previously
used as a second-line modality; however,
MRI has equal or better sensitivity than
scintigraphy and higher specificity. MRI is
now recommended as the second-line
imaging modality when plain radiographs
are negative and clinical suspicion of
stress fracture persists (SOR C).
Musculoskeletal ultrasonography has the
advantage of low cost with no radiation
exposure, but additional studies are needed
before it can be recommended as a
standard imaging modality.

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A 22-year-old male has acute low back


pain without paresthesias or other
neurologic signs. There is no lower
extremity weakness.
Which treatment has been shown to be of
most benefit initially? (check one)
A. Complete bed rest for 2 weeks
B. Bed rest plus local injection of
corticosteroids
C. A low-back strengthening program
D. Resumption of physical activity as
tolerated

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D. Resumption of physical activity as


tolerated. For patients who have acute
back pain without sciatic involvement, a
return to normal activities as tolerated has
been shown to be more beneficial than
either bed rest or a basic exercise program.
Bed rest for more than 2 or 3 days in
patients with acute low back pain is
ineffective and may be harmful. Patients
should be instructed to remain active.
Injections should be considered only if
conservative therapy fails.

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A 22-year-old male presents to your office


with a 2-hour history of a painful right
scrotal mass. The physical examination
raises concerns that the patient may have
testicular torsion. The imaging study of
choice would be (check one)
A. a plain film
B. color duplex Doppler ultrasonography
C. CT
D. MRI
E. a nuclear scan

B. color duplex Doppler ultrasonography.


The history and physical examination are
critical for making a diagnosis in patients
with scrotal pain. Transillumination may
also be performed as part of the clinical
assessment. If the diagnosis is uncertain,
ultrasonography with color Doppler
imaging has become the accepted standard
for evaluation of the acutely swollen
scrotum (SOR B). Ultrasonography alone
can confirm the diagnosis in a number of
conditions, such as hydrocele,
spermatocele, and varicocele. For other
conditions such as orchitis, carcinoma, or
torsion, color Doppler ultrasonography is
essential because it will show increased
flow in orchitis, normal or increased flow
in carcinoma, and decreased blood flow in
testicular torsion.
For testicular torsion, color Doppler
ultrasonography has a sensitivity of
86%-88% and a specificity of 90%-100%.
When testicular torsion is strongly
suspected, emergent surgical consultation
should be obtained before ultrasonography
is performed, because surgical exploration
as soon as possible is critical to salvaging
the testis and should not be delayed for
imaging unless the diagnosis is in doubt.
While radionuclide imaging would be
accurate for diagnosing testicular torsion,
it is not used for this purpose because of
time limits and lack of easy availability.
CT or MRI may be appropriate if
ultrasonography indicates a possibility of
carcinoma. Plain films are not useful in
assessing scrotal swelling or masses.

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A 22-year-old male with no previous


history of shoulder problems is injured in a
fall. He has immediate pain and is unable
to abduct his arm. You examine him and
order an MRI, which reveals an acute tear
of the rotator cuff. Which one of the
following is the best initial treatment for
this injury? (check one)
A. Observation without treatment for 1
month
B. Immobilization for 1 month
C. Physical therapy for 1 month
D. Corticosteroid injection
E. Surgical repair

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E. Surgical repair. An acute rupture of any


major tendon should be repaired as soon as
possible. Acute tears of the rotator cuff
should be repaired within 6 weeks of the
injury if possible (SOR C). Nonsurgical
management is not recommended for
active persons. Observing for an extended
period will likely lead to retraction of the
detached tendon, possible resorption of
tissue, and muscle atrophy.

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09/11/2014

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A 22-year-old white female comes to your


office complaining of dizziness. She was
in her usual good health until about 2
weeks before this visit, when she
developed a case of gastroenteritis that
other members of her family have also
had. Since that time she has been
lightheaded when standing, feels her heart
race, and gets headaches or blurred vision
if she does not sit or lie down. She has not
passed out but has been unable to work
due to these symptoms. She is otherwise
healthy and takes no regular medications.
A physical examination is normal except
for her heart rate, which rises from 72
beats/min when she is lying or sitting to
112 beats/min when she stands. Her blood
pressure remains unchanged with changes
of position. Routine laboratory tests and an
EKG are normal.
What is the most likely cause of this
patient's condition? (check one)
A. Myocarditis
B. A seizure disorder
C. Postural orthostatic tachycardia
syndrome (POTS)
D. Systemic lupus erythematosus
E. Somatization disorder

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C. Postural orthostatic tachycardia


syndrome (POTS). Postural orthostatic
tachycardia syndrome (POTS) is
manifested by a rise in heart rate >30
beats/min or by a heart rate >120
beats/min within 10 minutes of being in
the upright position. Symptoms usually
include position-dependent headaches,
abdominal pain, lightheadedness,
palpitations, sweating, and nausea. Most
patients will not actually pass out, but
some will if they are unable to lie down
quickly enough. This condition is most
prevalent in white females between the
ages of 15 and 50 years old. Often these
patients are hardworking, athletic, and
otherwise in good health.
There is a high clinical correlation
between POTS and chronic fatigue
syndrome. Although no single etiology for
POTS has been found, the condition is
thought to have a genetic predisposition, is
often incited after a prolonged viral illness,
and has a component of deconditioning.
The recommended initial management is
encouraging adequate fluid and salt intake,
followed by the initiation of regular
aerobic exercise combined with lowerextremity strength training, and then the
use of -blockers.

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A 23-month-old child is brought to your


office with a 2-day history of a fever to
102F (39C), cough, wheezing, and
mildly labored breathing. He has no prior
history of similar episodes and there is no
improvement with administration of an
aerosolized bronchodilator.
Which one of the following is now
indicated? (check one)
A. Bronchodilator aerosol treatment every
6 hours
B. Corticosteroids
C. An antibiotic
D. A decongestant
E. Supportive care only

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E. Supportive care only. This child has


typical findings of bronchiolitis. The initial
infection usually occurs by the age of 2
years. It is caused by respiratory syncytial
virus (RSV). Bronchodilator treatment
may be tried once and discontinued if there
is no improvement. Treatment usually
consists of supportive care only, including
oxygen and intravenous fluids if indicated
(SOR B). Corticosteroids, antibiotics, and
decongestants are of no benefit. RSV
infection may recur, since an infection
does not provide immunity. Up to 10% of
infected children will have wheezing past
age 5, and bronchiolitis may predispose
them to asthma.

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A 23-year-old female comes to your office


6 days after giving birth to her first child
by cesarean section. Her pregnancy was
complicated by preeclampsia. During the
history she reports brief crying spells,
irritability, poor sleep, and nervousness.
Her husband notes that "even the littlest
thing can set her off." She has a history of
major depression 2 years ago that resolved
with psychotherapy and SSRI treatment.
She and her husband are concerned that
she may be suffering from postpartum
depression.
Which one of the following is the greatest
risk factor for postpartum depression in
this patient? (check one)
A. Operative delivery
B. First pregnancy and delivery
C. Preeclampsia
D. A previous history of depression

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D. A previous history of depression. "Baby


blues" are differentiated from postpartum
depression by the severity and duration of
symptoms. Baby blues occur in 80% of
postpartum women and are associated with
mild dysfunction. They begin during the
first 2-3 days after delivery and resolve
within 10 days. Symptoms include brief
crying spells, irritability, poor sleep,
nervousness, and emotional reactivity. An
estimated 5%-7% of women develop a
postpartum major depression associated
with moderate to severe dysfunction
during the first 3 months post partum.
While women with baby blues are at risk
for progression to major depression, no
more than 8%-10% will progress to a
major postpartum depression.
A previous history of major depressive
disorder significantly increases the risk of
developing postpartum depression (RR =
4.5), and a prior episode of postpartum
depression is the strongest risk factor for
postpartum depression in subsequent
pregnancies. Prenatal and obstetric
complications and socioeconomic status
have not consistently been shown to be
risk factors. First pregnancy is also not a
significant risk factor.

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A 23-year-old female sees you with a


complaint of intermittent irregular
heartbeats that occur once every week or
two, but do not cause her to feel
lightheaded or fatigued. They last only a
few seconds and resolve spontaneously.
She has never passed out, had chest pain,
or had difficulty with exertion. She is
otherwise healthy, and a physical
examination is normal. Which one of the
following cardiac studies should be
ordered initially? (check one)
A. 24-hour ambulatory EKG monitoring
(Holter monitor)
B. 30-day continuous closed-loop event
recording
C. Echocardiography
D. An EKG
E. Electrophysiologic studies
A 23-year-old female with a history of
systemic lupus erythematosus presents
with a 48-hour history of vague left
precordial pain. Serum markers for acute
cardiac injury are normal. An EKG
performed in the emergency department is
shown in Figure 7.

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D. An EKG. The symptom of an increased


or abnormal sensation of one's heartbeat is
referred to as palpitations. This condition
is common to primary care, but is often
benign. Commonly, these sensations have
their basis in anxiety or panic. However,
about 50% of those who complain of
palpitations will be found to have a
diagnosable cardiac condition. It is
recommended to start the evaluation for
cardiac causes with an EKG, which will
assess the baseline rhythm and screen for
signs of chamber enlargement, previous
myocardial infarction, conduction
disturbances, and a prolonged QT interval.

...

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09/11/2014

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A 23-year-old gravida 1 para 0 at 36


weeks gestation presents to the office
complaining of ankle swelling and
headache for the past 2 days. She denies
any abdominal pain or visual disturbances.
On examination you note a fundal height
of 35 cm, a fetal heart rate of 140
beats/min, 2+ lower extremity edema, and
a blood pressure of 144/92 mm Hg. A
urine dipstick shows 1+ proteinuria. A
cervical examination reveals 2 cm dilation,
90% effacement, -1 station, and vertex
presentation.
Which one of the following is the most
appropriate next step in the management
of this patient? (check one)
A. Laboratory evaluation, fetal testing, and
24-hour urine for total protein
B. Ultrasonography to check for fetal
intrauterine growth restriction
C. Initiation of antihypertensive treatment
D. Immediate induction of labor
E. Immediate cesarean delivery

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A. Laboratory evaluation, fetal testing, and


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

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A 23-year-old gravida 3 para 1 at 28


weeks' gestation whose blood type is Onegative is antibody positive (D antibody)
on a routine 28-week screen. Which one of
the following best describes the clinical
significance of this finding? (check one)
A. The fetus HAS hemolytic disease and
requires appropriate monitoring and
treatment
B. The fetus is AT RISK for hemolytic
disease only if the biological father is Rhnegative
C. The fetus is AT RISK for hemolytic
disease only if the biological father is Rhpositive
D. The current fetus is NOT at risk for
hemolytic disease, but subsequent
pregnancies may be at risk

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C. The fetus is AT RISK for hemolytic


disease only if the biological father is Rhpositive. When a person is Rh negative,
this indicates that they do not have type D
antigen on their red blood cells. If a
woman is exposed to Rh D antigenpositive red blood cells, she can have an
immune response of variable strength.
This may occur in the setting of pregnancy
(transplacental fetomaternal transfusion),
or exposure outside of pregnancy (e.g.,
transfusion with mismatched blood). If a
maternal antibody screen for D antigen is
positive, this indicates that the current
fetus MAY be at risk for hemolytic
disease. The level of risk is determined by
the antibody titer. For example, an
antibody titer of 1:4 poses much less risk
to the fetus than a titer of 1:64.
Determination of the blood type of the
father is helpful if paternity is certain. If
the father is homozygous Rh negative,
there is no risk of alloimmunization to the
fetus and the fetus is NOT at risk for
hemolytic disease. In this scenario,
maternal sensitization occurred either from
a prior pregnancy with a different partner
or from another source (e.g., transfusion).
If the father is heterozygous or
homozygous Rh positive, then the fetus IS
at risk. If paternity is uncertain, a
polymerase chain reaction can be
performed on 2 mL of amniotic fluid or 5
mL of chorionic villi to accurately
determine the fetal Rh status.

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A 23-year-old Hispanic female at 18


weeks' gestation presents with a 4-week
history of a new facial rash. She has
noticed worsening with sun exposure. Her
past medical history and review of systems
is normal. On examination, you note
symmetric, hyperpigmented patches on her
cheeks and upper lip. The remainder of her
examination is normal. The most likely
diagnosis is: (check one)
A. Lupus erythematosus
B. Pemphigoid gestationis (herpes
gestationis)
C. Melasma (chloasma)
D. Prurigo gestationis

A 23-year-old male returns from a Florida


beach vacation, where he sustained a cut to
his foot while wading. The cut wasn't
treated when it happened, and it is healing,
but he says that it feels like something in
the wound is "poking" him. Of the
following, which one would most likely be
easily visible on plain film radiography?
(check one)

C. Melasma (chloasma). Melasma or


chloasma is common in pregnancy, with
approximately 70% of pregnant women
affected. It is an acquired hypermelanosis
of the face, with symmetric distribution
usually on the cheeks, nose, eyebrows,
chin, and/or upper lip. The pathogenesis is
not known. UV sunscreen is important, as
sun exposure worsens the condition.
Melasma often resolves or improves post
partum. Persistent melasma can be treated
with hydroquinone cream, retinoic acid,
and/or chemical peels performed post
partum by a dermatologist. The facial rash
of lupus is usually more erythematous, and
lupus is relatively rare. Pemphigoid
gestationis is a rare autoimmune disease
with extremely pruritic, bullous skin
lesions that usually spare the face. Prurigo
gestationis involves pruritic papules on the
extensor surfaces and is usually associated
with significant excoriation by the
uncomfortable patient.

A. A wood splinter
B. A glass splinter
C. A plastic splinter
D. A sea urchin spine

B. A glass splinter. Almost all glass is


visible on radiographs if it is 2 mm or
larger, and contrary to popular belief, it
doesn't have to contain lead to be visible
on plain films. Many common or highly
reactive materials, such as wood, thorns,
cactus spines, some fish bones, other
organic matter, and most plastics, are not
visible on plain films. Alternative
techniques such as ultrasonography or CT
scanning may be effective and necessary
in those cases. Sea urchin spines, like
many animal parts, have not been found to
be easily detected by plain radiography.

A 23-year-old white male is brought to the


emergency department with slurred
speech, confusion, and ataxia. He works as

D. Fomepizole (Antizol). Ethylene glycol


poisoning should be suspected in patients
with metabolic acidosis of unknown cause

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an auto mechanic and has been known to


consume alcohol heavily in the past, but
denies recent alcohol intake. He appears
intoxicated, but no odor of alcohol is noted
on his breath. Abnormalities on the
metabolic profile include a carbon dioxide
content of 10 mmol/L (N 20-30). His
blood alcohol level is <10 mg/dL (0.01%).
A urinalysis shows calcium oxalate
crystals and an RBC count of 10-20/hpf.
Woods lamp examination of the urine
shows fluorescence. His arterial pH is
7.25.
Which one of the following would be most
appropriate at this point? (check one)
A. Immediate hemodialysis
B. Gastric lavage
C. Administration of activated charcoal
D. Fomepizole (Antizol)

and subsequent renal failure, as rapid


diagnosis and treatment will limit the
toxicity and decrease both morbidity and
mortality. This diagnosis should be
considered in a patient who appears
intoxicated but does not have an odor of
alcohol, and has anion gap acidosis,
hypocalcemia, urinary crystals, and
nontoxic blood alcohol levels. Ethylene
glycol is found in products such as engine
coolant, de-icing solution, and carpet and
fabric cleaners. Ingestion of 100 mL of
ethylene glycol by an adult can result in
toxicity.
The American Academy of Clinical
Toxicology criteria for treatment of
ethylene glycol poisoning with an antidote
include a plasma ethylene glycol
concentration >20 mg/dL, a history of
ingesting toxic amounts of ethylene glycol
in the past few hours with an osmolal gap
>10 mOsm/kg H O2 (N 5-10), and strong
clinical suspicion of ethylene glycol
poisoning, plus at least two of the
following: arterial pH <7.3, serum
bicarbonate <20 mmol/L, or urinary
oxalate crystals.
Until recently, ethylene glycol poisoning
was treated with sodium bicarbonate,
ethanol, and hemodialysis. Treatment with
fomepizole (Antizol) has this specific
indication, however, and should be
initiated immediately when ethylene
glycol poisoning is suspected. If ethylene
glycol poisoning is treated early,
hemodialysis may be avoided, but once
severe acidosis and renal failure have
occurred hemodialysis is necessary.
Ethylene glycol is rapidly absorbed, and

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use of ipecac or gastric lavage is therefore


not effective. Large amounts of activated
charcoal will only bind to relatively small
amounts of ethylene glycol, and the
therapeutic window for accomplishing this
is less than 1 hour.
A 24-year-old female at 36 weeks'
gestation plans to breastfeed her infant.
She has a history of bipolar disorder, but
currently is doing well without medication,
and also has a history of frequent urinary
tract infections. She asks you about
medications that she may need to take after
delivery, and how they may affect her
newborn. Which one of the following
would be contraindicated if she breastfeeds
her infant? (check one)

D. Lithium. Of the drugs listed, the only


maternal medication that affects the infant
is lithium. Breastfed infants of women
taking lithium can have blood lithium
concentrations that are 30%-50% of
therapeutic levels.

A. Amoxicillin
B. Macrodantin (Macrobid)
C. Valproic acid (Depakote)
D. Lithium

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A 24-year-old female had been healthy


with no significant medical illnesses until
about 3 months ago, when she was
diagnosed with schizophrenia and
treatment was initiated. She is now
concerned because she has gained 10 lb
since beginning treatment. A
comprehensive metabolic panel is normal,
with the exception of a fasting blood
glucose level of 156 mg/dL.
Which one of the following medications
would be most likely to cause these
findings?
(check one)

E. Olanzapine (Zyprexa). Secondgeneration, or "atypical," antipsychotics


are associated with weight gain, elevated
triglycerides, and type 2 diabetes mellitus.
Olanzapine and clozapine are associated
with the highest risk. Clonazepam, a
benzodiazepine, does not share these risks.
Thioridazine and chlorpromazine are firstgeneration antipsychotics, and carry less
risk of these side effects. Aripiprazole,
although it is a second-generation
antipsychotic, has been found to cause
weight gain and metabolic changes similar
to those seen with placebo.

A. Clonazepam (Klonopin)
B. Thioridazine
C. Chlorpromazine
D. Aripiprazole (Abilify)
E. Olanzapine (Zyprexa)
A 24-year-old female has a history of
mood swings over the past several months,
which have created marital and financial
problems, in addition to jeopardizing her
career as a television news reporter. You
have made a diagnosis of bipolar disorder,
and she has finally accepted the need for
treatment. However, she insists that you
choose a drug that "won't make me fat."

A. Aripiprazole (Abilify). All of the


atypical antipsychotics are associated with
some degree of weight gain. Of the
choices listed, aripiprazole is associated
with the least amount of weight gain,
generally less than 1 kilogram. The other
agents listed are likely to cause
considerably more weight gain.

Which one of the following would be best


for addressing her concerns? (check one)
A. Aripiprazole (Abilify)
B. Olanzapine (Zyprexa)
C. Quetiapine (Seroquel)
D. Risperidone (Risperdal)

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A 24-year-old female has noted excessive


hair loss over the past 2 months, with a
marked increase in hairs removed when
she brushes her hair. She delivered a
healthy baby 5 months ago. She is on no
medications, and is otherwise healthy.
Examination of her scalp reveals diffuse
hair thinning without scarring. An
evaluation for thyroid dysfunction and iron
deficiency is negative.
Which one of the following is the most
likely cause of her hair loss?
(check one)
A. Telogen effluvium
B. Anagen effluvium
C. Alopecia areata
D. Female-pattern hair loss
E. Discoid lupus erythematosus

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A. Telogen effluvium. The recycling of


scalp hair is an ongoing process, with the
hair follicles rotating through three phases.
The actively growing anagen-phase hairs
give way to the catagen phase, during
which the follicle shuts down, followed by
the resting telogen phase, during which the
hair is shed. The normal ratio of anagen to
telogen hairs is 90:10.
This patient most likely has a telogen
effluvium, a nonscarring, shedding hair
loss that occurs when a stressful event,
such as a severe illness, surgery, or
pregnancy, triggers the shift of large
numbers of anagen-phase hairs to the
telogen phase. Telogen-phase hairs are
easily shed. Telogen effluvium occurs
about 3 months after a triggering event.
The hair loss with telogen effluvium lasts
6 months after the removal of the stressful
trigger.
Anagen effluvium is the diffuse hair loss
that occurs when chemotherapeutic
medications cause rapid destruction of
anagen-phase hair. Alopecia areata, which
causes round patches of hair loss, is felt to
have an autoimmune etiology. Femalepattern hair loss affects the central portion
of the scalp, and is not associated with an
inciting trigger or shedding. Discoid lupus
erythematosus causes a scarring alopecia.

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A 24-year-old female presents for her


annual examination. She is single and has
had several male sexual partners during
the past year. You include screening for
chlamydial infection in your evaluation,
and the test is reported as positive. She is
asymptomatic. Which one of the following
is true concerning this situation? (check
one)
A. Failure to treat this patient would place
her at higher risk of later infertility
B. Only sexual partners with whom she
has been active during the last 2 weeks
need to be treated
C. She should avoid sexual intercourse for
1 month after treatment
D. Use of barrier methods of contraception
increases her risk for repeat infection

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A. Failure to treat this patient would place


her at higher risk of later infertility. It is
recommended that sexually active women
under the age of 25 years be screened
routinely for Chlamydia trachomatis.
Treatment of asymptomatic infections in
women reduces their risk of developing
pelvic inflammatory disease, tubal
infertility, ectopic pregnancy, and chronic
pelvic pain. A 1-gram dose of oral
azithromycin is an appropriate treatment,
including during pregnancy. Sexual
contacts during the preceding 60 days
should be either treated empirically or
tested for infection and treated if positive.
The patient should avoid sexual
intercourse for 7 days after initiation of
treatment. Consistent use of barrier
methods for contraception reduces the risk
of C. trachomatis genital infection.

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A 24-year-old female presents to your


clinic with a 5-day history of fever to
103F. She has no localizing symptoms or
overt physical findings. Initial testing
shows an elevated WBC count with a
disproportionate number of reactive
lymphocytes.
Which one of the following conditions is
the most likely cause of these findings?
(check one)
A. Bacterial infection
B. Connective tissue disease
C. Lymphoma
D. Viral infection

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D. Viral infection. The conditions that


result in an absolute increase in
lymphocytes are divided into primary
causes (usually neoplastic
hyperproliferation) and secondary or
reactive causes. The presence of reactive
lymphocytes will often be reported on a
manual differential, since they have a
distinctive appearance. The most common
conditions that produce a reactive
lymphocytosis are viral infections. Most
notable are Epstein-Barr virus, infectious
mononucleosis, and cytomegalovirus.
Other viral infections known to cause this
finding include herpes simplex, herpes
zoster, HIV, hepatitis, and adenovirus.
Connective tissue disease can infrequently
cause a reactive lymphocytosis, but other
signs or symptoms are usually present.
Bacterial infections more commonly result
in an increase in neutrophils. One
exception to this is Bordetella pertussis,
which has been known to cause absolute
lymphocyte counts of up to 70,000/L.
This infection is associated with classic
symptoms that this patient does not have.

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A 24-year-old female presents with pelvic


pain. She says that the pain is present on
most days, but is worse during her menses.
Ibuprofen has helped in the past but is no
longer effective. Her menses are normal
and she has only one sexual partner. A
physical examination is normal.
Which one of the following should be the
next step in the workup of this patient?
(check one)
A. Transvaginal ultrasonography
B. CT of the abdomen and pelvis
C. MRI of the pelvis
D. A CA-125 level
E. Colonoscopy
A 24-year-old female who works at a daycare facility presents to your office to
discuss ways to avoid getting "all the
infections the kids get." She plans to enroll
her child in the facility. She is specifically
concerned about diarrheal illnesses, and a
friend has suggested the use of probiotics.
(check one)
A. can lessen the severity and duration of
infectious diarrhea
B. are recommended only for patients who
are immunocompromised
C. have no known side effects
D. often interact with common
prescription medications
E. are not appropriate for use in children

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A. Transvaginal ultrasonography. The


initial evaluation for chronic pelvic pain
should include a urinalysis and culture,
cervical swabs for gonorrhea and
Chlamydia, a CBC, an erythrocyte
sedimentation rate, a -hCG level, and
pelvic ultrasonography. CT and MRI are
not part of the recommended initial
diagnostic workup, but may be helpful in
further assessing any abnormalities found
on pelvic ultrasonography. Referral for
diagnostic laparoscopy is appropriate if the
initial workup does not reveal a source of
the pain, or if endometriosis or adhesions
are suspected. Colonoscopy would be
indicated if the history or examination
suggests a gastrointestinal source for the
pain after the initial evaluation.
A. can lessen the severity and duration of
infectious diarrhea. Probiotics are
microorganisms with likely health
benefits, based on recent randomized,
controlled trials. Good evidence suggests
that probiotics reduce the incidence,
duration, and severity of antibioticassociated and infectious diarrhea.
Common side effects include flatulence
and abdominal pain. Contraindications
include short-gut syndromes and
immunocompromised states. There are no
known drug interactions, and these agents
appear safe for all ages (SOR A).

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A 24-year-old female with a 2-year history


of dyspnea on exertion has been diagnosed
with exercise-induced asthma by another
physician. Which one of the following
findings on pulmonary function testing
would raise concerns that she actually has
vocal cord dysfunction? (check one)
A. A good response to an inhaled agonist
B. Flattening of the inspiratory portion of
the flow-volume loop, but a normal
expiratory phase
C. Flattening of the expiratory portion of
the flow-volume loop, but a normal
inspiratory phase
D. Flattening of both the inspiratory and
expiratory portion of the flow-volume loop
E. A decreased FEV1 and a normal FVC

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B. Flattening of the inspiratory portion of


the flow-volume loop, but a normal
expiratory phase. The diagnosis of vocal
cord dysfunction should be considered in
patients diagnosed with exercise-induced
asthma who do not have a good response
to -agonists before exercise. Pulmonary
function testing with a flow-volume loop
typically shows a normal expiratory
portion but a flattened inspiratory phase
(SOR C). A decreased FEV1 and normal
FVC would be consistent with asthma.

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A 24-year-old female with a past history of


asthma presents to the emergency
department with an asthma exacerbation.
Treatment with an inhaled bronchodilator
and ipratropium (Atrovent) does not lead
to significant improvement, and she is
admitted to the hospital for ongoing
management. On examination she is
afebrile, her respiratory rate is 24/min, her
pulse rate is 92 beats/min, and oxygen
saturation is 92% on room air. She has
diffuse bilateral inspiratory and expiratory
wheezes with mild intercostal retractions.
Which one of the following should be
considered in the acute management of
this patient? (check one)
A. Chest physical therapy
B. Inhaled fluticasone/salmeterol (Advair)
C. Oral azithromycin (Zithromax)
D. Oral prednisone
E. Oral theophylline

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D. Oral prednisone. Hospital management


of acute exacerbations of asthma should
include inhaled short-acting
bronchodilators in all patients. Systemic
corticosteroids are recommended for all
patients admitted to the hospital. The
efficacy of oral prednisone has been
shown to be equivalent to that of
intravenous methylprednisolone (SOR A).
Oxygen should also be considered in most
patients. Antibiotics are not recommended
in the treatment of asthma exacerbations
unless there is a comorbid infection.
Inhaled ipratropium bromide is
recommended for treatment in the
emergency department, but not in the
hospital (SOR A). Chest physical therapy
and methylxanthines are not recommended
in the treatment of acute asthma
exacerbations.

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A 24-year-old gravida 1 para 1 who is 2


weeks post partum complains of double
vision, shortness of breath, and almost
dropping her baby while trying to hold her.
She says her symptoms worsen as the day
progresses. She has no family history of
neurologic or muscular illness. A physical
examination is normal except for unilateral
ptosis and 4/5 proximal weakness of both
arms. Breath sounds are generally
decreased. Routine blood tests, including
TSH and creatine kinase levels, are
normal. A chest radiograph and an MRI of
the brain and cervical spine are also
normal. Of the following, this presentation
is most consistent with (check one)
A. fibromyalgia syndrome
B. Sheehan's syndrome (postpartum
hypopituitarism)
C. polymyositis
D. myasthenia gravis
E. stroke

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D. myasthenia gravis. Common neurologic


disorders in young women include
multiple sclerosis, Guillain-Barr
syndrome, and myasthenia gravis.
Myasthenia gravis is part of the
differential diagnosis for sudden
neurologic weakness, and Guillain-Barr
syndrome must also be considered in this
patient. Multiple sclerosis would not result
in respiratory compromise. Myasthenia
gravis is an autoimmune neuromuscular
disease characterized by varying degrees
of skeletal muscle weakness. Symptoms,
which vary in type and severity, may
include ptosis of one or both eyelids;
blurred vision; diplopia; unstable gait;
weakness in the arms, hands, fingers, legs,
and neck; difficulty swallowing; shortness
of breath; and impaired speech
(dysarthria). In most cases, the first
noticeable symptom is weakness of the eye
muscles. Muscles that control respiration
and neck and limb movements may also be
affected. Symptoms typically worsen
through the day or as the muscles are
repetitively used, and improve with rest.
Fibromyalgia does not produce objective
neurologic findings, and Sheehan's
syndrome would not cause a localized
neurologic deficit. In addition, the TSH
level would be low or zero, and the MRI
of the brain would be abnormal. An MRI
of the brain would also be abnormal if
stroke symptoms had been present for 2
weeks. The patient is unlikely to have
unilateral symptoms with polymyositis,
and creatine kinase would be elevated.

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A 24-year-old male presents with a fever


of 38.9C (102.0F), generalized body
aches, a sore throat, and a cough. His
symptoms started 24 hours ago. He is
otherwise healthy. You suspect novel
influenza A H1N1 infection, as there have
been numerous cases in your community
recently. A rapid influenza diagnostic test
is positive, and you recommend over-thecounter symptomatic treatment. You see
him 2 days later after he is admitted to the
hospital through the emergency
department with dehydration and mild
respiratory distress. A specimen is sent to
the state laboratory for PCR testing.
Which one of the following would be most
appropriate at this point? (check one)

A. Oseltamivir (Tamiflu). The currently


circulating novel influenza A H1N1 virus
is almost always susceptible to
neuraminidase inhibitors (oseltamivir and
zanamivir) and resistant to the
adamantanes (amantadine and
rimantadine). Zanamivir should not be
used in patients with COPD, asthma, or
respiratory distress. Antiviral treatment of
influenza is recommended for all persons
with clinical deterioration requiring
hospitalization, even if the illness started
more than 48 hours before admission.
Antiviral treatment should be started as
soon as possible. Waiting for laboratory
confirmation is not recommended.

A. Oseltamivir (Tamiflu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment
A 24-year-old male sustains a boxer's
fracture of the fifth metacarpal. A
radiograph shows no rotational deformity
and 25 of volar angulation. After an
attempt at closed reduction the angulation
remains unchanged.
Which one of the following would be most
appropriate at this time?
(check one)

D. An ulnar gutter splint. Up to 40 of


volar angulation is acceptable for fifth
metacarpal fractures. For second and third
metacarpal fractures, less angulation is
acceptable. Appropriate treatment is a
gutter splint.

A. Open reduction
B. Placement of a pin to prevent further
displacement
C. A short arm-thumb spica cast
D. An ulnar gutter splint

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A 24-year-old male, new to your practice,


presents for a mental health evaluation.
The patient has a past history of
schizophrenia, diagnosed several years
ago. Which one of the following, if
present, would lead to a reconsideration of
this diagnosis? (check one)
A. Auditory hallucinations
B. Loose associations
C. Elated mood
D. Social dysfunction
E. Incoherent speech

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C. Elated mood. Schizophrenia can be


very difficult to definitively diagnose, and
there are many subtypes. There are many
sets of diagnostic criteria, but most,
including DSM-IV, include the presence
of thought disorders such as
hallucinations, delusions, and loose
associations; disorganized speech;
catatonic behavior; and apathy or flat
affect. (Two of these must be present to
meet DSM-IV criteria.) Additionally, there
must be social or occupational impairment
and a minimum duration of symptoms (6
months for DSM-IV). Mood disorders,
including depression, mania, and
schizoaffective disorder, must be excluded
in order to diagnose schizophrenia.
Obviously, treatment of these disorders is
very different from that of schizophrenia.

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A 24-year-old primigravida has nausea and


vomiting associated with pregnancy.
Which one of the following is
recommended by the American Congress
of Obstetricians and Gynecologists
(ACOG) as first-line therapy? (check one)
A. Droperidol (Inapsine)
B. Ondansetron (Zofran)
C. Prochlorperazine
D. Metoclopramide (Reglan)
E. Doxylamine (Unisom) and vitamin B6

E. Doxylamine (Unisom) and vitamin B6.


Approximately 10% of women with
nausea and vomiting during pregnancy
require medication. Pharmacologic
therapies that have been used include
vitamin B6 , antihistamines, and prokinetic
agents, as well as other medications.
Randomized, placebo-controlled trials
have shown that vitamin B6 is effective for
this problem. The combination of vitamin
B 6 and doxylamine was studied in more
than 6000 patients and was associated with
a 70% reduction in nausea and vomiting,
with no evidence of teratogenicity. It is
recommended by the American Congress
of Obstetricians and Gynecologists as firstline therapy for nausea and vomiting in
pregnancy. A combination pill was
removed from the U.S. market in 1983
because of unjustified concerns about
teratogenicity, but the medications can be
bought separately over the counter.
In rare cases, metoclopramide has been
associated with tardive dyskinesia, and the
FDA has issued a black-box warning
concerning the use of this drug in general.
The 5-HT3 -receptor antagonists, such as
ondansetron, are being used for
hyperemesis in pregnancy, but information
is limited. Droperidol has been used for
this problem in the past, but it is now used
infrequently because of its risks,
particularly heart arrhythmias.

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A 24-year-old white female presents to the


office with a 6-month history of abdominal
pain. A physical examination, including
pelvic and rectal examinations, is normal.
Which one of the following would indicate
a need for further evaluation? (check one)
A. Relief of symptoms with defecation
B. Changes in stool consistency from
loose and watery to constipation
C. Passage of mucus with bowel
movements
D. Abdominal bloating
E. Worsening of symptoms at night

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E. Worsening of symptoms at night.


Irritable bowel syndrome (IBS) is a
benign, chronic symptom complex of
altered bowel habits and abdominal pain. It
is the most common functional disorder of
the gastrointestinal tract. The presence of
nocturnal symptoms is a red flag which
should alert the physician to an alternate
diagnosis and may require further
evaluation. The other symptoms listed are
Rome I and II criteria for diagnosing
irritable bowel syndrome.

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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

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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.

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A 25-year-old female at 36 weeks


gestation presents for a routine prenatal
visit. Her blood pressure is 118/78 mm Hg
and her urine has no signs of protein or
glucose. Her fundal height shows
appropriate fetal size and she says that she
feels well. On palpation of her legs, you
note 2+ pitting edema bilaterally. Which
one of the following is true regarding this
patient's condition? (check one)
A. You should order a 24-hr urine for
protein
B. A workup for possible cardiac
abnormalities is necessary
C. Her leg swelling requires no further
evaluation
D. She most likely has preeclampsia
E. She most likely has deep venous
thrombosis
A 25-year-old female comes to your office
requesting a referral to an otolaryngologist
for surgery on her nose. She states that her
nose is too large and that "something must
be done." She has already seen multiple
family physicians, as well as several
otolaryngologists. She is 168 cm (66 in)
tall and weighs 64 kg (141 lb). A physical
examination is normal, and even though
she initially resists a nasal examination, it
also is normal. The size of her nose is
normal.
Which one of the following is the most
likely cause of this patient's concern about
her nose? (check one)

C. Her leg swelling requires no further


evaluation. Lower-extremity edema is
common in the last trimester of normal
pregnancies and can be treated
symptomatically with compression
stockings. Edema has been associated with
preeclampsia, but the majority of women
who have lower-extremity edema with no
signs of elevated blood pressure will not
develop preeclampsia or eclampsia. For
this reason, edema has recently been
removed from the diagnostic criteria for
preeclampsia. Disproportionate swelling in
one leg versus another, especially
associated with leg pain, should prompt a
workup for deep venous thrombosis but is
unlikely given this patient's presentation,
as are cardiac or renal conditions.

D. Body dysmorphic disorder. Body


dysmorphic disorder is an increasingly
recognized somatoform disorder that is
clinically distinct from obsessivecompulsive disorder, eating disorders, and
depression. Patients have a preoccupation
with imagined defects in appearance,
which causes emotional stress. Body
dysmorphic disorder may coexist with
anorexia nervosa, atypical depression,
obsessive-compulsive disorder, and social
anxiety. Cosmetic surgery is often sought.
SSRIs and behavior modification may
help, but cosmetic procedures are rarely
helpful.

A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder
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A 25-year-old female has an annular rash


on the dorsal surface of both hands. The
rash does not respond to initial treatment
with an antifungal medication, and a
biopsy reveals granuloma annulare.
Which one of the following would be the
most appropriate advice for this patient?
(check one)
A. Allow the rash to resolve without
further treatment
B. Cover the rash because it is contagious
C. Treat the rash with systemic
corticosteroids
D. Treat the rash with a stronger antifungal
medication
A 25-year-old female has been trying to
conceive for over 1 year without success.
Her menstrual periods occur
approximately six times per year.
Laboratory evaluation of her hormone
status has been negative, and her husband
has a normal semen analysis. Her only
other medical problem is hirsutism, which
has not responded to topical treatment.
Pelvic ultrasonography of her uterus and
ovaries is unremarkable.
Of the following, which one would be the
most appropriate treatment for her
infertility? (check one)
A. Metformin (Glucophage)
B. Danazol
C. Medroxyprogesterone (Provera)
D. Spironolactone (Aldactone)

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A. Allow the rash to resolve without


further treatment. Granuloma annulare is a
self-limited condition. It is not contagious,
and therefore would not need to be
covered to prevent transmission.
Treatments may include injected or topical
corticosteroids, but oral corticosteroids
have not been specifically recommended.
It may be necessary to refer the patient to a
dermatologist because many of the
potential treatments can have serious side
effects.

A. Metformin (Glucophage). This patient


fits the criteria for polycystic ovary
syndrome (oligomenorrhea, acne,
hirsutism, hyperandrogenism, infertility).
Symptoms also include insulin resistance.
Evidence of polycystic ovaries is not
required for the diagnosis.
Metformin has the most evidence
supporting its use in this situation, and is
the only treatment listed that is likely to
decrease hirsutism and improve insulin
resistance and menstrual irregularities.
Metformin and clomiphene alone or in
combination are first-line agents for
ovulation induction. Clomiphene does not
improve hirsutism, however. Progesterone
is not indicated for any of this patient's
problems. Spironolactone will improve
hirsutism and menstrual irregularities, but
is not indicated for ovulation induction.

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A 25-year-old female is in active labor at


term and is dilated to 7 cm. An electronic
fetal monitoring tracing is shown in Figure
5.

...

A 25-year-old female presents with a


maculopapular rash that has progressed to
multiple areas and exhibits target lesions.
A cold sore appeared on her upper lip 2
days before the rash appeared. She is not
systemically ill and is on no medications.
Which one of the following is true
concerning this problem?
(check one)

A. Herpes simplex virus is a likely cause.


Herpes simplex virus is the most common
etiologic agent of erythema multiforme.
Other infections, particularly Mycoplasma
pneumoniae infections and fungal
infections, may also be associated with this
hypersensitivity reaction. Other causes
include medications and vaccines. Skin
biopsy findings are not specific for
erythema multiforme. As opposed to the
lesions of urticaria, the lesions of erythema
multiforme usually are present and fixed
for at least 1 week and may evolve into
target lesions. The palms of the hands and
soles of the feet may be involved. The
lesions of erythema multiforme usually
resolve spontaneously over 3-5 weeks
without sequelae.

A. Herpes simplex virus is a likely cause


B. A skin biopsy will confirm the
diagnosis
C. The lesions usually disappear within 24
hours
D. The palms of the hands and soles of the
feet are not involved
E. Scarring from the lesions is often seen
after resolution

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A 25-year-old female presents with


abdominal pain localized to the right lower
quadrant. Which one of the following
would be most helpful in diagnosing acute
appendicitis? (check one)
A. A CBC
B. Urinalysis
C. Plain abdominal films
D. Abdominal/pelvic ultrasonography
E. Abdominal/pelvic CT

A 25-year-old female sees you in the


office for follow-up after a visit to the
emergency department for respiratory
distress. She complains of several episodes
of an acute onset of shortness of breath,
wheezing, coughing, and a choking
sensation, without any obvious precipitant.
She has been on inhaled corticosteroids for
2 months without any improvement in her
symptoms. Albuterol (Proventil, Ventolin)
does not consistently relieve her
symptoms. She is asymptomatic today.
Spirometry shows a normal FEV1 , a
normal FVC and FEV1 /FVC ratio, and a
flattened inspiratory loop.

E. Abdominal/pelvic CT. Seventy to


ninety percent of patients with acute
appendicitis have leukocytosis, but this is
also a characteristic of other conditions,
and thus has poor specificity for acute
appendicitis. The urinalysis may exhibit
microscopic pyuria or hematuria in a
patient with acute appendicitis, but these
findings may also be present with urinary
tract disease. Plain radiographs of the
abdomen are of limited value in
diagnosing acute appendicitis.
Ultrasonography can be useful, especially
in ruling out gynecologic problems, but is
technician-dependent and is not as specific
nor sensitive as CT scanning, which has a
sensitivity, specificity, and overall
accuracy in excess of 90%. In cases where
the CT scan is indeterminate, patients
should be admitted to the hospital for close
observation with repeated physical
examinations to monitor clinical status.

The most likely diagnosis is: (check one)

B. vocal cord dysfunction. Vocal cord


dysfunction is an idiopathic disorder
commonly seen in patients in their
twenties and thirties in which the vocal
cords partially collapse or close on
inspiration. It mimics, and is commonly
mistaken for, asthma. Symptoms include
episodic tightness of the throat, a choking
sensation, shortness of breath, and
coughing. A careful history and
examination reveal that the symptoms are
worse with inspiration than with
exhalation, and inspiratory stridor during
the episode may be mistaken for the
wheezing of asthma. The sensation of
throat tightening or choking also helps to
differentiate it from asthma.

A. globus hystericus

Pulmonary function tests (PFTs) are

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B. vocal cord dysfunction


C. asthma
D. anaphylaxis
E. COPD

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normal, with the exception of flattening of


the inspiratory loop, which is diagnostic of
extra-thoracic airway compression.
Fiberoptic laryngoscopy shows
paradoxical inspiratory and/or expiratory
partial closure of the vocal cords. Vocal
cord dysfunction is treated with speech
therapy, breathing techniques, reassurance,
and breathing a helium-oxygen mixture
(heliox).
PFTs in patients with asthma are normal
between exacerbations, but when
symptoms are present the FEV1 /FVC
ratio is reduced, as with COPD. With
anaphylaxis, there will typically be itching
or urticaria and signs of angioedema, such
as lip or tongue swelling, in response to a
trigger such as food or medication; PFTs
are normal when anaphylaxis symptoms
are absent. Globus hystericus is a type of
conversion disorder in which emotional
stress causes a subjective sensation of pain
or tightness in the throat, and/or
dysphagia; diagnostic tests such as
spirometry and laryngoscopy are normal.

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A 25-year-old Hispanic male comes to the


emergency department with the sudden
onset of moderate to severe right-sided
chest pain and mild dyspnea. Vital signs
are normal. A chest film shows a loss of
markings along the right lung margins,
involving about 10%-15% of the lung
space. The mediastinum has not shifted.
The best INITIAL treatment would be
(check one)
A. strict bed rest
B. oxygen supplementation and close
observation
C. decompression of the chest by insertion
of a large-bore intravenous catheter into
the right second intercostal space at the
midclavicular line
D. immediate chest tube insertion using a
water seal
E. thoracotomy for wedge resection of
pulmonary blebs
A 25-year-old male has a dental infection
associated with facial swelling and
lymphadenopathy. Which one of the
following is the most appropriate
antibiotic? (check one)

B. oxygen supplementation and close


observation. A small spontaneous
pneumothorax involving less than
15%-20% of lung volume can be managed
by administering oxygen and observing the
patient. The pneumothorax will usually
resorb in about 10 days if no ongoing air
leak is present. Oxygen lowers the
pressure gradient for nitrogen and favors
transfer of gas from the pleural space to
the capillaries. Decompression with
anterior placement of an intravenous
catheter is usually reserved for tension
pneumothorax. Chest tube placement is
used if observation is not successful or for
larger pneumothoraces. Strict bed rest is
not indicated.

C. Penicillin. Dental infections


complicated by the development of
cellulitis should be treated with oral
antibiotic therapy. The antibiotic of choice
is penicillin. Clindamycin should be used
if a patient is allergic to penicillin.

A. Cephalexin (Keflex)
B. Tetracycline
C. Penicillin
D. Ciprofloxacin (Cipro)
E. Azithromycin (Zithromax)

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A 25-year-old male presents to your office


for evaluation of pain in the right index
finger that has been present for the past 4
days. The pain has been getting
progressively worse. On examination the
finger is swollen and held in a flexed
position. The pain increases with passive
extension of the finger, and there is
tenderness to palpation from the tip of the
finger into the palm.
Which one of the following is the most
appropriate management of this patient?
(check one)
A. Surgical drainage and antibiotics
B. Antiviral medication
C. Oral antibiotics and splinting
D. Needle aspiration
E. Corticosteroid injection

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A. Surgical drainage and antibiotics. This


patient has pyogenic tenosynovitis. When
early tenosynovitis (within 48 hours of
onset) is suspected, treatment with
antibiotics and splinting may prevent the
spread of the infection. However, this
patient's infection is no longer in the early
stages and is more severe, so it requires
surgical drainage and antibiotics. A delay
in treatment of these infections can lead to
ischemia of the tendons and damage to the
flexor tendon and sheath. This can lead to
impaired function of the finger. Needle
aspiration would not adequately drain the
infection. Antiviral medication would not
be appropriate, as this is a bacterial
infection. Corticosteroid injections are
contraindicated in the presence of
infection.

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A 25-year-old male presents to your office


with a 1-week history of neck pain with
radiation to the left hand, along with
intermittent numbness and tingling in the
left arm. His history is negative for injury,
fever, or lower extremity symptoms.
Extension and rotation of the neck to the
left while pressing down on the head
(Spurling's maneuver) exacerbates the
symptoms. His examination is otherwise
normal. Cervical radiographs are negative.
Which one of the following would be most
appropriate at this point? (check one)
A. NSAIDs for pain relief
B. A trial of tricyclic antidepressants
C. Cervical corticosteroid injection
D. Cervical MRI
E. Referral to a spine subspecialist

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A. NSAIDs for pain relief. Patients who


present with acute cervical radiculopathy
and normal radiographs can be treated
conservatively. The vast majority of
patients with cervical radiculopathy
improve without surgery. Of the
interventions listed, NSAIDs are the initial
treatment of choice. Tricyclic
antidepressants, as well as tramadol and
venlafaxine, have been shown to help with
chronic neuropathic pain. Cervical MRI is
not indicated unless there are progressive
neurologic defects or red flags such as
fever or myelopathy. Likewise, referral to
a subspecialist should be reserved for
patients who have persistent pain after 6-8
weeks of conservative management and
for those with signs of instability. Cervical
corticosteroid injections have been found
to be helpful in the management of
cervical radiculopathy, but should not be
administered before MRI is performed
(SOR C).

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A 25-year-old male who came to your


office for a pre-employment physical
examination is found to have 2+ protein on
a dipstick urine test. You repeat the
examination three times within the next
month and results are still positive. Results
of a 24-hour urine collection show protein
excretion of <2 g/day and normal
creatinine clearance. As part of his further
evaluation you obtain split urine
collections with a 16-hour daytime
specimen containing an increased
concentration of protein, and an 8-hour
overnight specimen that is normal.
Additional appropriate evaluation for this
man's problem at this time includes which
one of the following?
(check one)

E. No specific additional testing. Persons


younger than 30 years of age who excrete
less than 2 g of protein per day and who
have a normal creatinine clearance should
be tested for orthostatic proteinuria. This
benign condition occurs in about 3%-5%
of adolescents and young adults. It is
characterized by increased protein
excretion in the upright position, but
normal protein excretion when the patient
is supine. It is diagnosed using split urine
collections as described in the question.
The daytime specimen has an increased
concentration of protein, while the
nighttime specimen contains a normal
concentration. Since this is a benign
condition with normal renal function, no
further evaluation is necessary.

A. Serum and urine protein electrophoresis


B. Antinuclear antibody
C. Serum albumin and lipid levels
D. Renal ultrasonography
E. No specific additional testing
A 25-year-old medical student reads about
the benefits of moderate alcohol
consumption on lipid levels and begins to
drink 5 ounces of red wine a day, adding
100 calories to his diet. Assuming that his
diet and exercise levels stay the same,
what effect will the additional 3000
calories a month have on his body weight
over the next 10 years? (check one)
A. They will have essentially no effect
B. His weight will increase by about 25 kg
C. His weight will increase slightly then
stabilize
D. His normal caloric expenditure will
decrease
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C. His weight will increase slightly then


stabilize. There is not a direct relation
between daily calorie consumption and
weight. An adult male consuming an extra
100 calories a day above his caloric need
will not continue to gain weight
indefinitely; rather, his weight will
increase to a certain point and then become
constant. Fat must be fed, and maintaining
the newly created tissue requires an
increase in caloric expenditure. An extra
100 calories a day will result in a weight
gain of approximately 5 kg, which will
then be maintained.

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A 25-year-old primigravida presents with


sharp, stabbing, left-sided pelvic pain that
started yesterday, 45 days after her last
menstrual period. Her past history is not
remarkable, and a physical examination is
normal except for moderate tenderness in
the left adnexa on pelvic examination. A
urinalysis is normal, as is a CBC. Her
beta-hCG level is 1500 mIU/mL.
Assuming no adnexal mass is seen, which
one of the following transvaginal pelvic
ultrasonography findings would be
consistent with the highest likelihood of an
ectopic pregnancy? (check one)

A. Empty uterus: empty endometrial


cavity with or without a thickened
endometrium. At this time in the patient's
pregnancy, a gestational sac should be
visible on ultrasonography. An empty
uterus presents the highest risk (14%) for
ectopic pregnancy, while nonspecific fluid
and echogenic material are associated with
a 5% and 4% risk, respectively. An
abnormal or normal sac is associated with
no risk, with the rare exception of multiple
pregnancies with one being heterotopic.

A. Empty uterus: empty endometrial


cavity with or without a thickened
endometrium
B. Abnormal gestational sac: anechoic
intrauterine fluid collection either >10 mm
in mean sac diameter or with a grossly
irregular border
C. Nonspecific fluid: anechoic intrauterine
fluid collection <10 mm in mean sac
diameter without an echogenic border
D. Echogenic material: echogenic material
within the endometrial cavity without a
defined sac, or multiple discrete anechoic
collections of various sizes divided by
echogenic septations
A 25-year-old white female comes to your
office complaining of abdominal pain. She
requests that you hospitalize her and do
whatever is necessary to get rid of the pain
that has been present for a number of
years. She has difficulty describing the
pain. She is a single parent, and becomes
defensive when asked about her previous
marriage, stating only that her former
husband is an alcoholic, "just like my
father." Her previous medical history
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E. Scheduling frequent, regular office


visits. Somatoform disorder is often
encountered in family practice. Studies
have documented that 5% of patients meet
the criteria for somatization disorder,
while another 4% have borderline
somatization disorder. Most of these
patients are female and have a low
socioeconomic status. They have a high
utilization of medical services, usually
reflected by a thick medical chart, and are
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includes an appendectomy, a
cholecystectomy, and a hysterectomy. On
physical examination she appears healthy
and a CBC, erythrocyte sedimentation rate,
serum amylase level, serum electrolyte
levels, and multiple chemical profile are
all normal. Management of this patient
should include which one of the
following? (check one)
A. Long-term use of antidepressants
B. Referral to a surgeon for exploratory
laparotomy
C. Informing her that her problems are
psychogenic and that there is nothing to
worry about
D. Hospitalization as requested, then
consultation with a psychiatrist
E. Scheduling frequent, regular office
visits

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often single parents. As a rule, physicians


tend to be less satisfied with the care
rendered to these patients as opposed to
those without the disorder. Patients with
multiple unexplained physical complaints
have been described as functionally
disabled, spending an average of one week
per month in bed. Many of these patients
seek and are ultimately granted surgical
procedures, and it is not uncommon for
them to have multiple procedures,
especially involving the pelvic area. Often
there are associated psychiatric symptoms
such as anxiety, depression, suicidal
threats, alcohol or drug abuse,
interpersonal or occupational difficulties,
and antisocial behavior. A background of a
dysfunctional family unit in which one or
both parents abused alcohol or drugs or
were somatically preoccupied is also quite
common. Unfortunately, these individuals
tend to marry alcohol abusers, and thus
continue the pattern of dysfunctional
family life. Treatment of somatoform
disorder should be by one primary
physician where an established
relationship and regular visits can curtail
the dramatic symptoms that many times
lead to hospitalization. The family
physician is in a position to monitor family
dynamics and provide direction on such
issues as alcoholism and child abuse. Each
office visit should be accompanied by a
physical examination, and the temptation
to tell the patient that the problem is not
physical should be avoided. Knowing the
patient well helps to avoid unnecessary
hospitalization, diagnostic procedures,
surgery, and laboratory tests. These should
be done only if clearly indicated.
Psychotropic medications should be
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avoided except when clearly indicated, as


medications reinforce the sick role, may be
abused, and may be used for suicidal
gestures. Following these
recommendations significantly decreases
the cost of care for the patient.
A 25-year-old white female presents to
your office with the following complaints:
sudden onset of intense apprehension, fear,
terror associated with impending doom,
dyspnea, palpitations, and a feeling of loss
of control. Which one of the following is
the most likely diagnosis? (check one)
A. Pheochromocytoma
B. Panic attack
C. Hypochondriasis
D. Hypoglycemia
E. Hyperthyroidism

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B. Panic attack. Panic attacks generally


begin between the ages of 17 and 30, and
80% of those affected are women. Panic
attacks are manifested by the sudden onset
of intense apprehension, fear, or terror,
often associated with thoughts of
impending doom and at least four of the
following somatic symptoms: dyspnea
(patients often hyperventilate);
palpitations, chest pain, or discomfort;
choking or smothering sensations;
dizziness; a feeling of unreality;
paresthesias; diaphoresis; faintness;
trembling or shaking; hot and cold flashes;
and fears of dying, going crazy, or losing
control during an attack. Hypochondriasis
is a condition where the patient is
preoccupied with health and absorbed in
his/her own physical ailments. Major
depressive episodes/depression are
characterized by marked, sustained
changes of mood. In major depression the
prevailing mood is low, being described as
"blue," "down in the dumps," or apathetic.
Part of the low mood consists of a
decreased ability to enjoy activities that
usually are a source of pleasure.

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A 25-year-old white female with heavy


menstrual periods is noted to have a
hemoglobin level of 9.8 g/dL (N 12.016.0). The red cell distribution width is
16.0% (N 11.5-14.5) and the mean
corpuscular volume is 75 m3 (N 78-102).
The appropriate treatment for this
condition can be enhanced by the use of:
(check one)

E. Ascorbic acid. This patient has iron


deficiency anemia. There are several
substances that decrease the absorption of
iron, including antacids, soy protein,
calcium, tannin (which is in tea), and
phytate (which is found in bran). Since an
acidic environment increases iron
absorption, ascorbic acid (vitamin C) can
enhance absorption of an iron supplement.

A. Antacids
B. Soy milk
C. Iced tea
D. Bran
E. Ascorbic acid

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A 25-year-old white male truck driver


complains of 1 day of throbbing rectal
pain. Your examination shows a large,
thrombosed external hemorrhoid. Which
one of the following is the preferred initial
treatment for this patient? (check one)
A. Warm sitz baths, a high-residue diet,
and NSAIDs
B. Rubber band ligation of the hemorrhoid
C. Elliptical excision of the thrombosed
hemorrhoid
D. Stool softeners and a topical
analgesic/hydrocortisone cream (e.g.,
Anusol-HC)

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C. Elliptical excision of the thrombosed


hemorrhoid. The appropriate management
of a thrombosed hemorrhoid presenting
within 48 hours of onset of symptoms is an
elliptical excision of the hemorrhoid and
overlying skin under local anesthesia (i.e.,
0.5% bupivacaine hydrochloride
[Marcaine] in 1:200,000 epinephrine)
infiltrated slowly with a small (27 gauge)
needle for patient comfort. Incision and
clot removal may provide inadequate
drainage with rehemorrhage and clot
reaccumulation. Most thrombosed
hemorrhoids contain multilocular clots
which may not be accessible through a
simple incision. Rubber band ligation is an
excellent technique for management of
internal hemorrhoids. Banding an external
hemorrhoid would cause exquisite pain.
When pain is already subsiding or more
time has elapsed (in the absence of
necrosis or ulceration), measures such as
sitz baths, bulk laxatives, stool softeners,
and local analgesia may all be helpful.
Some local anesthetics carry the risk of
sensitization, however counseling to avoid
precipitating factors (e.g., prolonged
standing/sitting, constipation, delay of
defecation) is also appropriate.

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A 25-year-old white male who has a


poorly controlled major seizure disorder
and a 6-week history of recurrent fever,
anorexia, and persistent, productive
coughing visits your office. On physical
examination he is noted to have a
temperature of 38.3C (101.0F), a
respiratory rate of 16/min, gingival
hyperplasia, and a fetid odor to his breath.
Auscultation of the lungs reveals rales in
the mid-portion of the right lung
posteriorly.
Which one of the following is most likely
to be found on a chest radiograph? (check
one)
A. Sarcoidosis
B. Miliary calcifications
C. A lung abscess
D. A right hilar mass
E. A right pleural effusion

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C. A lung abscess. Anaerobic lung


abscesses are most often found in a person
predisposed to aspiration who complains
of a productive cough associated with
fever, anorexia, and weakness. Physical
examination usually reveals poor dental
hygiene, a fetid odor to the breath and
sputum, rales, and pulmonary findings
consistent with consolidation. Patients
who have sarcoidosis usually do not have a
productive cough and have bilateral
physical findings. A persistent productive
cough is not a striking finding in
disseminated tuberculosis, which would be
suggested by miliary calcifications on a
chest film. The clinical presentation and
physical findings are not consistent with a
simple mass in the right hilum nor with a
right pleural effusion.

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A 26-year-old female calls your office to


inquire about the results of her recent
Papanicolaou (Pap) test. The report
indicates the presence of atypical
squamous cells of undetermined
significance (ASC-US), and her reflex
HPV test is negative for high-risk HPV
types. The patient has never had an
abnormal Pap test and has had three
normal tests over the past 6 years. She is a
nonsmoker.
You advise the patient that the most
appropriate next step would be to: (check
one)
A. repeat the Pap test every 3 months for 1
year
B. repeat the Pap test in 6 months and 12
months
C. repeat the Pap test in 12 months
D. continue routine Pap tests, with the next
test in 3 years
E. schedule colposcopy as soon as possible

C. repeat the Pap test in 12 months. The


ASC-US/LSIL Triage Study (ALTS)
demonstrated that there are three
appropriate follow-up options for
managing women with an ASC-US
Papanicolaou (Pap) test result: (1) two
repeat cytologic examinations performed
at 6-month intervals; (2) reflex testing for
HPV; or (3) a single colposcopic
examination. This expert consensus
recommendation has been confirmed in
more recent clinical studies, additional
analyses of the ALTS data, and metaanalyses of published studies (SOR A).
Reflex HPV testing refers to testing either
the original liquid-based cytology residual
specimen or a separate sample collected
for HPV testing at the time of the initial
screening visit. This approach eliminates
the need for women to return to the office
or clinic for repeat testing, rapidly
reassures women who do not have a
significant lesion, spares 40%-60% of
women from undergoing colposcopy, and
has been shown to have a favorable costeffectiveness ratio. In this patient's case,
the HPV testing was negative, and there is
no need to repeat the Pap test at 6-month
intervals or to perform colposcopy.
Although women in certain low-risk
groups need routine cervical cancer
screening only every 3 years, this patient
should have a repeat Pap test in 12 months.
Immediately repeating the test or testing at
3-month intervals is not recommended in
any of the algorithms to manage ASC-US
results for otherwise healthy women.

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A 26-year-old female presents with


symptoms of anhedonia and anxiousness.
Your evaluation leads to a diagnosis of
major depressive disorder. The patient
consents to medical treatment and
counseling, but she is engaged to be
married in 2 months and is concerned that
antidepressants may lower her libido even
further.
Which one of the following would be best
for reducing the likelihood of sexual
dysfunction?
(check one)

A. Bupropion (Wellbutrin). Paroxetine has


been found to cause higher rates of sexual
dysfunction than bupropion, fluoxetine,
and sertraline. Bupropion has been found
to have significantly lower rates of adverse
effects on sexual function than fluoxetine
or sertraline.

A. Bupropion (Wellbutrin)
B. Paroxetine (Paxil)
C. Fluoxetine (Prozac)
D. Sertraline (Zoloft)
A 26-year-old gravida 1 para 0 presents for
a prenatal examination. She has two cats
and expresses concern about
toxoplasmosis.
Which one of the following would be most
appropriate for this patient?
(check one)
A. Recommend that she avoid directly
handling the cats' litter box
B. Immunize the patient against
toxoplasmosis
C. Prophylactically treat the cats with
antibiotics
D. Screen the patient's urine for
Toxoplasma antigens
E. Screen the patient's serum for
Toxoplasma antibody

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A. Recommend that she avoid directly


handling the cats' litter box. There is no
immunization against toxoplasmosis, and
the use of antibiotics is limited to cases in
which there is known maternal infection
with the protozoa. Screening pregnant
women for seroconversion (not with urine
antigen testing) is controversial, and
recommendations by various professional
groups differ. Currently, the American
College of Obstetrics and Gynecology
does not recommend routine screening
except in patients who are known to be
HIV positive. However, because the
infection is thought to be passed primarily
from undercooked meat or through
infected animal feces, it is universally
recommended that pregnant women avoid
direct contact with cats' litter boxes. If
avoidance is not possible, wearing gloves
when handling a litter box is
recommended.
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A 26-year-old gravida 2 para 1 at 10


weeks' gestation presents to the emergency
department with abdominal pain and
vaginal spotting. Ultrasonography reveals
an ectopic pregnancy. Her blood type is Anegative, antibody-negative. Appropriate
management with regard to her Rh status
includes: (check one)
A. Administration of 50 g of RHO
immune globulin (RhoGAM)
B. Administration of 300 g of RhoGAM
C. Administration of 50 g of RhoGAM
only if she requires laparoscopic
intervention
D. Administration of 300 g of RhoGAM
only if she requires laparoscopic
intervention
E. No RhoGAM, as it is not indicated in
an Rh-negative woman with an ectopic
pregnancy
A 26-year-old gravida 2 para 1 presents at
30 weeks gestation with a complaint of
severe itching. She has excoriations from
scratching in various areas. She says that
she had the same problem during her last
pregnancy, and her medical records reveal
a diagnosis of intrahepatic cholestasis of
pregnancy. Elevation of which one of the
following is most characteristic of this
disorder? (check one)
A. -Glutamyltransferase (GGT)
B. Bile acids
C. Direct bilirubin
D. Indirect bilirubin
E. Prothrombin time

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A. Administration of 50 g of RHO
immune globulin (RhoGAM). Both
ectopic pregnancy and spontaneous or
therapeutic abortion pose a significant risk
for fetomaternal hemorrhage. Thus,
administration of RHO immune globulin
(RhoGAM) is recommended in any Rhnegative patient who is unsensitized (D
antibody screen-negative prior to
administration of RhoGAM). If the
estimated gestational age is 12 weeks or
less, 50 mcg of RhoGAM is
recommended. If the estimated gestational
age is greater than 12 weeks, 300 g of
RhoGAM is recommended.

B. Bile acids. Intrahepatic cholestasis of


pregnancy classically presents as severe
pruritus in the third trimester.
Characteristic findings include the absence
of primary skin lesions and elevation of
serum levels of total bile acids. Jaundice
and elevated bilirubin levels may or may
not be present. The GGT usually is normal
or modestly elevated, which can help
differentiate this condition from other
cholestatic liver diseases. The prothrombin
time usually is normal, but if elevated it
may reflect a vitamin K deficiency from
malabsorption.

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A 26-year-old gravida 3 para 2 was


diagnosed with gestational diabetes
mellitus at 24 weeks gestation. She was
prescribed appropriate nutritional therapy
and an exercise program. After 4 weeks,
her fasting plasma glucose levels remain in
the range of 105-110 mg/dL.
Which one of the following would be the
most appropriate treatment for this patient
at this time? (check one)
A. Continuation of the current regimen
B. Long-acting insulin glargine (Lantus)
once daily
C. Pioglitazone (Actos) once daily
D. A combination of intermediate-acting
insulin (e.g., NPH) and a short-acting
insulin (e.g., lispro) twice daily
E. Sliding-scale insulin 4 times daily using
ultra-short-acting insulin

D. A combination of intermediate-acting
insulin (e.g., NPH) and a short-acting
insulin (e.g., lispro) twice daily. In
addition to an appropriate diet and exercise
regimen, pharmacologic therapy should be
initiated in pregnant women with
gestational diabetes mellitus whose fasting
plasma glucose levels remain above 100
mg/dL despite diet and exercise. There is
strong evidence that such treatment to
maintain fasting plasma glucose levels
below 95 mg/dL and 1-hour postprandial
levels below 140 mg/dL results in
improved fetal well-being and neonatal
outcomes. While oral therapy with
metformin or glyburide is considered safe
and possibly effective, insulin therapy is
the best option for the pharmacologic
treatment of gestational diabetes.
Thiazolidinediones such as pioglitazone
have not been shown to be effective or
safe in pregnancy.
The use of long-acting basal insulin
analogues, such as glargine and detemir,
has not been sufficiently evaluated in
pregnancy. Sliding-scale coverage with
ultra-short-acting insulin or insulin
analogues, such as lispro and aspart, is
generally not required in most women with
gestational diabetes. While it may be
effective, it involves four daily glucose
checks and injections.
Most patients are successfully treated with
a twice-daily combination of an
intermediate-acting insulin and a shortacting insulin while continuing a diet and
exercise program.

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A 26-year-old male presents with hand


pain. He tells you he was out drinking with
friends last night and does not remember
sustaining any injuries. On examination,
there is diffuse swelling and tenderness
across the dorsal and lateral aspects of the
hand. Radiographs are shown in Figures 8
and 9.

Which one of the following would be the


most appropriate treatment? (check one)
A. A wrist extension splint
B. A molded finger splint
C. A ular gutter splint
D. A short arm cast
E. Surgical pin fixation

A 27-year-old female presents to the


emergency department with a complaint of
bloody diarrhea and abdominal cramping.
A few days ago she ate a rare hamburger at
a birthday party for her 4-year-old son. He
ate hot dogs instead, and has not been ill.
A stool specimen is positive for
Escherichia coli O:157.
Which one of the following should you do
next? (check one)
A. Provide levofloxacin (Levaquin)
prophylaxis to her close contacts
B. Monitor her liver enzymes
C. Monitor her renal function
D. Reassure her that her son is not at risk
of illness

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C. A ular gutter splint. In the radiograph


shown, there is a fracture of the fifth
metacarpal head, commonly known as a
boxer's fracture. There is only slight volar
angulation and no displacement. The
proper treatment for this fracture is an
ulnar gutter splint, which immobilizes the
wrist, hand, and fourth and fifth digits in
the neutral position. Generally, 3 or 4
weeks of continuous splinting is adequate
for healing.
Surgical pinning is indicated in cases of
significant angulation (35-40 or more of
volar angulation) or in fractures with
significant rotational deformity or
displacement. The other options listed are
not appropriate treatments for this injury.
This injury most commonly results from
"man-versus-wall" pugilistics, but other
mechanisms of injury are possible.
C. Monitor her renal function. Escherichia
coli O:157 is an increasingly common
cause of serious gastrointestinal illness.
The usual source is undercooked beef. The
child is at risk, since at least 20% of cases
result from secondary spread.
Transmission is frequent in children's daycare facilities and nurseries. Some cases
are asymptomatic, but the great majority
are symptomatic, and patients present with
bloody diarrhea. Levofloxacin is not useful
for prophylaxis in contacts. This patient
has a 10%-15% risk of developing
hemolytic uremic syndrome secondary to
her E. coli O:157 infection, making close
monitoring of renal function essential.

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A 27-year-old female presents with 2


weeks of generalized pruritus. She had
previously been in good health except for a
laparoscopic cholecystectomy 3 weeks
earlier. She has had intermittent right
upper quadrant abdominal pain since the
surgery, and has occasionally taken
acetaminophen with hydrocodone for pain
relief. Her examination is remarkable only
for questionable scleral icterus.
The most likely diagnosis is: (check one)

C. retained common duct stone.


Postcholecystectomy pain associated with
jaundice (which can cause itching) is a
classic presentation for a retained common
duct stone. Acetaminophen toxicity is
usually painless, and is associated with
ingestion of large amounts of the drug
and/or alcohol, or other potentially
hepatotoxic drugs. Viral hepatitis is
usually painless and accompanied by other
systemic symptoms. Hydrocodone can
cause pruritus but not pain and jaundice.

A. hydrocodone allergy
B. liver toxicity from acetaminophen
C. retained common duct stone
D. acute hepatitis
A 27-year-old female radiology technician
developed an area of redness over the left
interscapular region while visiting a friend
in Paris last week. The rash has progressed
to include the area shown in Figure 10 and
the patient says it itches. She recalls
feeling somewhat tired and achy once she
arrived in Paris but attributed this to jet
lag. She denies any other systemic
symptoms. Your examination reveals no
significant findings except for the rash.

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...

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A 27-year-old Korean female consults you


regarding several painful ulcers she has
developed in the vaginal area. Your
examination reveals multiple 0.5-cm to
1.5-cm oval ulcers with sharply defined
borders and a yellowish-white membrane.
She denies recent sexual activity. Except
for recurring aphthous ulcers of her mouth,
her past history is unremarkable. You
obtain blood for a CBC and serology. A
Tzanck smear and culture of her ulcer is
negative for herpes simplex virus. Two
days later she returns to discuss her
laboratory findings. She draws your
attention to a pustule with an erythematous
margin at the site where the venipuncture
was done.
At this time the most likely diagnosis is:
(check one)
A. Reiter's syndrome
B. Behet's syndrome
C. syphilis
D. mucocutaneous lymph node syndrome
(Kawasaki disease)
E. AIDS

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B. Behet's syndrome. The original


description of Behet's syndrome included
recurring genital and oral ulcerations and
relapsing uveitis. It is more common in
Japan, Korea, and the Eastern
Mediterranean area, and affects primarily
young adults. The cause is unknown. Twothirds of patients will develop ocular
involvement that may progress to
blindness. Patients may develop arthritis,
vasculitis, intestinal manifestations, or
neurologic manifestations. This disease is
also associated with cutaneous
hypersensitivity; 60%-70% of patients will
develop a sterile pustule with an
erythematous margin within 48 hours of an
aseptic needle prick. Reiter's syndrome is
not associated with genital ulcers. The
ulcers of syphilis are characteristically
painless. Mucocutaneous lymph node
syndrome (Kawasaki disease) primarily
affects children under 6 years of age.
While AIDS causes distinctive skin
lesions, genital ulcers are not a common
manifestation of this disease.

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A 27-year-old male presents with what he


thinks is a sinus infection. He has a 2-day
history of right maxillary pain associated
with nasal congestion and clear rhinorrhea.
The only significant findings on
examination are a low-grade fever and
subjective tenderness with palpation over
the right maxillary sinus. Which one of the
following treatments is most supported by
current evidence? (check one)
A. Antihistamines
B. Oral decongestants
C. Topical vasoconstrictor sprays
D. Oral analgesics
E. Nasal lavage

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D. Oral analgesics. Although oral


antibiotics are overwhelmingly prescribed
as initial treatment in acute sinusitis, it has
been shown that the majority of acute
illnesses are viral in origin and that 98% of
cases will resolve spontaneously.
Analgesics are considered the mainstay of
therapy for acute sinusitis, according to
evidence-based recommendations (SOR
A). Other treatments should be considered
if symptoms are prolonged (>7 days) or
severe (two or more localizing symptoms
or signs of serious bacterial
complications). There is little evidence of
effectiveness for antihistamines, oral
decongestants, or vasoconstrictor sprays.
There is also little evidence of
effectiveness for nasal lavage in acute
sinusitis, although it has an emerging role
in chronic sinusitis.

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A 27-year-old white female has a 10-year


history of significant premenstrual
dysphoria. Her condition has significantly
worsened in the past 3 years, to the point
that it is endangering her marriage of 5
years. Her symptoms are worse for the 10
days prior to her menstrual period and are
gone by day 2 of her period. She has tried
several measures without success,
including birth control pills, various herbal
preparations, and counseling at a woman's
health center. Which one of the following
is most likely to improve her symptoms?
(check one)
A. Reduction of caffeine and refined sugar
intake
B. Alprazolam (Xanax)
C. Bupropion (Wellbutrin)
D. Progesterone for 2 weeks starting at
about the time of ovulation
E. Fluoxetine (Prozac, Serafem) for the
last 2 weeks of the menstrual cycle
A 27-year-old white female sees you for
the first time for a routine evaluation. A
Papanicolaou test reveals atypical
glandular cells of undetermined
significance (AGUS). Of the following,
which one is most commonly found in this
situation? (check one)
A. Cervical intraepithelial neoplasia
B. Endometrial hyperplasia
C. An endocervical polyp
D. Endometrial cancer
E. Ectopic decidua

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E. Fluoxetine (Prozac, Serafem) for the


last 2 weeks of the menstrual cycle.
Several randomized trials have shown that
they are superior to placebo for this
condition. Fluoxetine and sertraline have
been studied the most. There have been no
controlled trials to support anecdotal
reports of benefit from the reduction of
caffeine or refined sugar. Studies using
alprazolam have shown it to be effective
for premenstrual anxiety only.
Progesterone has not been proven more
effective than placebo in clinical trials, and
bupropion is less effective than agents that
primarily boost serotonergic activity.
Treatment during the luteal phase alone
has been shown to be more effective than
continuous treatment for this condition.

A. Cervical intraepithelial neoplasia.


Clinical practice guidelines recommend
that all patients with atypical glandular
cells of undetermined significance
(AGUS) be evaluated by colposcopy and
endocervical curettage; endometrial
sampling is recommended in women 35
years of age or older, and in those with
AGUS favoring neoplasia or suggesting an
endometrial source. Cervical
intraepithelial neoplasia is the most
common histologic diagnosis found in
patients evaluated for AGUS.

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A 27-year-old white male construction


worker suffers from severe plaque-type
psoriasis that has required systemic
therapy. Which one of the following is
associated with this condition? (check one)
A. A reduced overall risk of cardiovascular
mortality
B. A decreased risk of skin cancer with
successful treatment
C. A low likelihood of recurrence with
successful treatment
D. An increased risk for the condition in
the children of affected individuals
E. Low body mass index and difficulty
maintaining weight

D. An increased risk for the condition in


the children of affected individuals.
Psoriasis is a genetic inflammatory
condition that has been associated with a
significant risk of cardiovascular
morbidity and mortality. Children of
patients with the disorder are at increased
risk. This is especially true if both parents
have the disorder. Life expectancy is
somewhat reduced in patients with severe
psoriasis, particularly if the disease had an
early onset. Plaque psoriasis is usually a
lifelong disease; this is in contrast to
guttate psoriasis, which may be selflimited and never recur.
Cigarette smoking may increase the risk of
developing psoriasis. Psoriasis is also
associated with an increased likelihood of
obesity, diabetes mellitus, and metabolic
syndrome.

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A 27-year-old white male has been in


rehabilitation for C6 complete
quadriplegia. His health had been good
prior to a diving accident 2 months ago
which caused his paralysis. The patient has
been catheterized since admission and his
recovery has been steady. His vital signs
have been normal and stable. The nurse
calls and tells you that for the past hour the
patient has experienced sweating,
rhinorrhea, and a pounding headache. His
heart rate is 55/min and his blood pressure
is 220/115 mm Hg. His temperature and
respirations are reported as normal. There
has been no vomiting and his neurologic
examination is unchanged. The most likely
diagnosis is: (check one)
A. Cluster headache
B. Autonomic hyperreflexia
C. Sepsis
D. Intracranial hemorrhage
E. Progression of the spinal cord lesion

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B. Autonomic hyperreflexia. Autonomic


hyperreflexia is characterized by the
sudden onset of headache and
hypertension in a patient with a lesion
above the T6 level. There may be
associated bradycardia, sweating, dilated
pupils, blurred vision, nasal stuffiness,
flushing, or piloerection. It usually occurs
several months after the injury and has an
incidence as high as 85% in quadriplegic
patients. Frequently, it subsides within 3
years of injury, but it can recur at any time.
Bowel and bladder distention are common
causes. Hypertension is the major concern
because of associated seizures and cerebral
hemorrhage. Cluster headaches have a
constant unilateral orbital localization. The
pain is steady (non-throbbing) and
lacrimation and rhinorrhea may be part of
the syndrome. Sepsis is usually manifested
by chills, fever, nausea, and vomiting.
Common signs include tachycardia and
hypotension rather than bradycardia and
hypertension. Signs and symptoms of
intracranial hemorrhage vary depending
upon the site of the hemorrhage, but the
unchanged neurologic status and the lack
of a history of hypertension decrease the
likelihood of this diagnosis. There are no
neurologic findings or history which
suggest progression of the patient's lesion
at C6.

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A 27-year-old white male presents to the


emergency department 2 hours after being
bitten by a rattlesnake. He complains of
weakness, abdominal cramping, left leg
pain, and left leg swelling. His speech is
slurred, and his breath smells of alcohol.
Physical Findings Temperature 37.0 C
(98.6 F) Blood pressure 100/60 mm Hg
Pulse 122 beats/min Respirations 24/min
Skin diaphoretic; ecchymoses on both
forearms; bite puncture site just above left
lateral malleolus Lungs clear to
auscultation Cardiac normal heart tones,
1+ posterior tibial pulses Abdomen flat;
hypoactive bowel sounds; no masses or
guarding Extremities visible swelling of
left leg and thigh; skin tightness of left leg
Neurologic decreased sensation to light
touch and sharp sensation in left foot
Which one of the following therapeutic
interventions is indicated? (check one)
A. Antivenin administration
B. Venom extractor use
C. Tourniquet application at the upper
thigh
D. Surgical consultation for
decompression fasciotomy
E. Administration of platelets and fresh
frozen plasma

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A. Antivenin administration. This patient


presents with a history of snakebite,
swelling of an entire extremity, weakness,
and ecchymosis. This is consistent with a
grade III envenomation and merits
antivenin therapy. Production of equinederived antivenin has stopped, but may
still be indicated where available. The
ovine product, CroFab, is less allergenic
but still scarce due to limited production.
Venom extractors are thought to be useful
only in the first few minutes after a bite.
Two hours is too late to be of any use.
Tourniquets are thought to be
contraindicated when used to compress an
artery. Low-pressure constriction of
lymphatic and venous vessels is
controversial. Fasciotomy has not proved
useful. Antivenin is indicated before any
consideration of compartment syndrome.
Pressure measurements would be required
because of the clinical similarities between
envenomation injury and compartment
syndrome. Coagulation factors and blood
products are rapidly inactivated. They are
indicated only in the presence of
exsanguination.

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A 28-year-old female consults you because


of fatigue, arthralgias that are worse in the
morning, and painful, swollen finger
joints. She is a high-school teacher. Her
erythrocyte sedimentation rate is 60 mm/hr
and a test for rheumatoid factor is strongly
positive.
The best choice for initial therapy would
be: (check one)
A. prednisone
B. aspirin
C. naproxen (Naprosyn)
D. rituximab (Rituxan)
E. methotrexate (Rheumatrex)

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E. methotrexate (Rheumatrex). Aspirin


was once the best initial therapy for
rheumatoid arthritis and then NSAIDs
became the preferred treatment. Now,
however, disease-modifying drugs such as
methotrexate are the best choice for initial
therapy. Aspirin and NSAIDs are no
longer considered first-line treatment
because of concerns about their limited
effectiveness, inability to modify the longterm course of the disease, and
gastrointestinal and cardiotoxic effects.
Glucocorticoids such as prednisone are
often useful, but have significant side
effects. Biologic agents such as rituximab
are expensive and have significantly more
side effects than methotrexate.

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A 28-year-old female presents for


evaluation of a persistent thin discharge,
with a "fishy" odor particularly noticeable
after intercourse. She has no dyspareunia
or dysuria, is in a monogamous
relationship, and has used oral
contraceptives for many years. Physical
examination reveals no vulvar, vaginal, or
cervical erythema. There is a homogenous
white discharge that coats the vaginal
walls. The vaginal pH is 7.0 and on
microscopy you note stippled epithelial
cells but no hyphae or trichomonads.
Which one of the following is true
regarding this patient? (check one)

A. The treatment of choice may interact


with alcohol. The patient has the typical
symptoms and signs of bacterial vaginosis.
There is no need for confirmatory testing.
The treatment of choice is oral
metronidazole, which may cause a
disulfiram-like interaction with alcohol.
Treatment of the partner has not been
shown to improve the outcome.

A. The treatment of choice may interact


with alcohol
B. The patient's partner needs to be treated
simultaneously
C. The diagnosis should be confirmed with
a culture
D. Oral contraceptives contribute to the
risk for this condition

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A 28-year-old female sees you with a


complaint of irregular menses. She has not
had a menstrual period for 6 months. She
is also concerned about weight gain,
worsening acne, and dark hair on her
upper lip, chin, and periareolar region. She
is also interested in becoming pregnant
soon. The patient tells you she has started
an exercise program, which has helped
with weight loss, but she continues to have
amenorrhea. She has a negative urine hCG test, a mild elevation in free
testosterone levels, and glucose
intolerance.
Which one of the following would you
consider initially for inducing ovulation?
(check one)
A. Insulin
B. Metformin (Glucophage)
C. Ethinyl estradiol/norgestimate (Ortho
Tri-Cyclen)
D. Glipizide (Glucotrol)
E. Spironolactone (Aldactone)

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B. Metformin (Glucophage). First-line


agents for ovulation induction and
treatment of infertility in patients with
polycystic ovary syndrome (PCOS)
include metformin and clomiphene, alone
or in combination, as well as rosiglitazone
(SOR A). In one study of nonobese
women with PCOS, metformin was found
to be more effective than clomiphene for
improving the rate of conception (level of
evidence 1b). However, the treatment of
infertile women with PCOS remains
controversial. One recent group of experts
recommended that metformin use for
ovulation induction in PCOS be restricted
to women with glucose intolerance (SOR
C).
Oral contraceptives are commonly used to
treat menstrual irregularities in women
with PCOS; however, there are few studies
supporting their use, and they would not
be appropriate for ovulation induction.
Spironolactone is a first-line agent for
treatment of hirsutism (SOR A) and has
shown promise in treating menstrual
irregularities, but is not commonly
recommended for ovulation induction.
There is a high prevalence of insulin
resistance in women with PCOS, as
measured by glucose intolerance; insulinsensitizing agents are therefore indicated,
but not insulin or sulfonylurea
medications.

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A 28-year-old gravida 2 para 1 at 32


weeks' gestation presents with severe
itching. She denies fever or vomiting. Her
physical examination is remarkable for
jaundice, but is otherwise benign.
Laboratory studies reveal a normal CBC,
normal platelets, normal glucose and
serum creatinine levels, normal
transaminase levels, and a bilirubin level
of 4.0 mg/dL (N 0.0-1.0). Which one of
the following is the most likely diagnosis?
(check one)
A. Intrahepatic cholestasis of pregnancy
B. Acute viral hepatitis
C. Acute fatty liver of pregnancy
D. Pruritic urticarial papules and plaques
of pregnancy (PUPPP)
E. Hemolysis, elevated liver enzymes, low
platelets (HELLP) syndrome

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A. Intrahepatic cholestasis of pregnancy.


Intrahepatic cholestasis of pregnancy is
rare, occurring in 0.01% of pregnancies. It
usually presents in the third trimester.
Approximately 80% of patients present
with pruritus alone, and another 20% with
jaundice and pruritus. Laboratory results
usually reveal normal or minimal elevation
in transaminase levels, elevated bilirubin
(usually <5 mg/dL), and occasional
elevations in cholesterol and triglyceride
levels. It is important to recognize and
diagnose this entity, as it is associated with
prematurity, fetal distress, and increased
perinatal mortality. Acute viral hepatitis is
a common cause of jaundice in pregnancy;
however, it usually does not present with
severe pruritus, and transaminase levels
are markedly elevated. Acute fatty liver of
pregnancy is another rare condition
occurring in the third trimester and is
usually associated with preeclampsia
(50%-100% of cases). It presents with
nausea and vomiting, anorexia, jaundice,
abdominal pain, headache, and neurologic
abnormalities. Transaminase levels are
moderately elevated, PT and PTT are
prolonged, and profound hypoglycemia
and renal failure are usually present.
Pruritic urticarial papules and plaques of
pregnancy (PUPPP) is more common in
women that present with severe pruritus.
However, jaundice and liver function
abnormalities are absent. HELLP
syndrome is an uncommon but serious
condition which presents in the third
trimester with hemolysis, elevated
transaminases, and low platelet count.

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A 28-year-old male is seen for follow-up


of acute low back pain. He has a past
history of substance abuse. Ibuprofen and
acetaminophen have helped some, but he
is experiencing muscle spasms.
It is best to avoid which one of the
following when treating this patient's
problem?
(check one)
A. Chlorzoxazone (Parafon Forte DSC)
B. Metaxalone (Skelaxin)
C. Cyclobenzaprine (Flexeril)
D. Methocarbamol (Robaxin)
E. Carisoprodol (Soma)

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E. Carisoprodol (Soma). There is limited


data regarding the effectiveness of muscle
relaxants in musculoskeletal conditions,
but strong evidence regarding their
toxicity. Because the evidence for
comparable effectiveness is weak, drug
selection should be based on patient
preference, side-effect profile, drug
interactions, and abuse potential.
Carisoprodol is metabolized to
meprobamate, which is a class III
controlled substance. It has been shown to
produce both physical and psychologic
dependence.

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A 28-year-old male presents with the


recent onset of intermittent urethral
discharge accompanied by dysuria. He is
heterosexual, has no prior history of a
sexually transmitted infection, and
acquired a new sexual partner a month
ago. He has no regional lymphadenopathy
or ulcers, and gentle milking of the urethra
produces no discharge. Evaluation of a
first-void urine specimen, however,
reveals 15 WBCs/hpf. You treat him with
oral azithromycin (Zithromax), 1 g in a
single dose, and ceftriaxone (Rocephin),
125 mg intramuscularly. Test results for
gonorrhea, Chlamydia, syphilis, HIV, and
hepatitis B are negative.
He returns 2 months later because his
urethral discharge has persisted. He reports
no relationships with a different sexual
partner, and is confident that his current
partner has only had sexual contact with
him. You repeat the previous tests and
again treat him with oral azithromycin.
According to CDC testing and treatment
guidelines, which one of the following
drugs should be added to his treatment
regimen? (check one)
A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
E. Cefixime (Suprax)

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A. Metronidazole (Flagyl). According to


CDC guidelines, the initial workup for
urethritis in men includes gonorrhea and
Chlamydia testing of the penile discharge
or urine, urinalysis with microscopy if no
discharge is present, VDRL or RPR testing
for syphilis, and HIV and hepatitis B
testing. Empiric treatment for men with a
purulent urethral discharge or a positive
urine test (positive leukocyte esterase or
10 WBCs/hpf in the first-void urine
sediment) includes azithromycin, 1 g
orally as a single dose, OR doxycycline,
100 mg orally twice a day for 7 days,
PLUS ceftriaxone, 125 mg
intramuscularly, OR cefixime, 400 mg
orally as a single dose.
If the patient presents with the same
complaint within 3 months, and does not
have a new sexual partner, the tests
obtained at his first visit should be
repeated, and consideration should be
given to obtaining cultures for
Mycoplasma or Ureaplasma and
Trichomonas from the urethra or urine.
Treatment should include azithromycin,
500 mg orally once daily for 5 days, or
doxycycline, 100 mg orally twice daily for
7 days, plus metronidazole, 2 g orally as a
single dose.

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A 28-year-old male recreational runner has


a midshaft posteromedial tibial stress
fracture. Although he can walk without
pain, he cannot run without pain.
The most appropriate treatment at this
point includes which one of the following?
(check one)
A. A short leg walking cast
B. A non-weight-bearing short leg cast
C. A non-weight-bearing long leg cast
D. An air stirrup leg brace (Aircast)
E. Low-intensity ultrasonic pulse therapy

A 28-year-old primigravida is at 20 weeks'


gestation by dates but her fundal height is
consistent with a 26-week gestation. She
has had episodes of vomiting during the
pregnancy that were more severe than the
physiologic vomiting typically seen in
pregnancy. A sonogram performed at
about 5 weeks' gestation for vaginal
bleeding was normal and showed a single
fetus. Which one of the following would
be most appropriate at this point? (check
one)
A. A serum hCG level
B. A repeat sonogram
C. MRI of the pelvis
D. Expectant management

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D. An air stirrup leg brace (Aircast).


Midshaft posteromedial tibial stress
fractures are common and are considered
low risk. Management consists of relative
rest from running and avoiding other
activities that cause pain. Once usual daily
activities are pain free, low-impact
exercise can be initiated and followed by a
gradual return to previous levels of
running. A pneumatic stirrup leg brace has
been found to be helpful during treatment
(SOR C). Non-weight bearing is not
necessary, as this patient can walk without
pain. Casting is not recommended.
Ultrasonic pulse therapy has helped
fracture healing in some instances, but has
not been shown to be beneficial in stress
fractures.
B. A repeat sonogram. Ultrasonography is
the initial test of choice for evaluating the
possibility of multiple gestation. It should
be done if uterine size is larger than
expected, or if pregnancy-associated
symptoms are excessive. It should also be
done in women who received fertility
treatment. An initial sonogram that shows
a single pregnancy does not rule out
multiple gestation. In one study, 30 of 220
twin pregnancies had an original sonogram
which showed a single pregnancy. Serum
hCG and MRI would not be indicated at
this stage in the evaluation.

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A 28-year-old white female consults you


with a complaint of irregular heavy
menstrual periods. A general physical
examination, pelvic examination, and
Papanicolaou test are normal and a
pregnancy test is negative. A CBC and
chemistry profile are also normal.
The next step in her workup should be:
(check one)
A. endometrial aspiration
B. dilatation and curettage
C. LH and FSH assays
D. administration of estrogen
E. cyclic administration of progesterone
for 3 months

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E. cyclic administration of progesterone


for 3 months. Abnormal uterine bleeding is
a relatively common disorder that may be
due to functional disorders of the
hypothalamus, pituitary, or ovary, as well
as uterine lesions. However, the patient
who is younger than 30 years of age will
rarely be found to have a structural uterine
defect. Once pregnancy, hematologic
disease, and renal impairment are
excluded, administration of intramuscular
or oral progesterone will usually produce
definitive flow and control the bleeding.
No further evaluation should be necessary
unless the bleeding recurs.
Endometrial aspiration, dilatation and
curettage, and other diagnostic procedures
are appropriate for recurrent problems or
for older women. Estrogen would only
increase the problem, which is usually due
to anovulation with prolonged estrogen
secretion, producing a hypertrophic
endometrium.

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A 28-year-old white female presents with


painful genital ulcers. She has not had any
previous episodes of similar outbreaks.
She is single, but has had several
heterosexual relationships. She has been
with her current partner for 3 years. A
culture confirms a herpes simplex virus
(HSV) infection. Which one of the
following is true regarding her situation?
(check one)
A. Suppressive therapy can reduce the risk
of transmission to her partner
B. In the genital area, HSV type 1
infection can be differentiated clinically
from HSV type 2 infection
C. This outbreak is conclusive evidence of
infidelity in her partner
D. An HSV vaccine is available for her
partner to reduce his risk of infection

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A. Suppressive therapy can reduce the risk


of transmission to her partner. Suppressive
therapy with acyclovir, valacyclovir, or
famciclovir reduces, but does not
eliminate, the risk of transmission of HSV
to sexual partners. HSV type 1 and HSV
type 2 infections in the genital area are
clinically identical. Psychological issues,
including anger, guilt, low self-esteem,
anxiety, and depression are common after
first receiving a diagnosis of genital HSV
infection. Initial clinical outbreaks of
genital HSV infections are often
recurrences of previous infection. Either of
the partners may have had an
asymptomatic infection acquired in a
previous relationship. An experimental
HSV type 2 vaccine has been developed,
but it is ineffective in men.

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A 28-year-old white male comes to your


office complaining of pain in the right
wrist since falling 2 weeks ago. On
examination, he is tender in the anatomic
snuffbox. A radiograph reveals a
nondisplaced fracture of the distal onethird of the carpal navicular bone
(scaphoid).
Which one of the following is the most
appropriate management at this time?
(check one)
A. A bone scan
B. Physical therapy referral
C. A Velcro wrist splint
D. A short arm cast
E. A thumb spica cast

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E. A thumb spica cast. Fracture of the


scaphoid should be suspected in every
"sprained wrist" presenting with
tenderness in the anatomic snuffbox.
Radiographs may be negative initially. The
scaphoid circulation enters the bone for the
most part through the distal half. Fractures
through the proximal third tend to cause
loss of circulation and are slower to heal,
and should be referred to an orthopedist
because of the risk of nonunion and
avascular necrosis. Fractures through the
middle or distal one-third can be handled
by the family physician in consultation
with an orthopedist. The fracture is treated
with a thumb spica cast for 10-12 weeks.
A wrist splint does not provide adequate
immobilization. A bone scan is
unnecessary, and physical therapy is
inappropriate. If there is still no evidence
of union after 10 weeks of immobilization,
the patient should be referred to an
orthopedist for further care.

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09/11/2014

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A 29-year-old gravida 1 para 0 at 8 weeks


gestation is concerned about Down
syndrome. She had a sibling with Down
syndrome, and she and her spouse want to
know what antenatal tests are available to
them.
Which one of the following has the best
detection rate for Down syndrome in the
first trimester of pregnancy?
(check one)
A. Serum -hCG and pregnancyassociated plasma protein A (PAPP-A),
with nuchal translucency (combined
screening)
B. Maternal serum levels of inhibin A, fetoprotein, unconjugated estriol, and hCG (quadruple screening)
C. Ultrasonography
D. Chorionic villus sampling
E. Amniocentesis

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D. Chorionic villus sampling. In today's


environment, there are multiple screening
tools and tests to detect fetal aneuploidy.
All pregnant women, regardless of age,
should be offered the opportunity to
undergo some form or combination of
screening to detect fetal abnormalities
(SOR B). Chorionic villus sampling can be
offered at 10-13 weeks gestation, and has a
97.8% detection rate for Down syndrome
the best detection rate of studies offered
in the first trimester (SOR C). Combined
screening can be offered at 11-14 weeks
gestation, and has a 78.7%-89% detection
rate (SOR A). Although amniocentesis has
the best detection rate of the options listed
(99.4%), it cannot be offered until 16-18
weeks gestation (SOR C). Quadruple
screening is done at 15-20 weeks
gestation, and has a 67%-81% detection
rate (SOR A); ultrasonography at 18-22
weeks gestation has a 35%-79% detection
rate (SOR C).

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A 29-year-old gravida 2 para 1 presents for


pregnancy confirmation. Her last
menstrual period began 6 weeks ago. Her
medical history is significant for
hypothyroidism, which has been wellcontrolled on levothyroxine (Synthroid),
150 g daily, for the past 2 years.
Which one of the following would be the
most appropriate next step in the treatment
of this patient's hypothyroidism during her
pregnancy? (check one)

C. Increase the levothyroxine dosage.


Maternal hypothyroidism can have serious
effects on the fetus, so thyroid dysfunction
should be treated during pregnancy.
Because of hormonal and metabolic
changes in early pregnancy, the
levothyroxine dosage often needs to be
increased at 4-6 weeks gestation, and the
patient eventually may require a 30%-50%
increase in dosage in order to maintain her
euthyroid status.

A. Add liothyronine (Cytomel) to her


current regimen
B. Decrease the levothyroxine dosage
C. Increase the levothyroxine dosage
D. Continue her current regimen

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A 29-year-old white female is hospitalized


following a right middle cerebral artery
stroke confirmed by MRI. Her past
medical history is remarkable only for a
history of an uncomplicated tonsillectomy
during childhood and a second-trimester
miscarriage 3 years ago. The only
remarkable finding on physical
examination is left hemiplegia.The initial
laboratory workup reveals normal
hematocrit and hemoglobin levels, a
normal prothrombin time, and a platelet
count of 200,000/mm3 (N 140,000440,000). The activated partial
thromboplastin time is 95 sec (N 23.634.6), and it does not normalize when the
patient's serum is mixed with normal
plasma. A serum VDRL is positive, and a
serum FTA-ABS is nonreactive.
Which one of the following is the most
likely diagnosis?
(check one)
A. Hemophilia
B. Neurosyphilis
C. Antiphospholipid syndrome
D. Thrombotic thrombocytopenic purpura
E. Protein C deficiency

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C. Antiphospholipid syndrome. The


antiphospholipid syndrome is due to the
appearance of a heterogeneous group of
circulating antibodies to negatively
charged phospholipids, including most
commonly a lupus anticoagulant and
anticardiolipin antibodies. The antibodies
are usually detected by a false-positive
serologic test for syphilis. Clinical features
include venous and arterial thrombosis,
fetal wastage, thrombocytopenia, and the
presence of an activated partial
thromboplastin time (aPTT) inhibitor. It is
an important diagnostic consideration in
all patients with unexplained thrombosis or
cerebral infarction, particularly in young
patients.
Although hemophilia would also be
associated with a prolonged aPTT, the
PTT would normalize when
the patient's serum was mixed with normal
plasma. Neurosyphilis is excluded by the
negative serum FTAABS result.
Thrombotic thrombocytopenic purpura is
not associated with prolongation of the
aPTT and is associated with a hemolytic
anemia. Although protein C deficiency is a
hypercoagulable state that can lead to
stroke, none of the laboratory
abnormalities suggests this diagnosis.

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A 30-year-old African-American female is


being evaluated because of absent menses
for the last 6 months. Menarche was at age
12. Her menstrual periods have frequently
been irregular, and are accompanied only
occasionally by dysmenorrhea. She had
her first child 4 years ago, but has not been
able to become pregnant since. A physical
examination and pelvic examination are
unremarkable. A serum pregnancy test is
negative, prolactin levels are normal, and
LH and FSH levels are both three times
normal on two occasions.
These findings are consistent with:
(check one)
A. hypothalamic amenorrhea
B. ovarian failure
C. pituitary microadenoma
D. polycystic ovary syndrome

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B. ovarian failure. The history and


physical findings in this patient are
consistent with all of the conditions listed.
However, the elevated FSH and LH
indicate an ovarian problem, and this case
is consistent with ovarian failure or
premature menopause. Most pituitary
tumors associated with amenorrhea
produce hyperprolactinemia. Polycystic
ovary syndrome usually results in normal
to slightly elevated LH levels and tonically
low FSH levels. Hypothalamic amenorrhea
is a diagnosis of exclusion, and can be
induced by weight loss, excessive physical
exercise (running, ballet), or systemic
illness. It is associated with tonically low
levels of LH and FSH.

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A 30-year-old female comes to your office


because she is concerned about irregular
menses (fewer than 9/year), acne, and
hirsutism. Her BMI is 36.0 kg/m2. She has
no other medical problems and would like
to have a baby. Her fasting blood glucose
level is 140 mg/dL.
Which one of the following would be the
most appropriate treatment for this
patient's condition and concerns?
(check one)
A. Lifestyle modification only
B. Lifestyle modification and pioglitazone
(Actos)
C. Lifestyle modification and metformin
(Glucophage)
D. Lifestyle modification and an oral
contraceptive
E. Lifestyle modification and oral
testosterone

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C. Lifestyle modification and metformin


(Glucophage). This patient has classic
features of polycystic ovary syndrome
(PCOS). The diagnosis is based on the
presence of two of the following:
oligomenorrhea or amenorrhea, clinical or
biochemical hyperandrogenism, or
polycystic ovaries visible on
ultrasonography. Lifestyle modifications
are necessary, but medications are also
needed. First-line agents for the treatment
of hirsutism in patients with PCOS include
spironolactone, metformin, and
eflornithine (SOR A). Firstline agents for
ovulation induction and treatment of
infertility in patients with PCOS include
metformin and clomiphene, alone or in
combination with rosiglitazone (SOR A).
Metformin can also improve menstrual
irregularities in patients with PCOS (SOR
A), and is probably the first-line agent for
obese patients to promote weight reduction
(SOR B). In addition, metformin improves
insulin resistance (diagnosed by elevated
fasting blood glucose) in patients with
PCOS, as do rosiglitazone and
pioglitazone. Pioglitazone would not be
appropriate for this patient because it
causes weight gain. Oral contraceptives
would improve the patient's menstrual
irregularities and hirsutism, but she wishes
to become pregnant. Testosterone would
worsen the hyperandrogenism and would
not treat the PCOS.

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A 30-year-old female presents to your


office for an initial visit. She reports a long
history of asthma that currently awakens
her three times per month, necessitating
the use of an albuterol inhaler (Proventil,
Ventolin).
According to current guidelines, which
one of the following would be optimal
treatment?
(check one)

D. Adding a low-dose inhaled


corticosteroid. Inhaled corticosteroids
improve asthma control more effectively
in children and adults than any other single
long-term controller medication (SOR A).
This patient has mild persistent asthma and
should be treated with a low-dose inhaled
corticosteroid.

A. Continued use of a short-acting agonist only as needed


B. Adding a long-acting -agonist
C. Adding a leukotriene receptor
antagonist
D. Adding a low-dose inhaled
corticosteroid
E. Adding theophylline
A 30-year-old female presents with
concerns about vaginal bleeding. She
states that her menstrual periods have
occurred at regular intervals of 28-30 days
for the past 15 years, but recently bleeding
has also occurred for a day or two in the
middle of her cycle. This bleeding has
been heavy enough to require the use of
multiple pads. Which one of the following
terms best describes her bleeding pattern?
(check one)
A. Polymenorrhea
B. Mid-cycle spotting
C. Metrorrhagia
D. Menometrorrhagia
E. Acute emergent abnormal uterine
bleeding

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C. Metrorrhagia. This patient has


metrorrhagia, or "bleeding intermenstrual,"
characterized by bleeding heavy enough to
require the use of multiple pads; the heavy
bleeding occurs between normal menstrual
bleeding. It is important to evaluate
metrorrhagia because potential causes
include cervical disease, problems with
IUDs, endometritis, polyps, submucous
myomas, endometrial hyperplasia, and
cancer. Mid-cycle spotting, as the term
implies, refers to light spotting and is often
caused by a decline in estrogen levels.
Polymenorrhea is bleeding occurring at
intervals of less than 21 days.
Menometrorrhagia is heavy and/or
prolonged bleeding occurring at irregular,
noncyclic intervals. Acute emergent
abnormal uterine bleeding is characterized
by significant blood loss resulting in
hypovolemia.
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A 30-year-old female who had a deep


venous thrombosis in her left leg during
pregnancy has an uneventful delivery.
During the pregnancy she was treated with
low molecular weight heparin. Just after
delivery her left leg is pain free and is not
swollen. She plans to resume normal
activities soon.
Which one of the following would be most
appropriate with regard to anticoagulation?
(check one)

C. Continuing low molecular weight


heparin for 6 more weeks. The risk of
pulmonary embolism continues in the
postpartum period, and may actually
increase during that time. For patients who
have had a deep-vein thrombosis during
pregnancy, treatment should be continued
for 6 weeks after delivery, with either
warfarin or low molecular weight heparin.

A. Discontinuing treatment, with no


further evaluation
B. Discontinuing treatment if venous
Doppler ultrasonography is negative for
thrombus
C. Continuing low molecular weight
heparin for 6 more weeks
D. Switching to low-dose unfractionated
heparin for 6 weeks
E. Switching to aspirin for 6 weeks
A 30-year-old female with dysfunctional
uterine bleeding asks about treatment
options. An examination is normal and
blood testing is negative. She is unmarried
and is undecided about having children.
Which one of the following would be the
most appropriate treatment for this patient?
(check one)
A. A levonorgestrel-releasing intrauterine
device
B. Endometrial ablation
C. Hysterectomy
D. Oral progestin during the luteal phase

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

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A 30-year-old gravida 3 para 2 at 28


weeks' gestation is a restrained passenger
in a high-speed motor vehicle accident.
After initial stabilization in the field with
supplemental oxygen and intravenous
fluids, she is brought into the emergency
department on a backboard and wearing a
cervical collar. Until you are able to rule
out a spinal injury, in what position should
the patient be kept? (check one)
A. Supine
B. Supine, with the uterus manually
deflected laterally
C. Prone
D. Trendelenburg's position
E. Left lateral decubitus

A 30-year-old male complains of the


gradual onset of anterior right knee pain on
climbing the stairs. On examination there
is no effusion, but there is tenderness over
the medial retinaculum. There is good
ligament strength, and range of motion is
normal. When the knee is extended from
90 flexion to full extension, the patella
deviates laterally.
Which one of the following would be the
best initial treatment for this condition?
(check one)

B. Supine, with the uterus manually


deflected laterally. In general, it is best to
place a woman who is greater than 20
weeks pregnant in the left lateral decubitus
position because the uterus can compress
the great vessels, resulting in decreased
systolic blood pressure and uterine blood
flow. However, in the case of trauma
where a spinal cord injury cannot be ruled
out, the woman needs to be kept supine on
a backboard. The weight of the uterus can
be shifted off the great vessels by either
manual deflection laterally or by elevating
the right hip 4-6 inches by placing towels
under the backboard. The Trendelenburg
position does not relieve the weight of the
uterus on the great vessels. The prone
position does not provide adequate spinal
cord protection, and would be extremely
awkward in a large pregnant woman.
E. Physical therapy. This patient has
patellofemoral stress syndrome. It is often
called runner's knee or anterior knee pain.
The patellofemoral joint comprises the
patella and femoral trochlea. The best
initial treatment is physical therapy.
Bracing, taping, and medications are
unlikely to have better outcomes.
Arthroscopic surgery is not indicated.

A. Bracing
B. Taping
C. NSAIDs
D. Arthroscopic surgery
E. Physical therapy

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A 30-year-old male presents to the


emergency department with a sensation of
a racing heart. His history is significant for
known Wolff-Parkinson-White syndrome
(WPW). On examination he is alert and in
no severe distress. His blood pressure is
130/70 mm Hg, pulse rate 220 beats/min,
and oxygen saturation 96%. An EKG
reveals a regular, wide-complex
tachycardia with a rate of 220 beats/min.
You determine that he is stable, the EKG
is consistent with WPW, and
pharmacologic conversion is a safe initial
therapy.

C. Procainamide. Adenosine, digoxin, and


calcium channel antagonists act by
blocking conduction through the
atrioventricular (AV) node, which may
increase the ventricular rate paradoxically,
initiating ventricular fibrillation. These
agents should be avoided in WolffParkinson-White syndrome. Procainamide
is usually the treatment of choice in these
situations, although amiodarone may also
be used.

Which one of the following would be the


treatment of choice? (check one)
A. Verapamil (Calan)
B. Adenosine (Adenocard)
C. Procainamide
D. Digoxin

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A 30-year-old male presents with a 3-week


history of severe, burning pain in his right
shoulder. He recalls no mechanism of
injury. An examination reveals weakness
to resistance of the biceps and triceps, and
with external rotation of the shoulder. Full
range of motion of the neck and shoulder
does not worsen the pain.
Which one of the following would be most
likely to identify the cause of this patient's
problem? (check one)
A. Electromyography and nerve
conduction studies
B. MRI of the neck
C. MR arthrography (MRA) of the
shoulder
D. CT of the brain
E. Ultrasonography of the upper extremity
A 30-year-old white gravida 2 para 1 who
has had no prenatal care presents for
urgent care at 33 weeks gestation. Her
symptoms include vaginal bleeding,
uterine tenderness, uterine pain between
contractions, and fetal distress. Her first
pregnancy was uncomplicated, with a
vaginal delivery at term.
Which one of the following is the most
likely diagnosis? (check one)
A. Uterine rupture
B. Vasa previa
C. Placenta previa
D. Placental abruption
E. Cervical cancer

A. Electromyography and nerve


conduction studies. This patient has
brachial neuritis, which can be difficult to
differentiate from cervical radiculopathy,
shoulder pathology, and cerebrovascular
accident. The pain preceded the weakness,
no trauma was involved, and the weakness
is in a nondermatomal distribution, making
brachial neuritis the most likely diagnosis.
Electromyography is most likely to show
this lesion, but only after 3 weeks of
symptoms. MRI of the neck may show
abnormalities, but not the cause of the
current problem. Symptoms are not
consistent with shoulder pathology, deepvein thrombosis of the upper extremity, or
cerebrovascular accident.

D. Placental abruption. Late pregnancy


bleeding may cause fetal morbidity and/or
mortality as a result of uteroplacental
insufficiency and/or premature birth. The
condition described here is placental
abruption (separation of the placenta from
the uterine wall before delivery).
There are several causes of vaginal
bleeding that can occur in late pregnancy
that might have consequences for the
mother, but not necessarily for the fetus,
such as cervicitis, cervical polyps, or
cervical cancer. Even advanced cervical
cancer would be unlikely to cause the
syndrome described here. The other
conditions listed may bring harm to the
fetus and/or the mother.
Uterine rupture usually occurs during
active labor in women with a history of a
previous cesarean section or with other

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predisposing factors, such as trauma or


obstructed labor. Vaginal bleeding is an
unreliable sign of uterine rupture and is
present in only about 10% of cases. Fetal
distress or demise is the most reliable
presenting clinical symptom. Vasa previa
(the velamentous insertion of the umbilical
cord into the membranes in the lower
uterine segment) is typically manifested by
the onset of hemorrhage at the time of
amniotomy or by spontaneous rupture of
the membranes. There are no prior
maternal symptoms of distress. The
hemorrhage is actually fetal blood, and
exsanguination can occur rapidly. Placenta
previa (placental implantation that overlies
or is within 2 cm of the internal cervical
os) is clinically manifested as vaginal
bleeding in the late second or third
trimester, often after sexual intercourse.
The bleeding is typically painless, unless
labor or placental abruption occurs.
A 30-year-old white male complains of
several weeks of nasal stuffiness, purulent
nasal discharge, and facial pain. He does
not respond to a 3-day course of
trimethoprim/sulfamethoxazole (Bactrim,
Septra). Follow-up treatment with 2 weeks
of amoxicillin/clavulanate (Augmentin) is
similarly ineffective. Of the following
diagnostic options, which one is most
appropriate at this time? (check one)
A. Pulmonary function testing
B. Coronal CT of the sinuses
C. Culture and sensitivity testing of the
discharge
D. Erythrocyte sedimentation rate

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B. Coronal CT of the sinuses. This patient


has a clinical presentation consistent with
acute sinusitis. Failure to respond to
adequate antibiotic therapy suggests either
a complication, progression to chronic
sinusitis, or a different, confounding
diagnosis. The diagnostic procedure of
choice in this situation is coronal CT of the
sinuses, due to its increased sensitivity and
competitive cost when compared with
standard radiographs. Cultures of the nasal
discharge give unreliable results because
of bacterial contamination from the
resident flora of the nose. The other
options listed do not contribute to the
diagnosis and treatment of sinusitis.

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A 30-year-old white male visits your clinic


after being in a bar fight. He describes
hitting another man in the mouth with his
closed fist. He reports a painful distal fifth
metacarpal with a superficial abrasion.
After assessing tetanus status and
copiously irrigating the wound, you should
do which one of the following? (check
one)
A. Obtain a radiograph and give
prophylactic antibiotics
B. Obtain a radiograph only
C. Give prophylactic antibiotics only
D. Probe the abrasion

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A. Obtain a radiograph and give


prophylactic antibiotics. This presentation
is consistent with a common injury called
a "fight bite." Radiographs are needed to
determine if there is a distal metacarpal
fracture so that it can be treated
appropriately. Because human bites
commonly cause infection, prophylactic
antibiotics are recommended with any
break in the skin. If the skin break is
superficial, this is sufficient. Deeper
wounds should be explored by a surgeon,
but superficial wounds should not be
probed indiscriminately.

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A 31-year-old female who is a successful


professional photographer complains of
hoarseness that started suddenly 3 weeks
ago. She says she can remember exactly
what day it was, because her divorce
became final the next day. The day the
problem began, she was only able to
whisper from the time she woke up, and
she is able to speak only in a weak whisper
while relating her history. She does not
appear to strain while speaking. She does
not smoke, has had no symptoms of an
upper respiratory infection, and has no
pain, cough, or wheezing.
She is on a proton pump inhibitor
prescribed by an urgent care provider 2
weeks ago. This has not changed her
symptoms. She takes no other medications
and has no known allergies. A head and
neck examination, including indirect
laryngoscopy, is within normal limits.
Which one of the following is the most
likely diagnosis?
(check one)
A. Muscle tension aphonia
B. Laryngopharyngeal reflux
C. Spasmodic dysphonia
D. Vocal abuse
E. Conversion aphonia

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E. Conversion aphonia. This patient has


conversion aphonia. In this condition, the
patient loses his or her spoken voice, but
the whispered voice is maintained. The
vocal cords appear normal, but if observed
closely by an otolaryngologist, there is a
loss of vocal cord adduction during
phonation, but normal adduction with
coughing or throat clearing. This often
occurs after a traumatic event (in this case
a divorce) (SOR C).
Muscle tension aphonia presents with
strained, effortful phonation, vocal fatigue,
and normal vocal cords. It is caused by
excessive laryngeal or extralaryngeal
tension associated with a variety of factors,
including poor breath control and stress,
for example. The patient with
laryngopharyngeal reflux presents with a
raspy or harsh voice. The hoarseness is
usually worse early in the day and
improves as the day goes by. There is
usually associated heartburn, dysphagia,
and/or throat clearing.
The patient with spasmodic dysphonia
(also known as laryngeal dystonia) has a
halting, strangled vocal quality. It is a
distinct neuromuscular disorder of
unknown cause. Uncontrolled contractions
of the laryngeal muscles cause focal
laryngeal spasm. The hoarseness of vocal
abuse is usually worse later in the day after
effortful singing or talking. The history
usually reveals vocal cord abuse, such as
with an untrained singer or some other
situation that increases demands on the
voice. Nodules or cysts may be seen on the
vocal cords with this condition.

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A 31-year-old healthy female is admitted


to the hospital from the emergency
department after presenting with aching in
her right shoulder and swelling in the
ipsilateral forearm and hand. The only
precipitating event that she can recall is
digging strenuously in the back yard to put
in a new garden. Ultrasonography is
remarkable for a thrombus in the
axillosubclavian vein. She has no prior
history of clotting, takes no medications,
and has no previous history of medical or
surgical procedures involving this
extremity. The most likely etiology for this
patient's condition is (check one)
A. a hypercoagulable state
B. a compressive anomaly in the thoracic
outlet
C. use of injection drugs
D. Budd-Chiari syndrome

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B. a compressive anomaly in the thoracic


outlet. Thrombosis of the upper extremity
accounts for about 10% of all venous
thromboembolism (VTE) cases. However,
axillosubclavian vein thrombosis (ASVT)
is becoming more frequent with the
increased use of indwelling subclavian
vein catheters. Spontaneous ASVT (not
catheter related) is seen most commonly in
young, healthy individuals. The most
common associated etiologic factor is the
presence of a compressive anomaly in the
thoracic outlet. These anomalies are often
bilateral, and the other upper extremity at
similar risk for thrombosis. While a
hypercoagulable state also may contribute
to the thrombosis, it is much less common.
Budd-Chiari syndrome refers to
thrombosis in the intrahepatic,
suprahepatic, or hepatic veins. It is not
commonly associated with spontaneous
upper-extremity thrombosis.

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A 32-year-old African-American female


presents with a 3-day history of fever,
cough, and shortness of breath. She has
been healthy otherwise, except for a sinus
infection 2 months ago treated with
amoxicillin. She does not appear toxic. A
chest radiograph reveals an infiltrate in the
right lower lobe, consistent with
pneumonia. Which one of the following
would be the best choice for antibiotic
treatment? (check one)
A. High-dose amoxicillin
B. Azithromycin (Zithromax)
C. Doxycycline
D. Levofloxacin (Levaquin)
E. Cefuroxime axetil (Ceftin)

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D. Levofloxacin (Levaquin). For


previously healthy patients with
community-acquired pneumonia and no
risk factors for drug resistance, a
macrolide such as azithromycin is the
preferred treatment (SOR A). Doxycycline
is also acceptable (SOR C). Patients who
have been treated with antibiotics within
the previous 3 months should be treated
with a respiratory fluoroquinolone
(moxifloxacin, gemifloxacin, or
levofloxacin) (SOR A). A -lactam plus a
macrolide is also an alternative (SOR A).
The antibiotic chosen should be from a
different class than the one used for the
previous infection. These alternative
treatments are also recommended for those
with comorbidities such as chronic heart,
lung, liver, or renal disease; diabetes
mellitus; alcoholism; malignancies;
asplenia; immunosuppressing conditions
or use of immunosuppressing drugs; or
other risk factors for drug-resistant
Streptococcus pneumoniae infection (SOR
A).

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A 32-year-old farmer comes to your office


because of an upper respiratory infection.
While he is there he points out a lesion on
his forearm that he first noted
approximately 1 year ago. It is a 1-cm
asymmetric nodule with an irregular
border and variations in color from black
to blue. The patient says that it itches and
has been enlarging for the past 2 months.
He says he is so busy that he is not sure
when he can return to have it taken care of.
In such cases the best approach would be
to (check one)
A. perform a punch biopsy and have the
patient return if the biopsy indicates
pathology
B. perform a shave biopsy and recheck in
2 months for signs of recurrence
C. use electrocautery to destroy the lesion
and the surrounding tissue
D. perform an elliptical excision as soon as
possible
E. freeze the site with liquid nitrogen

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D. perform an elliptical excision as soon as


possible. Despite this individual's busy
schedule, he has a potentially lifethreatening problem that needs proper
diagnosis and treatment. Though an
excisional biopsy takes longer, it is the
procedure of choice when melanoma is
suspected. After removal and diagnosis,
prompt referral is essential for further
evaluation and therapy. A shave biopsy
should never be done for suspected
melanoma, as this is likely to transect the
lesion and destroy evidence concerning its
depth, thus making it difficult to assess the
prognosis. A punch biopsy should be used
only with discretion when the lesion is too
large for complete excision, or if
substantial disfigurement would occur.
Since this may not actually retrieve
cancerous tissue from an unsampled area
of a large lesion that might be malignant, it
would be safest to refer such patients.
Neither cryotherapy nor electrocautery
should be used for a suspected melanoma.

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A 32-year-old female experiences an


episode of unresponsiveness associated
with jerking movements of her arms and
legs. Which one of the following
presentations would make a diagnosis of
true seizure more likely? (check one)
A. Post-event confusion
B. Eye closure during the event
C. A history of fibromyalgia
D. A history of chronic back pain
E. A normal serum prolactin level after the
event

A 32-year-old female who is an avid


runner presents with knee pain. You
suspect patellofemoral pain syndrome.
Which one of the following signs or
symptoms would prompt an evaluation for
an alternative diagnosis? (check one)
A. Peripatellar pain while running
B. Knee stiffness with sitting
C. A popping sensation in the knee
D. Locking of the joint
E. A positive J sign (lateral tracking of the
patella when moved from flexion to full
extension)

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A. Post-event confusion. Up to 20% of


patients diagnosed with epilepsy actually
have pseudoseizures. Eye closure
throughout the event is uncommon in true
seizures, and a history of fibromyalgia or
chronic pain syndrome is predictive of
pseudoseizures. If obtained within 20
minutes of the event, a serum prolactin
level may be useful in differentiating a true
seizure from a pseudoseizure. An elevated
level has a sensitivity of 60% for
generalized tonic-clonic seizures and 46%
for complex partial seizures. Other
features suggestive of seizure activity
include tongue biting, the presence of an
aura, postictal confusion, and focal
neurologic signs.
D. Locking of the joint. Patellofemoral
pain syndrome is a clinical diagnosis and
is the most common cause of knee pain in
the outpatient setting. It is characterized by
anterior knee pain, particularly with
activities that overload the joint, such as
stair climbing, running, and squatting.
Patients complain of popping, catching,
stiffness, and giving way. On examination
there will be a positive J sign, with the
patella moving from a medial to a lateral
location when the knee is fully extended
from the 90 position. This is caused by an
imbalance in the medial and lateral forces
acting on the patella. Locking is not
characteristic of patellofemoral pain
syndrome, so a loose body or meniscal tear
should be considered if this is reported.

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A 32-year-old gravida 3 para 2 is in labor


at term following an uncomplicated
prenatal course. As you deliver the fetal
head it retracts against the perineum.
Downward traction fails to free the
anterior shoulder. The most appropriate
course of action would be to: (check one)
A. Apply increasingly strong downward
traction to the fetal head
B. Have an assistant apply fundal pressure
C. Deliberately fracture the clavicle of the
fetus
D. Begin an intravenous nitroglycerin drip
E. Place the mother's thighs on her
abdomen

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E. Place the mother's thighs on her


abdomen. While there are several risk
factors for shoulder dystocia, most cases
occur in fetuses of normal birth weight and
are not anticipated. Once it does occur,
excessive force should not be applied to
the fetal head or neck and fundal pressure
should be avoided, as these manuevers are
unlikely to free the fetus and can injure
both mother and infant. Up to 40% of
shoulder dystocia cases can be
successfully treated with the McRoberts
maneuver, in which the maternal hips are
flexed and abducted, placing the thighs up
on the abdomen. Adding suprapubic
pressure can resolve about half of all
shoulder dystocias. Additional maneuvers
include internal rotation, removal of the
posterior arm, and rolling the patient over
into the all-fours position. As a last resort,
one can deliberately fracture the fetal
clavicle, perform a cesarean section with
the vertex being pushed back into the birth
canal, or have the surgeon rotate the infant
transabdominally with vaginal extraction
performed by another physician. General
anesthesia or nitroglycerin, orally or
intravenously, may be used to achieve
musculoskeletal or uterine relaxation.
Intentional division of the cartilage of the
symphysis under local anesthesia has been
used in developing countries, but should
be used only if all other maneuvers have
failed and a cesarean delivery is not
feasible.

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A 32-year-old primipara is ready to be


discharged after a full-term vaginal
delivery that was complicated by a
prolonged second stage of labor. She
required a second-degree posterior vaginal
repair, but had no periurethral trauma. A
transurethral catheter was removed a few
hours after delivery, but 48 hours later she
complained of abdominal pain and a
persistent need to urinate. The catheter was
replaced and yielded approximately 2000
cc of straw-colored urine. Urinary
symptoms quickly resolved, but the patient
continues to be unable to void on her own.
A perineal examination is normal, as is a
urinalysis.
Which one of the following would be the
most appropriate management at this time?
(check one)
A. Oxybutynin (Ditropan), 10 mg daily
B. Prednisone, starting with 60 mg/day
and tapering quickly over 7 days
C. Urgent vaginal ultrasonography
D. Urology consultation for cystoscopy
E. Discharge with a catheter in place and
close follow-up
A 32-year-old white female at 16 weeks'
gestation presents to your office with right
lower quadrant pain. Which one of the
following imaging studies would be most
appropriate for initial evaluation of this
patient? (check one)
A. CT of the abdomen
B. MRI of the abdomen
C. Ultrasonography of the abdomen
D. A small bowel series
E. Intravenous pyelography

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E. Discharge with a catheter in place and


close follow-up. This patient suffers from
postpartum urinary retention (PUR). PUR
is often defined as a post-void bladder
residual of at least 150 cc that is present 6
hours or more after delivery. This
condition is more likely to occur in
patients who are primiparous, have a
prolonged first or second stage of labor,
have instrumented vaginal deliveries, or
require a cesarean section for failure to
progress. The question of whether epidural
anesthesia promotes the condition is still
debated. Most cases of PUR will resolve
2-6 days after delivery, but some can take
up to several weeks. The use of
intermittent self-catheterization or a
transurethral catheter is recommended
until the patient's ability to spontaneously
micturate returns. Imaging studies and
referrals to a specialist are rarely
necessary, and no medication has been
proven helpful.

C. Ultrasonography of the abdomen. CT


has demonstrated superiority over
transabdominal ultrasonography for
identifying appendicitis, associated
abscess, and alternative diagnoses.
However, ultrasonography is indicated for
the evaluation of women who are pregnant
and women in whom there is a high degree
of suspicion for gynecologic disease.

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A 32-year-old white female presents with


a 6-week history of increasing headache,
which she now describes as severe. The
only abnormal finding on examination is a
BMI of 32.4 kg/m2 . A neurologic
examination is normal. CT of the head is
normal and a lumbar puncture is
remarkable only for increased
cerebrospinal fluid pressure. There is no
history of trauma or hypercoagulable
disorder.
Management should be directed toward
preventing which one of the following?
(check one)
A. Visual loss
B. Hearing loss
C. Vertigo
D. A cerebrovascular accident
E. Cerebral herniation
A 32-year-old white male teacher is seen
for a paroxysmal cough of 5 days duration.
He tells you that a student in his class was
diagnosed with pertussis 3 weeks ago.
Which one of the following would be the
best treatment? (check one)

A. Visual loss. Loss of vision is a


devastating neurologic deficit that occurs
with idiopathic intracranial hypertension
(pseudotumor cerebri, benign intracranial
hypertension), although it is uncommon.
Sixth cranial nerve palsies may also occur
as a false localizing sign. The typical
presentation is a young, obese woman with
a headache, palpable tinnitus, and nausea
and vomiting. CT is usually normal or
shows small ventricles. The lumbar
puncture shows elevated pressure with
normal fluid examination. CSF protein
levels may be low.
Hearing loss and vertigo are not
characteristic of this disorder. Long tract
signs and facial nerve palsies have been
attributed to idiopathic intracranial
hypertension; they are atypical and should
lead to consideration of other diagnoses.
B. Azithromycin (Zithromax). Macrolides
are considered first-line therapy for
Bordetella pertussis infection.
Trimethoprim/sulfamethoxazole is
considered second-line therapy.

A. Amoxicillin
B. Azithromycin (Zithromax)
C. Cephalexin (Keflex)
D. Ciprofloxacin (Cipro)
E. Doxycycline

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32-year-old white male undergoes an


emergency splenectomy after a motor
vehicle accident. Which one of the
following should he receive after the
surgery? (check one)
A. Pneumococcal vaccine and
meningococcal vaccine
B. Pneumococcal vaccine alone
C. Meningococcal vaccine alone
D. No immunizations
A 33-year-old white female has a 12-year
history of headache occurring 3-4 times
per month, accompanied by nausea and
vomiting. She takes over-the-counter
analgesics, but relief is usually obtained
only when she falls asleep. This is her first
visit to you for this problem. You diagnose
migraine without aura. Although the
patient is willing to consider prescription
drugs, she says that she would prefer
"something that is natural and without side
effects." Which one of the following
would be the best recommendation?
(check one)
A. Biofeedback
B. Ma huang
C. Oxygen
D. Epley canalith respositioning maneuver
E. Phototherapy

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A. Pneumococcal vaccine and


meningococcal vaccine. Pneumococcal
and meningococcal vaccines are currently
recommended for patients with asplenia.
Haemophilus influenzae type b (Hib)
vaccine can be considered as well.
Emergency splenectomy for trauma is an
indication for vaccination, even though
splenic remnants may persist.

A. Biofeedback. Of the listed options


covering the realm of complementary and
alternative medicine, only biofeedback has
been shown to have a therapeutic effect on
migraine. Specifically, the modality that
seeks to control physiologic response to
skin temperature and skin conductance
appears to be the most successful. It is best
performed in a medical office by caring,
supportive staff members under physician
supervision. Oxygen is used to treat cluster
headaches. The Epley maneuver is used
for managing benign positional vertigo,
and phototherapy is useful in seasonal
affective disorder. Ma huang, a Chinese
herb, has ephedrine properties but is not
useful in treating migraine headaches.

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A 33-year-old white female presents with


tremor and a history of weight loss. On
examination she is found to have mild,
regular tachycardia and exophthalmos.
Laboratory tests confirm hyperthyroidism.
Which one of the following treatments has
been found to potentially worsen Grave's
ophthalmopathy? (check one)
A. Radioactive iodine
B. Propylthiouracil
C. Methimazole (Tapazole)
D. Thyroid hormone replacement plus
propylthiouracil
E. Thyroidectomy
A 34-year-old female presents to the
emergency department with a severe
migraine headache unresponsive to
tramadol (Ultram) and sumatriptan
(Imitrex) at home. She takes fluoxetine
(Prozac) for depression. Soon after being
given an injection of meperidine
(Demerol), she develops agitation,
diaphoresis, tremor, diarrhea, fever, and
incoordination. The most likely cause of
this patient's symptoms is: (check one)

A. Radioactive iodine. The


ophthalmopathy of Grave's disease may
initially flare and worsen when treated
with radioactive iodine. Antithyroid drugs,
including propylthiouracil, and
methimazole, are not associated with this
problem. The addition of thyroid hormone
to these drugs at suppressive doses has not
shown any clear benefit over titration of
the antithyroid drug, and relapse rates are
similar. Thyroid surgery in the controlled
patient has not been significantly
associated with this problem.

A. Serotonin syndrome
B. Thyrotoxic storm
C. Sepsis
D. Viral encephalitis
E. Panic attack

A. Serotonin syndrome. Physicians who


prescribe SSRIs such as fluoxetine should
be aware of potential drug interactions.
Several of the SSRIs may increase the
effects of warfarin and raise tricyclic
antidepressant levels. Combination of an
SSRI with a drug that increases serotonin
concentrations may induce the potentially
life-threatening serotonin syndrome, with
mental status changes, agitation,
myoclonus, hyperreflexia, diaphoresis,
shivering, tremor, diarrhea, incoordination,
and fever. These drugs include monoamine
oxidase inhibitors, tramadol, sibutramine,
meperidine, sumatriptan, lithium, St.
John's wort, ginkgo biloba, and atypical
antipsychotic agents.

A 34-year-old female who delivered a


healthy infant 18 months ago complains of
a milky discharge from both nipples. She
reports that normal periods have resumed
since cessation of breastfeeding 6 months
ago. She takes ethinyl
estradiol/norgestimate (Ortho Tri-Cyclen)
for birth control. A complete review of

A. a medication side effect. This patient


has galactorrhea, which is defined as a
milk-like discharge from the breast in the
absence of pregnancy in a nonbreastfeeding patient who is more than 6
months post partum. It is more common in
women ages 20-35 and in women who are
previously parous. It also can occur in

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systems is otherwise negative. The most


likely cause of the discharge is (check one)
A. a medication side effect
B. breast cancer
C. a hypothalamic tumor
D. hypothyroidism

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men. Medication side effect is the most


common etiology. The most common
pharmacologic cause of galactorrhea is
oral contraceptives. Oral contraceptives
that contain estrogen can both suppress
prolactin inhibitory factor and stimulate
the pituitary directly, both of which can
cause galactorrhea. Other medications that
can cause galactorrhea include
metoclopramide, cimetidine, risperidone,
methyldopa, codeine, morphine,
verapamil, SSRIs, butyrophenones,
dopamine-receptor blockers, tricyclics,
phenothiazines, and thioxanthenes. Breast
cancer is unlikely to present with a
bilateral milky discharge. The nipple
discharge associated with cancer is usually
unilateral and bloody. Pituitary tumors are
a pathologic cause of galactorrhea due to
the hyperprolactinemia that is caused by
the blockage of dopamine from the
hypothalamus, or by the direct production
of prolactin. However, patients often have
symptoms such as headache, visual
disturbances, temperature intolerance,
seizures, disordered appetite, polyuria, and
polydipsia. Patients with prolactinomas
often have associated amenorrhea. These
tumors are associated with marked levels
of serum prolactin, often >200 ng/mL.
Hypothalamic lesions such as
craniopharyngioma, primary hypothalamic
tumor, metastatic tumor, histiocytosis X,
tuberculosis, sarcoidosis, and empty sella
syndrome are significant but infrequent
causes of galactorrhea, and generally cause
symptoms similar to those of pituitary
tumors, particularly headache and visual
disturbances. It is rare for primary
hypothyroidism to cause galactorrhea in
adults. Symptoms that would be a clue to
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this diagnosis include fatigue,


constipation, menstrual irregularity, weight
changes, and cold intolerance.
A 34-year-old female with menorrhagia is
found to have iron deficiency anemia.
Which one of the following is true
regarding the treatment of this problem
with oral iron? (check one)
A. An acidic environment enhances the
absorption of iron from the gastrointestinal
tract
B. Iron is absorbed better if taken with
food
C. Diarrhea is a common complication
D. Iron supplementation can be
discontinued once the hemoglobin reaches
a normal level
E. Sustained-release formulations increase
the total amount of iron available for
absorption

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A. An acidic environment enhances the


absorption of iron from the gastrointestinal
tract. Oral iron is absorbed better with an
acidic gastric environment, which can be
accomplished with the concomitant
administration of vitamin C. Agents that
raise gastric pH, such as antacids, proton
pump inhibitors, and H2 blockers, should
be avoided if possible. Oral iron
absorption is improved if the iron is taken
on an empty stomach, but this may not be
well tolerated because gastric irritation is a
frequent side effect. Constipation also is
common with oral iron therapy. Iron
therapy should be continued for several
months after the hemoglobin reaches a
normal level, in order to fully replenish
iron stores. Sustained-release oral iron
products provide a decreased amount of
iron for absorption.

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A 34-year-old white female comes to the


office for a Papanicolaou (Pap) test. On a
review-of-system checklist, she checks
"yes" to depressive symptoms, insomnia,
and anxiety. On questioning, she admits to
feeling depressed for about 4 months, after
a recent job change. She is not suicidal.
With probing, she admits that she
repeatedly checks her locks and constantly
worries about cleanliness; she has been
this way "all of her life," but finds it very
time-consuming. Which one of the
following drugs is the best choice for this
patient? (check one)

E. Fluoxetine (Prozac). The patient most


likely has obsessive-compulsive disorder
(OCD) with a depressive episode. SSRIs
are most frequently used. Risperidone and
clonazepam are considered second-line
drugs and are used as augmentation drugs
when there is a partial response to an
SSRI. There is no evidence that
clorazepate or imipramine is effective in
OCD.

A. Risperidone (Risperdal)
B. Clorazepate (Tranxene)
C. Clonazepam (Klonopin)
D. Imipramine (Tofranil)
E. Fluoxetine (Prozac)
A 34-year-old white female visits your
office complaining of a sore throat. She
takes haloperidol, 2 mg after each meal,
for schizophrenia, and you notice that she
seems unable to sit still and is extremely
anxious.
The most likely diagnosis is:
(check one)
A. drug-induced parkinsonism
B. akathisia
C. tardive dyskinesia
D. hysteria
E. dystonia

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B. akathisia. Motor side effects of the


antipsychotic drugs can be separated into
five general categories: dystonias,
parkinsonism, akathisia, withdrawal
dyskinesias, and tardive dyskinesia.
Akathisia is a syndrome marked by motor
restlessness. Affected patients commonly
complain of being inexplicably anxious, of
being unable to sit still or concentrate, and
of feeling comfortable only when moving.
A diagnosis of hysteria is inconsistent with
the findings presented.

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A 34-year-old white male is brought to the


emergency department following an
automobile accident in which he was the
only occupant of the vehicle. He lost
control of the vehicle and hit a utility pole.
He was knocked unconscious initially, but
he is now awake and combative. You note
a strong smell of alcohol. He has a frontal
hematoma approximately 3 cm in diameter
and an actively bleeding 4-cm laceration
of the occiput. He will not permit you to
examine him further and he prepares to
leave the emergency department.
You should: (check one)
A. detain him in the emergency
department
B. make him sign out against medical
advice
C. tell him that he cannot return if he
leaves
D. tell him that if he leaves he can return
later

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A. detain him in the emergency


department. Two of the most important
ethical principles in medicine are respect
for autonomy and beneficence. Respect for
autonomy means regarding patients as
rightfully self-governing in matters of
choice and action. To make an
autonomous decision, the patient must be
mentally sound, have knowledge and
understanding of the facts, and be free of
coercion. Beneficence means that
physicians are motivated solely by what is
good for the patient. There are often
ethical conflicts between these two
principles. This particular patient is clearly
in need of further emergency treatment,
but he refuses. He has had a significant
head injury, is combative and possibly
intoxicated, and therefore cannot be
considered mentally sound. The physician
should detain him for his own good and
provide the appropriate care. Threatening
the patient, having him sign out against
medical advice, or encouraging him to
return later is not appropriate because his
mentation is impaired.

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A 34-year-old white male letter carrier has


developed progressively worsening
dysphagia for liquids and solids over the
past 3 months. He says that he has lost
about 30 lb during that time. On
examination, you note that he is emaciated
and appears ill. His pulse rate is 98
beats/min, temperature 37.8C (100.2F),
respiratory rate 24/min, and blood pressure
95/60 mm Hg. His weight is 45 kg (99 lb)
and his height is 170 cm (67 in). His
dentition is poor, and there is evidence of
oral thrush. His mucous membranes are
dry.
You palpate small posterior cervical and
axillary nodes. The heart, lung, and
abdominal examinations are normal. You
promptly consult a gastroenterologist, who
performs upper endoscopy, which reveals
numerous small ulcers scattered
throughout the esophagus with otherwise
normal mucosa.
As you continue to investigate, you take a
more detailed history. Which one of the
following is most likely to be related to the
patient's problem?
(check one)

A. Intravenous drug use. A young man


with weight loss, oral thrush,
lymphadenopathy, and ulcerative
esophagitis is likely to have HIV infection.
Intravenous drug use is responsible for
over a quarter of HIV infections in the
United States. Esophageal disease
develops in more than half of all patients
with advanced infection during the course
of their illness. The most common
pathogens causing esophageal ulceration
in HIV-positive patients include Candida,
herpes simplex virus, and
cytomegalovirus. Identifying the causative
agent through culture or tissue sampling is
important for providing prompt and
specific therapy.

A. Intravenous drug use


B. A family history of esophageal cancer
C. Chest pain relieved by nitroglycerin
D. Recent travel to Russia

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A 34-year-old white mechanic felt a slight


impact on his left eye while hammering on
an axle 2 days ago. He has experienced
some discomfort since that time, and
complains of blurring of vision. Physical
examination discloses no local erythema or
other evidence of injury to the eye.
Fluorescein staining is negative. His visual
acuity is 20/40 in the affected eye. The
most likely diagnosis is: (check one)

C. Intraocular foreign body. Complaints of


discomfort in the eye with blurred vision
and a history of striking steel should
arouse strong suspicion of an intraocular
foreign body.

A. Traumatic iritis
B. Corneal abrasion
C. Intraocular foreign body
D. Bacterial corneal ulcer
E. Retinal detachment
A 35-year-old African-American female
with symptomatic uterine fibroids that are
unresponsive to medical management
prefers to avoid a hysterectomy. Which
one of the following would be a reason for
preferring myomectomy over fibroid
embolization? (check one)
A. A desire for future pregnancy
B. Medical problems that increase general
anesthesia risk
C. Religious objections to blood
transfusion
D. The likelihood of a shorter hospital stay
and recovery time
E. The minimal risk of fibroid recurrence

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A. A desire for future pregnancy. In the


symptomatic patient with uterine fibroids
unresponsive to medical therapy,
myomectomy is recommended over
fibroid embolization for patients who wish
to become pregnant in the future. Uterine
fibroid embolization requires a shorter
hospitalization and less time off work.
General anesthesia is not required, and a
blood transfusion is unlikely to be needed.
Uterine fibroids can recur or develop after
either myomectomy or embolization.

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A 35-year-old female is planning a second


pregnancy. Her last pregnancy was
complicated by placental abruption caused
by a large fibroid tumor of the uterus,
which is still present. Which one of the
following would be the most appropriate
treatment for the fibroid tumor? (check
one)
A. Myomectomy
B. Myolysis with endometrial ablation
C. Uterine artery embolization
D. Observation

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A. Myomectomy. There are numerous


options for the treatment of uterine
fibroids. When pregnancy is desired,
myomectomy offers the best chance for a
successful pregnancy when prior
pregnancies have been marked by fibroidrelated complications. Endometrial
ablation eliminates fertility, and there is a
lack of long-term data on fertility after
uterine artery embolization. Observation
without treatment would not remove the
risk for recurrent complications during
subsequent pregnancies.

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A 35-year-old female sees you because she


has lost her voice. She has had no recent
upper respiratory infection symptoms,
cough, or heartburn, and she has not done
anything that would strain her voice.
Findings are normal on examination of the
head and neck. A review of her chart
shows this has happened before, but an
ear, nose, and throat evaluation found no
abnormalities. She also has been seen
numerous times in the past few years for
headaches, chest pains, abdominal pains,
rectal pressure, and vaginal symptoms.
Despite several workups and referrals, no
definite cause has been found and the
symptoms persist. Which one of the
following would be the most reasonable
plan of action? (check one)
A. Test for food allergies
B. Begin low-dose lorazepam (Ativan)
C. Begin a 6-week trial of a proton pump
inhibitor
D. Schedule frequent office visits

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D. Schedule frequent office visits.


Somatization disorders should be
considered in patients who have a history
of various complaints over a several-year
period that involve multiple organ
systems. There is no test to confirm this
diagnosis. It is often intertwined in other
psychiatric problems, including anxiety
disorder, personality disorder, and
depression. Treatment includes testing to
make sure that there is nothing physically
wrong, while building a trusting
relationship with the patient. Once this is
accomplished, it is reasonable to discuss
the disorder with the patient. Cognitive
therapy has been shown to be of value, as
well as regularly scheduled office visits for
monitoring and support. Medicines for
coexisting psychiatric problems also are of
benefit. In addition, referral for psychiatric
consultation may be worthwhile. Food
allergies can cause a variety of symptoms,
but usually not to the extent seen with this
patient, and testing for this might confuse
the issue. Lorazepam may help the
symptoms if there is a coexisting anxiety
disorder, but it will not address the
underlying problem. Laryngeal esophageal
reflux can cause hoarseness and will
respond to proton pump inhibitors, but
given the repetitive nature of her
symptoms and the previous negative
workups, it is not consistent with the
whole picture.

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A 35-year-old male amateur rugby player


seeks your advice because right hip pain of
several months' duration has progressed to
the point of interfering with his athletic
performance. The pain is accentuated
when he transitions from a seated to a
standing position, and especially when he
pivots on the hip while running, but he
cannot recall any significant trauma to the
area and finds no relief with over-thecounter analgesics. On examination his
gait is stable. The affected hip appears
normal and is neither tender to palpation
nor excessively warm to touch. Although
he has a full range of passive motion,
obvious discomfort is evident with internal
rotation of the flexed and adducted right
hip.
Which one of the following is most
strongly suggested by this clinical picture?
(check one)
A. Osteoarthritis
B. Avascular necrosis
C. Bursitis
D. Impingement
E. Pathologic fracture

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D. Impingement. Gradually worsening


anterolateral hip joint pain that is sharply
accentuated when pivoting laterally on the
affected hip or moving from a seated to a
standing position is consistent with
femoroacetabular impingement.
Reproduction of the pain on range-ofmotion examination by manipulating the
hip into a position of flexion, adduction,
and internal rotation (FADIR test) is the
most sensitive physical finding. Special
radiographic imaging of the flexed and
adducted hip can emphasize the anatomic
abnormalities associated with
impingement that may go unnoticed on
standard radiographic series views.
Although the pain associated with
avascular necrosis is similarly insidious
and heightened when bearing weight,
tenderness is usually evident with hip
motion in any direction. Osteoarthritis of
the hip generally occurs in individuals of
more advanced age than this patient, and
the pain produced is typically localized to
the groin area and can be elicited by
flexion, abduction, and external rotation
(FABER test) of the affected hip.Bursitis
manifests as soreness after exercise and
tenderness over the affected bursa.

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A 35-year-old male consults you about


vague chest pain he developed while
sitting at his desk earlier in the day. The
pain is right-sided and was sharp for a
brief time when it began, but it rapidly
subsided. There was no hemoptysis and
the pain does not seem pleuritic. His
physical examination, EKG, and oxygen
saturation are unremarkable. A chest film
shows a 10% right pneumothorax.
Which one of the following should you do
next? (check one)
A. Admit the patient to the hospital for
observation
B. Admit the patient to the hospital for
chest tube placement
C. Obtain a repeat chest radiograph in 2448 hours
D. Obtain an expiratory chest radiograph

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C. Obtain a repeat chest radiograph in 2448 hours. The majority of patients


presenting with spontaneous
pneumothorax are tall, thin individuals
under 40 years of age. Most do not have
clinically apparent lung disease, and the
chest pain is sometimes minimal at the
time of onset and may resolve within 24
hours even if untreated. Patients with small
pneumothoraces involving <15% of the
hemithorax may have a normal physical
examination, although tachycardia is
occasionally noted. The diagnosis is
confirmed by chest radiographs. When a
pneumothorax is suspected but not seen on
a standard chest film, an expiratory film
may be obtained to confirm the diagnosis.
Studies have found that an average of 30%
of patients will have a recurrence within 6
months to 2 years. An initial
pneumothorax of <20% may be monitored
if the patient has few symptoms. Followup should include a chest radiograph to
assess stability at 24-48 hours. Indications
for treatment include progression, delayed
expansion, or the development of
symptoms. The majority of patients with
spontaneous pneumothoraces, and perhaps
almost all of them, will have subcutaneous
bullae on a CT scan.

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A 35-year-old male presents with a 4month history of pain in the lower lumbar
region without radiation. He works in
retail sales, and the pain and stiffness
prevent him from working. He estimates
the pain to be 7 on a 10-point scale. He has
been under the care of a chiropractor and
has experienced some relief with spinal
manipulation. His history is negative for
red flags indicating a serious cause for his
pain.
The only positive findings on a physical
examination are diffuse mild tenderness
over the lumbar region and mild limitation
of lumbar mobility on forward and lateral
flexion/extension maneuvers. Appropriate
laboratory tests and imaging studies are all
within normal limits.
In addition to appropriate analgesics,
which one of the following modalities has
the best evidence of long-term benefit in
this situation?
(check one)

D. Multidisciplinary rehabilitation. This


patient has nonspecific chronic back pain,
most likely a lumbar strain or sprain. In
addition to analgesics (e.g., acetaminophen
or NSAIDs) (SOR A) and spinal
manipulation (SOR B), a multidisciplinary
rehabilitation program is the best choice
for management (SOR A). This program
includes a physician and at least one
additional intervention (psychological,
social, or vocational). Such programs
alleviate subjective disability, reduce pain,
return the person to work earlier, and
reduce the amount of sick time taken in the
first year by 7 days. Benefits persist for up
to 5 years. Back school, TENS, and SSRIs
have been found to have negative or
conflicting evidence of effectiveness (SOR
C). There is no evidence to support the use
of epidural corticosteroid injections in
patients without radicular signs or
symptoms (SOR C).

A. Transdermal electric nerve stimulation


(TENS)
B. Epidural corticosteroid injections
C. SSRIs
D. Multidisciplinary rehabilitation

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A 35-year-old male with a previous history


of kidney stones presents with symptoms
consistent with a recurrence of this
problem. The initial workup reveals
elevated serum calcium. Which one of the
following tests would be most appropriate
at this point? (check one)
A. Serum calcitonin
B. 24-hour urine for calcium and
phosphate
C. Serum phosphate and magnesium
D. Serum parathyroid hormone
E. Spot urine for microalbumin

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D. Serum parathyroid hormone. A patient


with a recurrent kidney stone and an
elevated serum calcium level most likely
has hyperparathyroidism, and a
parathyroid hormone (PTH) level would
be appropriate. Elevated PTH is caused by
a single parathyroid adenoma in
approximately 80% of cases. The resultant
hypercalcemia is often discovered in
asymptomatic persons having laboratory
work for other reasons. An elevated PTH
by immunoassay confirms the diagnosis.
In the past, tests based on renal responses
to elevated PTH were used to make the
diagnosis. These included blood
phosphate, chloride, and magnesium, as
well as urinary or nephrogenous cyclic
adenosine monophosphate. These tests are
not specific for this problem, however, and
are therefore not cost-effective. Serum
calcitonin levels have no practical clinical
use.

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A 35-year-old male with a toothache


presents to a local clinic for uninsured
patients. On examination you find a
decayed left lower molar that is tender
when tapped lightly, and surrounding
gingival inflammation and tenderness.
There is no obvious mandibular swelling,
but he does have a tender submandibular
lymph node. The earliest available dental
appointment is in 1 week. He is allergic to
penicillin. Which one of the following
would be the best antibiotic treatment for
this patient? (check one)

C. Clindamycin (Cleocin). This patient


most likely has periodontitis of the tooth's
roots with cellulitis, complicated by an
apical abscess. This infection is caused by
anaerobic oral bacteria. Penicillin VK,
amoxicillin or amoxicillin/clavulanate is
preferred for antibiotic treatment, but this
patient is allergic to penicillin.
Clindamycin is a good choice to cover the
likely pathogens. Doxycycline,
trimethoprim/sulfamethoxazole,
ciprofloxacin, and cephalexin have limited
effectiveness against anaerobes and would
not be indicated.

A. Doxycycline
B. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
C. Clindamycin (Cleocin)
D. Ciprofloxacin (Cipro)
E. Cephalexin (Keflex)
A 35-year-old right-handed softball player
injures his left wrist when sliding into
second base. When he sees you the next
day his description of the injury indicates
that he hyperextended his wrist while
sliding, and the pain was later
accompanied by swelling. Your
examination is remarkable only for mild
swelling and tenderness of the dorsal wrist,
distal to the ulnar styloid. A radiograph of
the wrist is shown in Figure 2.

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...

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A 35-year-old white female complains of


unilateral frontotemporal headaches.
During these episodes, which occur every
2-3 weeks, she becomes nauseated,
sometimes to the point of vomiting. The
headaches are throbbing in character and
last for 1-3 hours, often causing her to
leave work early. Relief is sometimes
obtained with simple analgesics, but more
often with sleep or the passage of time. On
the basis of this history alone, the most
likely diagnosis is (check one)
A. sinusitis
B. a brain tumor
C. muscle tension headache
D. cluster headache
E. migraine headache

A 35-year-old white gravida 2 para 1 sees


you for her initial prenatal visit. Since
delivering her first child 10 years ago, she
has developed type 2 diabetes mellitus.
She has kept her disease under excellent
control by taking metformin (Glucophage).
A recent hemoglobin A1c level was 6.5%.
You should now treat her diabetes with:
(check one)
A. metformin
B. acarbose (Precose)
C. pioglitazone (Actos)
D. human insulin

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E. migraine headache. Migraine is the


most likely diagnosis in this scenario,
because the patient is young and female;
the headaches are unilateral, infrequent,
and throbbing; the headaches are
associated with nausea and vomiting; and
sleep offers relief. Symptoms of sinusitis
usually include fever, facial pain, and a
purulent nasal discharge. The pain of
cerebral tumor tends to occur daily and
becomes more frequent and severe with
time. Furthermore, the prevalence of brain
tumor is far less than that of migraine. The
pain of muscle tension headache is
described as a pressure or band-like
tightening, often in a circumferential or
cap distribution. This headache also has a
pattern of daily persistence, often
continuing day and night for long periods
of time. Cluster headache is more common
in males, and presents as a very severe,
constant, agonizing orbital pain, usually
beginning within 2 or 3 hours after falling
asleep.
D. human insulin. The safety of most oral
hypoglycemics in pregnancy has not been
established with regard to their teratogenic
potential. However, all oral agents cross
the placenta (in contrast to insulin),
leading to the potential for severe neonatal
hypoglycemia. For these reasons, plus the
requirement for exquisitely tight glucose
control to reduce fetal macrosomia and
organ dysgenesis, the American Diabetes
Association advocates the use of human
insulin for pregnant women. Insulin
requirements generally increase
throughout gestation, but the precise
dosage is unimportant as long as it is
sufficient to maintain glucose control.
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A 35-year-old white male has a blood


pressure of 142/88 mm Hg, confirmed on
repeat measurements. A complete
metabolic panel and urinalysis reveal a
serum creatinine level of 1.9 mg/dL (N
0.6-1.5) and 2+ protein in the urine. Which
one of the following would be the most
appropriate initial treatment? (check one)
A. ACE inhibitors
B. Aldosterone antagonists
C. -Blockers
D. Calcium channel blockers
E. Diuretics

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A. ACE inhibitors. Although JNC-7


guidelines recommend a diuretic as the
initial pharmacologic agent for most
patients with hypertension, the presence of
compelling indications may indicate the
need for treatment with antihypertensive
agents that demonstrate a particular benefit
in primary or secondary prevention. JNC-7
guidelines recommend ACE inhibitors
(ACEIs) or angiotensin receptor blockers
(ARBs) for hypertensive patients with
chronic kidney disease (SOR A). First-line
therapy for proteinuric kidney disease
includes an ACEI or an ARB. Because
these drugs can cause elevations in
creatinine and potassium, these levels
should be monitored. A serum creatinine
level as much as 35% above baseline is
acceptable in patients taking these agents
and is not a reason to withhold treatment
unless hyperkalemia develops. If an ACEI
or an ARB does not control the
hypertension, the addition of a diuretic or a
calcium channel blocker may be required.
The combination of ACEIs and diuretics
may be used to control hypertension in
patients with diabetes mellitus, heart
failure, or high coronary disease risk, as
well as post myocardial infarction.
Calcium channel blockers are
recommended for managing hypertension
in patients with diabetes or high coronary
disease risk. -Blockers are useful as part
of combination therapy in patients with
hypertension and heart failure, or post
myocardial infarction.

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A 35-year-old white male presents to the


emergency department with chest pain of
30 minutes duration. He describes the pain
as feeling like pressure on his chest, and
says it radiates into his left arm. It is
accompanied by dyspnea, diaphoresis,
anxiety, and palpitations. His past medical
history is unremarkable and he has no
family history of premature heart disease.
He smokes 2 packs of cigarettes per day
and admits to intranasal cocaine use 2
hours ago.
Vital signs include a blood pressure of
180/110 mm Hg, a pulse rate of 110
beats/min, a respiratory rate of 24/min, and
a temperature of 37.2C (99.0F). Other
than the anxiety and diaphoresis, the
general examination is unremarkable. An
EKG shows sinus tachycardia with an
early repolarization pattern. Aspirin and
nitroglycerin have been administered, as
well as oxygen via nasal cannula.
Which one of the following would be most
appropriate at this point?
(check one)

C. Lorazepam (Ativan) intravenously.


Treatment of cocaine-associated chest pain
is similar to that of acute coronary
syndrome, unstable angina, or acute
myocardial infarction, but there are
exceptions. The hypertension, tachycardia,
and chest pain will often respond to
intravenous benzodiazepines as early
management. While -blockers are
recommended for acute myocardial
infarction, they can exacerbate coronary
artery spasm in cocaineassociated chest
pain. Fibrinolytic therapy should be given
only to patients who clearly have an
STsegment elevation myocardial infarction
and cannot receive immediate direct
percutaneous coronary intervention.
Calcium channel blocker use in the setting
of cocaine-induced ischemia has not been
studied, but may be considered if there is
no response to benzodiazepines and
nitroglycerin. There are no
recommendations regarding the use of
ACE inhibitors, but these agents would not
address the tachycardia.

A. Nifedipine (Procardia)
B. Enalaprilat intravenously
C. Lorazepam (Ativan) intravenously
D. Metoprolol (Toprol) intravenously
E. Thrombolytic therapy

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A 35-year-old white male presents with


dyspepsia. He has had no symptoms that
suggest gastroesophageal reflux or
bleeding, but a test for Helicobacter pylori
is positive. After 2 weeks of treatment
with omeprazole (Prilosec), amoxicillin,
and clarithromycin (Biaxin), he is
asymptomatic.
Which one of the following is
recommended to test for the eradication of
H. pylori in this patient?
(check one)
A. Immunoglobulin G serology
B. A urea breath test
C. Upper endoscopy with a biopsy
D. An upper gastrointestinal series

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B. A urea breath test. There is strong


evidence that eradication of H. pylori
improves healing and reduces the risk of
recurrence or rebleeding in patients with
duodenal or gastric ulcer. A test-and-treat
approach is recommended for most
patients with undifferentiated dyspepsia.
This strategy reduces the need for
antisecretory medications, as well as the
number of endoscopies. The currently
recommended test for eradication of H.
pylori in this clinical setting is either the
urea breath test or H. pylori stool antigen.
Serology remains positive for months after
eradication and may give misleading
information. Although upper endoscopy,
with a biopsy for histology, urease
activity, or culture, can be used to test for
eradication, it is an invasive procedure
with a higher cost and the potential for
more morbidity compared to the urea
breath test or the H. pylori stool antigen
test. Rather than recommending endoscopy
for all patients, most national guidelines
suggest a test-and-treat strategy unless the
patient is over 45 years old or has red flags
for malignancy or a complicated ulcer.
Although an upper gastrointestinal series
might provide information about gross
pathology, it will not provide information
about the eradication of H. pylori
following treatment.

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A 36-year-old female consults you because


of concerns about "fatigue." After
carefully reviewing her history and
performing a physical examination, which
one of the following would be LEAST
valuable in assessing this patient? (check
one)
A. A baseline serum cortisol level
B. An erythrocyte sedimentation rate
C. A complete metabolic panel
D. A TSH level
E. A pregnancy test

A 36-year-old female has been seen


multiple times in the past several months
for various pain-related complaints. On
each occasion, no physical or laboratory
findings were found to explain the
symptoms. The patient is involved in a
workers compensation case and could
make a significant amount of money if it is
demonstrated that her physical complaints
are related to work conditions. Which one
of the following diagnoses characterizes
her unexplained physical symptoms?
(check one)
A. Somatization disorder
B. Conversion disorder
C. Hypochondriasis
D. Malingering

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A. A baseline serum cortisol level. In


patients with fatigue, family physicians
should complete an appropriate history and
physical examination. Laboratory studies
should be considered, although the results
affect management in only 5% of patients.
A baseline cortisol level would be valuable
only in patients with significant findings of
Addison's disease. In addition to an
erythrocyte sedimentation rate, a complete
metabolic panel, and a TSH level, many
physicians request a CBC and a urinalysis.
A pregnancy test should be ordered for
women of childbearing age. No other tests
have been shown to be useful unless a
specific medical condition is suspected.
D. Malingering. This patient most likely is
malingering, which is to purposefully
feign physical symptoms for external gain.
Factitious disorder involves adopting
physical symptoms for unconscious
internal gain, such as deriving comfort
from taking on the role of being sick.
Somatization disorder is related to
numerous unexplained physical symptoms
that last for several years and typically
begin before 30 years of age. Conversion
disorder involves a single voluntary motor
or sensory dysfunction suggestive of a
neurologic condition, but not conforming
to any known anatomic pathways or
physiologic mechanisms.

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A 36-year-old female makes an


appointment because her husband of 12
years was just diagnosed with hepatitis C
when he tried to become a blood donor for
the first time. He recalls multiple blood
transfusions following a motorcycle crash
in 1988. His wife denies past liver disease,
blood transfusions, and intravenous drug
use. She has had no other sexual partners.
The couple has three children. Which one
of the following is the best advice about
testing the wife and their three children?
(check one)
A. No testing is required in the absence of
jaundice or gastrointestinal symptoms
B. No testing is required if her husband
has normal liver enzyme levels
C. No testing is required because tests
have low sensitivity
D. She should be offered testing because
sexual transmission is possible
E. All family members should be tested
because of possible household fecal-oral
spread

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D. She should be offered testing because


sexual transmission is possible. Key risk
factors for hepatitis C infection are longterm hemodialysis, intravenous drug use,
blood transfusion or organ transplantation
prior to 1992, and receipt of clotting
factors before 1987. Sexual transmission is
very low but possible, and the likelihood
increases with multiple partners. The
lifetime transmission risk of hepatitis C in
a monogamous relationship is less than
1%, but the patient should be offered
testing because she may choose to confirm
that her test is negative. If the mother is
seronegative, the children are at no risk.
Maternal-fetal transmission is rare except
in the setting of co-infection with HIV.
Hepatitis C is insidious, and symptoms do
not correlate with the extent of the disease.
Normal liver enzyme levels do not indicate
lack of infectivity. There is no risk to
household contacts. Current HCV antibody
tests are more than 99% sensitive and
specific and are recommended for
screening at-risk populations.

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A 36-year-old female presents with a


several-week history of polyuria and
intense thirst. She currently takes no
medications. On examination her blood
pressure and pulse rate are normal, and she
is clinically euvolemic. Laboratory tests,
including serum electrolyte levels, renal
function tests, and plasma glucose, are all
normal. A urinalysis is significant only for
low specific gravity. Her 24-hour urine
output is >5 L with low urine osmolality.
The most likely cause of this patient's
condition is a deficiency of:
(check one)
A. angiotensin II
B. aldosterone
C. renin
D. insulin
E. arginine vasopressin

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E. arginine vasopressin. This patient has


diabetes insipidus, which is caused by a
deficiency in the secretion or renal action
of arginine vasopressin (AVP). AVP, also
known as antidiuretic hormone, is
produced in the posterior pituitary gland
and the route of secretion is generally
regulated by the osmolality of body fluid
stores, including intravascular volume. Its
chief action is the concentration of urine in
the distal tubules of the kidney. Both low
secretion of AVP from the pituitary and
reduced antidiuretic action on the kidney
can be primary or secondary, and the
causes are numerous.
Patients with diabetes insipidus present
with profound urinary volume, frequency
of urination, and thirst.The urine is very
dilute, with osmolality <300 mOsm/L.
Further workup will help determine the
specific type of diabetes insipidus and its
cause, which is necessary in order to
implement appropriate treatment.
Low levels of aldosterone, plasma renin
activity, or angiotensin would cause
abnormal blood pressure, electrolyte
levels, and/or renal function. Insulin
deficiency results in diabetes mellitus.

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A 36-year-old female presents with the


sudden onset of severe headache, nausea,
and photophobia. Her level of
consciousness is progressively
diminishing. Which one of the following
would be the most appropriate next step?
(check one)
A. Head CT without contrast
B. Head CT with contrast
C. Head MRI
D. Lumbar puncture
E. CT angiography

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A. Head CT without contrast. The first


study ordered in any patient with
suspected subarachnoid hemorrhage
should be a head CT without contrast. It
will reveal subarachnoid hemorrhage in
100% of cases within 12 hours of the
bleed, and it is useful for identifying other
sources for the headache, for predicting the
site of the aneurysm, and for predicting
cerebral vasospasm and poor outcome. As
blood is cleared from the affected area, CT
sensitivity drops to 93% within 24 hours,
and to 50% at 7 days. Patients with a
positive CT result for subarachnoid
hemorrhage should proceed directly to
angiography and treatment. Patients with a
suspected subarachnoid hemorrhage who
have negative or equivocal results on head
CT should have a lumbar puncture. MRI
and CT with contrast are not used for the
diagnosis of acute subarachnoid
hemorrhage.

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A 36-year-old female sees you for a 6week postpartum visit. Her pregnancy was
complicated by gestational diabetes
mellitus. Her BMI at this visit is 33.0
kg/m2 and she has a family historyof
diabetes mellitus.
This patient's greatest risk factor for
developing type 2 diabetes mellitus is her:
(check one)
A. age
B. obesity
C. history of a completed pregnancy
D. history of gestational diabetes
E. family history of diabetes

A 36-year-old male complains of clear


rhinorrhea, nasal congestion, and watery,
itchy eyes for several months. Tests in the
past have suggested that he has an allergy
to dust mites.
Which one of the following is most likely
to provide the most relief from his
symptoms? (check one)
A. Oral antihistamines
B. An oral leukotriene-receptor antagonist
C. Intranasal antihistamines
D. Intranasal corticosteroids
E. Furnace filters and mite-proof bedding
covers

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D. history of gestational diabetes. A


history of gestational diabetes mellitus
(GDM) is the greatest risk factor for future
development of diabetes mellitus. It is
thought that GDM unmasks an underlying
propensity to diabetes. While a healthy
pregnancy is a diabetogenic state, it is not
thought to lead to future diabetes. This
patient's age is not a risk factor. Obesity
and family history are risk factors for the
development of diabetes, but having GDM
leads to a fourfold greater risk of
developing diabetes, independent of other
risk factors (SOR C). It is thought that
5%-10% of women who have GDM will
be diagnosed with type 2 diabetes within 6
months of delivery. About 50% of women
with a history of GDM will develop type 2
diabetes within 10 years of the affected
pregnancy.
D. Intranasal corticosteroids. This patient
has classic symptoms of allergic rhinitis.
Intranasal corticosteroids are considered
the mainstay of treatment for mild to
moderate cases. In multiple studies,
intranasal corticosteroid sprays have
proven to be more efficacious than the
other options listed, even for ocular
symptoms. Air filtration systems and
bedding covers have not been shown to
reduce symptoms.

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A 36-year-old male presents to the


emergency department with disorientation,
tachycardia, diaphoresis, and hypertension.
According to his family, he has been
consuming up to a fifth of vodka daily but
abruptly discontinued alcohol consumption
2 days ago. There is no history of
additional substance abuse and a urine
drug screen is negative.
Which one of the following is most
indicated in the management of this
patient? (check one)
A. An anticonvulsant
B. A typical antipsychotic
C. A benzodiazepine
D. A centrally-acting 2-agonist
E. Baclofen

A 36-year-old male presents with pain


over the lumbar paraspinal muscles. He
says the pain began suddenly while he was
shoveling snow. Which one of the
following is true regarding this patients
injury? (check one)
A. Systemic corticosteroids speed recovery
B. Exercises specific to low back injuries
speed recovery
C. Opioids have significant advantages for
symptom relief when compared with
NSAIDs or acetaminophen
D. Continued activity rather than bed rest
helps speed recovery
E. Trigger-point injections are superior to
placebo in relieving acute back pain

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C. A benzodiazepine. Psychomotor
agitation is experienced by most patients
during alcohol withdrawal.
Benzodiazepines are clearly the drug class
of choice. Providing medication on an asneeded basis rather than on a fixed
schedule is generally preferred.
Antipsychotics and butyrophenones
(including haloperidol) lower the seizure
threshold and should not be used. For
short-term management of status
epilepticus, anticonvulsants may be used
in conjunction with benzodiazepines. The
vast majority of seizures from withdrawal
are self-limited and do not require
anticonvulsant treatment. Clonidine and
other 2-agonists do reduce minor
symptoms of withdrawal, but have not
been shown to prevent seizures. The
effectiveness of baclofen in acute alcohol
withdrawal is unknown.
D. Continued activity rather than bed rest
helps speed recovery. Multiple studies
have demonstrated that bed rest is
detrimental to recovery from low back
pain. Patients should be encouraged to
remain as active as possible. Exercises
designed specifically for the treatment of
low back pain have not been shown to be
helpful. Neither opioids nor trigger-point
injections have shown superiority over
placebo, NSAIDs, or acetaminophen in
relieving acute back pain. There is no good
evidence to suggest that systemic
corticosteroids are effective for low back
pain with or without sciatica.

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A 36-year-old member of the National


Guard who has just returned from Iraq
consults you because of several "boils" on
the back of his neck that have failed to
heal over the last 6 months, despite two
week-long courses of cephalexin (Keflex).
You observe three 1- to 2-cm raised
minimally tender lesions with central
ulceration and crust formation. He denies
any fever or systemic symptoms. The most
likely cause of these lesions is: (check one)
A. Pyogenic granuloma
B. Leishmaniasis
C. Atypical mycobacterial infection
D. Squamous cell carcinoma
E. Epidermal inclusion cysts

A 36-year-old white female presents to the


emergency department with palpitations.
Her pulse rate is 180 beats/min. An EKG
reveals a regular tachycardia with a narrow
complex QRS and no apparent P waves.
The patient fails to respond to carotid
massage or to two doses of intravenous
adenosine (Adenocard), 6 mg and 12 mg.
The most appropriate next step would be
to administer intravenous (check one)
A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)

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B. Leishmaniasis. The most likely


diagnosis is cutaneous leishmaniasis,
caused by an intracellular parasite
transmitted by the bite of small sandflies.
Lesions develop gradually, and are often
misdiagnosed as folliculitis or as infected
epidermal inclusion cysts, but they fail to
respond to usual skin antibiotics. Hundreds
of cases have been diagnosed in troops
returning from Iraq, most due to
Leishmania major. Treatment is not
always required, as most lesions will
resolve over several months; however,
scarring is frequent. U.S. military medical
facilities and the CDC are coordinating
treatment when indicated with sodium
stibogluconate. Family physicians can play
a key role in correctly identifying these
lesions.
E. verapamil (Calan). If supraventricular
tachycardia is refractory to adenosine or
rapidly recurs, the tachycardia can usually
be terminated by the administration of
intravenous verapamil or a -blocker. If
that fails, intravenous propafenone or
flecainide may be necessary. It is also
important to look for and treat possible
contributing causes such as hypovolemia,
hypoxia, or electrolyte disturbances.
Electrical cardioversion may be necessary
if these measures fail to terminate the
tachyarrhythmia.

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A 36-year-old white male complains of


episodic pain in the rectum over the past
several years. The pain occurs every 3-6
weeks and is sharp, cramp-like, and
severe. It lasts from 1 to 15 minutes. He
has no other gastrointestinal complaints. A
physical examination, including a digital
rectal examination and anoscopy, is
normal.
The most likely diagnosis is:
(check one)
A. fecal impaction
B. coccygodynia
C. anal fissure
D. proctalgia fugax
E. sacral nerve neuralgia

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D. proctalgia fugax. Symptoms consistent


with proctalgia fugax occur in 13%-19%
of the general population. These consist of
episodic, sudden, sharp pains in the
anorectal area lasting several seconds to
minutes. The diagnosis is based on a
history that fits the classic picture in a
patient with a normal examination. All the
other diagnoses listed would be evident
from the physical examination, except for
sacral nerve neuralgia, which would not be
intermittent for years and would be longer
lasting.

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A 37-year-old female presents with


concerns about difficulty initiating and
maintaining sleep for the past 3-4 months.
She is irritable and feels fatigued and
sleepy during the day. After further
evaluation, she is diagnosed with chronic
insomnia. She asks about alternatives to
hypnotic drug treatments. Which one of
the following management options is best
supported by current evidence? (check
one)
A. Diphenhydramine (Benadryl)
B. Cognitive behavior therapy
C. St. Johns wort
D. 4 oz of red wine 30 minutes before
bedtime
E. Vigorous aerobic exercise 30-45
minutes before bedtime

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B. Cognitive behavior therapy. Routine


use of over-the-counter antihistamines
should be discouraged because they are
only minimally effective in inducing sleep,
may reduce sleep quality, and can cause
residual drowsiness. Cognitive-behavioral
therapy helps change incorrect beliefs and
attitudes about sleep (e.g., unrealistic
expectations, misconceptions, amplifying
consequences of sleeplessness).
Techniques include reattribution training
(goal setting and planning coping
responses), decatastrophizing (balancing
anxious automatic thoughts), reappraisal,
and attention shifting. Cognitivebehavioral therapy is recommended as an
effective, nonpharmacologic treatment for
chronic insomnia (SOR A). Many herbs
and dietary supplements have been
promoted as sleep aids. However, with the
exceptions of melatonin and valerian, there
is insufficient evidence of benefit. Alcohol
acts directly on GABA-gated channels,
reducing sleep-onset latency, but it
increases wakefulness after sleep onset and
suppresses rapid eye movement (REM)
sleep. It also has the potential for abuse
and should not be used as a sleep aid.
Moderate-intensity exercise can improve
sleep, but exercising just before bedtime
can delay sleep onset.

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A 37-year-old gravida 3 para 2 at 33


weeks' gestation reports the onset of brisk
vaginal bleeding. On examination the
uterus is nontender and 32 cm above the
symphysis. Pelvic examination reveals the
presence of a large amount of bright red
vaginal blood. This presentation is most
consistent with: (check one)
A. Threatened abortion
B. Hemorrhagic cystitis
C. Placenta previa
D. Chorioamnionitis
E. Abruptio placentae

A 37-year-old recreational skier is unable


to lift his right arm after falling on his right
side with his arm elevated. Radiographs of
the right shoulder are negative, but
diagnostic ultrasonography shows a
complete rotator cuff tear.
Which one of the following is most
accurate with regard to treatment? (check
one)
A. Surgery is most likely to be beneficial if
performed less than 6 weeks after the
injury
B. Treatment with NSAIDs for 3 months is
recommended before further intervention
C. Subacromial corticosteroid injections
will provide functional and symptomatic
relief in the majority of patients
D. Surgical repair of rotator cuff tears to
restore function is necessary only in
geriatric patients
E. Therapeutic ultrasound of the shoulder
will make the condition tolerable during
spontaneous healing
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C. Placenta previa. The classic clinical


presentation of placenta previa is painless,
bright red vaginal bleeding. This diagnosis
must be considered in all patients beyond
24 weeks' gestation who present with
bleeding. Threatened abortion is unlikely
at this stage of pregnancy and hemorrhagic
cystitis is not accompanied by brisk
bleeding. Abruption of the placenta is the
most common cause of intrapartum fetal
death but is associated not only with brisk
vaginal bleeding, but also with uterine
tenderness that may be marked. Clinical
signs of chorioamnionitis include purulent
vaginal discharge, fever, tachycardia, and
uterine tenderness.
A. Surgery is most likely to be beneficial if
performed less than 6 weeks after the
injury. Surgery for rotator cuff tears is
most beneficial in young, active patients.
In cases of acute, traumatic, complete
rotator cuff tears, repair is recommended
in less than 6 weeks, as muscle atrophy is
associated with reduced surgical benefit
(SOR B). Advanced age and limited
strength are also associated with reduced
surgical benefit.
NSAIDs are used for analgesia. Their
benefit has not been shown to exceed that
of other simple analgesics, and the sideeffect profile may be higher.
Corticosteroid injections will not improve
a complete tear. Some experts also
recommend avoiding their use in partial or
complete tendon tears. Therapeutic
ultrasound does not add to the benefit from
range-of-motion exercises and exercises to
strengthen the involved muscle groups.

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A 38-year-old day-care worker consults


you for "a cold that won't go away." It
began with a runny nose, malaise, and a
slight temperature elevation up to 100F
(37.8C). She notes that after 2 weeks she
is now experiencing "coughing fits,"
which are sometimes so severe that she
vomits. She has had no immunizations
since her freshman year in college and
does not smoke. On examination you note
excessive lacrimation and conjunctival
injection. Her lungs are clear.
Which one of the following is the most
likely diagnosis? (check one)
A. Pertussis
B. Rhinovirus infection
C. Nonasthmatic eosinophilic bronchitis
D. Cough-variant asthma
E. Gastroesophageal reflux

A. Pertussis. Pertussis, once a common


disease in infants, declined to around 1000
cases in 1976 as a result of widespread
vaccination. The incidence began to rise
again in the 1980s, possibly because the
immunity from vaccination rarely lasts
more than 12 years.
The disease is characterized by a
prodromal phase that lasts 1-2 weeks and
is indistinguishable from a viral upper
respiratory infection. It progresses to a
more severe cough after the second week.
The cough is paroxysmal and may be
severe enough to cause vomiting or
fracture ribs. Patients are rarely febrile, but
may have increased lacrimation and
conjunctival injection. The incubation
period is long compared to a viral
infection, usually 7-10 days.
Nonasthmatic eosinophilic bronchitis,
cough-variant asthma, and
gastroesophageal reflux disease cause a
severe cough not associated with a
catarrhal phase. A rhinovirus infection
would probably be resolving within 2-3
weeks.

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A 38-year-old female with seasonal


allergies presents with a 10-day history of
sinus pain and purulent nasal drainage,
along with temperature elevations up to
102F (39C). She has been taking
nonprescription loratidine (Claritin), but
says it provides little relief. She asks you
to prescribe an antibiotic.
Which one of the following would be most
appropriate at this point?
(check one)
A. Continuation of symptomatic treatment
only
B. In-office nasal irrigation2
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Imaging of the sinuses
A 38-year-old male who is a new patient
reports mild intermittent jaundice without
other associated symptoms for the past
several years. His liver function tests are
normal except for a total bilirubin of 1.3
mg/dL (N 0.3-1.0) and an indirect or
unconjugated bilirubin of 1.0 mg/dL (N
0.2-0.8). His CBC is normal. His past
medical and surgical history is
unremarkable. Findings are similar on
repeat laboratory testing. The most likely
cause of these findings is: (check one)

C. Amoxicillin. The American Academy


of Otolaryngology published guidelines
for the diagnosis and management of
rhinosinusitis in adults in 2007. They cite
reasonable evidence for initiating
antibiotic treatment in patients with
symptoms persisting for 7-10 days that are
not improving or worsening (SOR B).
Amoxicillin should be the first-line agent,
with azithromycin or
trimethroprim/sulfamethoxazole
recommended for penicillinallergic
patients. Broader-spectrum antibiotics
such as fluoroquinolones should be
reserved for treatment failures. Imaging is
indicated only if other etiologies are being
considered or if the problem is recurrent.
D. Gilbert's syndrome. Gilbert's syndrome
is the most common inherited disorder of
bilirubin metabolism. In patients with a
normal CBC and liver function tests,
except for recurrent mildly elevated total
and unconjugated hyperbilirubinemia, the
most likely diagnosis is Gilbert's
syndrome. Fasting, heavy physical
exertion, sickle cell anemia, and drug
toxicity can also cause hyperbilirubinemia.

A. Hepatitis C
B. Wilson's disease
C. Sickle cell anemia
D. Gilbert's syndrome
E. Drug toxicity

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A 38-year-old white female presents to


your office with a 4-cm palpable nodule in
her right breast. Fine-needle aspiration
yields 4 cc of bloody fluid. Following the
aspiration, the breast nodule is no longer
palpable. Which one of the following
would be most appropriate at this point?
(check one)
A. No further workup
B. Cytologic examination of the fluid
C. Surgical referral for core needle biopsy
D. Surgical referral for excisional biopsy
E. Ultrasonography of the breast
A 38-year-old widow consults you 2 years
after her husband's accidental death. She is
planning to remarry and asks about the
possibility of resuming the low-dose oral
contraceptives she took before she was
widowed. Which one of the following may
contraindicate resumption of oral
contraceptives? (check one)
A. Her 42-year-old sister has breast cancer
B. Her blood pressure is 135/88 mm Hg
C. She smokes a pack of cigarettes each
day
D. She has a history of migraines resistant
to triptans
E. Her LDL/HDL ratio is 2.8

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B. Cytologic examination of the fluid.


When straw-colored or grey-green fluid is
obtained by fine-needle aspiration of a
breast nodule and the lesion completely
disappears, the diagnosis is simple cyst.
The fluid should not be sent for analysis
because the risk for cancer is exceedingly
small. If the fluid is bloody or otherwise
unusual, it should be sent for cytologic
examination because about 7% of
bloodstained aspirates are associated with
cancer.

C. She smokes a pack of cigarettes each


day. Oral contraceptives increase the risk
of venous thromboembolic phenomena.
The combination of oral contraceptives
and smoking substantially increases the
risk of cardiovascular disease. Caution
should be exercised in prescribing oral
contraceptives for women older than 35
years of age who smoke. In general, oral
contraceptive use is considered absolutely
contraindicated in women older than 35
who are heavy smokers. Women who
smoke fewer than 15 cigarettes a day and
patients with mildly elevated blood
pressure and elevated lipid levels are not at
increased risk for cardiovascular disease
when oral contraceptives are used.

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A 39-year-old African-American
multigravida at 36 weeks gestation
presents with a temperature of 40.0C
(104.0F), chills, backache, and vomiting.
On physical examination, the uterus is
noted to be nontender, but there is slight
bilateral costovertebral angle tenderness. A
urinalysis reveals many leukocytes, some
in clumps, as well as numerous bacteria.
Of the following, the most appropriate
therapy at this time would be: (check one)
A. oral trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. oral nitrofurantoin (Macrodantin)
C. oral levofloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceftriaxone (Rocephin)

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E. intravenous ceftriaxone (Rocephin).


Pyelonephritis is the most common
medical complication of pregnancy. The
diagnosis is usually straightforward, as in
this case. Since the patient is quite ill,
treatment is best undertaken in the hospital
with parenteral agents, at least until the
patient is stabilized and cultures are
available. Ampicillin plus gentamicin or a
cephalosporin is typically used.
Sulfonamides are contraindicated late in
pregnancy because they may increase the
incidence of kernicterus. Tetracyclines are
contraindicated because administration late
in pregnancy may lead to discoloration of
the child's deciduous teeth. Nitrofurantoin
may induce hemolysis in patients who are
deficient in G-6-PD, which includes
approximately 2% of African-American
women. The safety of levofloxacin in
pregnancy has not been established, and it
should not be used unless the potential
benefit outweighs the risk.

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A 39-year-old female presents with lower


abdominal/pelvic pain. On examination,
with the patient in a supine position, you
palpate the tender area of her abdomen.
When you have her raise both legs off the
table while you palpate the abdomen, her
pain intensifies.
Which one of the following is the most
likely diagnosis?
(check one)

B. A hematoma within the abdominal wall


musculature. Carnett's sign is the easing of
the pain of abdominal palpation with
tightening of the abdominal muscles. If the
cause is visceral, the taut abdominal
muscles could guard the source of pain
from the examining hand. In contrast,
intensification of pain with this maneuver
points to a source of pain within the
abdominal wall itself.

A. Appendicitis
B. A hematoma within the abdominal wall
musculature
C. Diverticulitis
D. Pelvic inflammatory disease
E. An ovarian cyst
A 40-year-old businessman has recently
been diagnosed with irritable bowel
syndrome after extensive testing by his
gastroenterologist. His predominant
symptoms are diarrhea and pain.
Which one of the following has been
shown to be helpful in controlled trials?
(check one)
A. Probiotics such as yogurt and
buttermilk
B. Insoluble fiber such as wheat bran, corn
bran, and defatted flaxseed
C. Soluble fiber such as psyllium
(ispaghula)
D. Turmeric
E. Peppermint oil

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E. Peppermint oil. Studies suggest that in


25% of patients, irritable bowel syndrome
may be caused or aggravated by one or
more dietary components. Restriction of
fermentable, poorly absorbed
carbohydrates is beneficial, including
fructan (found in wheat and onions),
sorbitol, and other such alcohols. Further
studies are needed, however. Despite its
popularity, fiber is marginally beneficial
and insoluble fiber may worsen symptoms
in patients with diarrhea. Probiotics in the
form of foods such as buttermilk and liveculture yogurt have thus far not been
established as useful. Daily use of
peppermint oil has been shown to relieve
symptoms.

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A 40-year-old female comes to your office


for a routine examination. She has been in
good health and has no complaints other
than obesity. Her mother is diabetic and
the patient has had a child that weighed 9
lb at birth. Her examination is negative
except for her obesity. A fasting glucose
level is 128 mg/dL, and when repeated 2
days later it is 135 mg/dL. Which one of
the following would be most appropriate at
this point? (check one)
A. Diagnose type 2 diabetes mellitus and
begin diet and exercise therapy
B. Begin an oral hypoglycemic agent
C. Order a glucose tolerance test
D. Tell the patient that she has impaired
glucose homeostasis but is not diabetic

A 40-year-old female comes to your office


with a 1-month history of right heel pain
that she describes as sharp, searing, and
severe. The pain is worst when she first
bears weight on the foot after prolonged
sitting and when she gets out of bed in the
morning. It gets better with continued
walking, but worsens at the end of the day.
She does not exercise except for being on
her feet all day in the hospital where she
works as a floor nurse. She denies any
history of trauma. An examination reveals
point tenderness to palpation on the plantar
surface of the heel at the medial calcaneal
tuberosity.
Which one of the following should you
recommend as first-line treatment? (check
one)
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A. Diagnose type 2 diabetes mellitus and


begin diet and exercise therapy. The
criteria for diagnosing diabetes mellitus
include any one of the following:
symptoms of diabetes (polyuria,
polydipsia, weight loss) plus a casual
glucose level 200 mg/dL; a fasting
plasma glucose level 126 mg/dL; or a 2hour postprandial glucose level 200
mg/dL after a 75 gram glucose load. In the
absence of unequivocal hyperglycemia the
test must be repeated on a different day.
The criteria for impaired glucose
homeostasis include either a fasting
glucose level of 100-125 mg/dL (impaired
fasting glucose) or a 2-hour glucose level
of 140-199 mg/dL on an oral glucose
tolerance test. Normal values are now
considered <100 mg/dL for fasting glucose
and <140 mg/dL for the 2-hour glucose
level on an oral glucose tolerance test.
B. Over-the-counter heel inserts. Plantar
fasciitis is a common cause of heel pain. It
may be unilateral or bilateral, and the
etiology is unknown, although it is thought
to be due to cumulative overload stress.
While it may be associated with obesity or
overuse, it may also occur in active or
inactive patients of all ages. Typically the
pain is located in the plantar surface of the
heel and is worst when the patient first
stands up when getting out of bed in the
morning (first step phenomenon) or after
prolonged sitting. The pain may then
improve after the patient walks around,
only to worsen after prolonged walking.
The diagnosis is made by history and
physical examination. Typical findings
include point tenderness to palpation on
the plantar surface of the heel at the medial
calcaneal tuberosity where the calcaneal
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A. Taping/strapping
B. Over-the-counter heel inserts
C. Extracorporeal shock wave therapy
D. A corticosteroid injection
E. A fiberglass walking cast

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aponeurosis inserts. Radiographs are not


necessary unless there is a history of
trauma or if the diagnosis is unclear.
The condition may last for months or
years, and resolves in most patients over
time with or without specific therapy. One
long-term follow-up study showed that
80% of patients had complete resolution of
their pain after 4 years. Treatments with
limited (level 2) evidence of effectiveness
include off-the-shelf insoles, custom-made
insoles, stretching of the plantar fascia,
corticosteroid iontophoresis, custom-made
night splints, and surgery (for those who
have failed conservative therapy). NSAIDs
and ice, although not independently
studied for plantar fasciitis, are included in
most studies of other treatments, and are
reasonable adjuncts to first-line therapy.
Magnetic insoles and extracorporeal
shockwave therapy are ineffective in
treating plantar fasciitis.
Due to their expense, custom-made
insoles, custom-made night splints, and
corticosteroid iontophoresis should be
reserved as second-line treatments for
patients who fail first-line treatment.
Surgery may be offered if more
conservative therapies fail. Corticosteroid
injection may have a short-term benefit at
1 month, but is no better than other
treatments at 6 months and carries a risk of
plantar fascia rupture.

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A 40-year-old female is scheduled for a


cholecystectomy and you wish to estimate
her risk for postoperative bleeding. Which
one of the following provides the most
sensitive method for identifying her risk?
(check one)
A. Bleeding time
B. Prothrombin time (PT)
C. Activated partial thromboplastin time
(aPTT)
D. Bleeding history
A 40-year-old female presents with a
complaint of fatigue. She says she is also
concerned because she has gained about
10 lb over the last several months.
Physical examination reveals no
enlargement or other abnormalities of the
thyroid gland. Laboratory testing reveals a
TSH level of 0.03 U/mL (N 0.4-4.0) and
a free T4 level of 1.0 g/dL (N 1.5-5.5).
Which one of the following is the most
likely cause of her problem? (check one)
A. Malnutrition
B. Graves' disease
C. Goiter
D. Hashimoto's thyroiditis
E. Pituitary failure

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D. Bleeding history. Bleeding time,


activated partial thromboplastin time
(aPTT), and prothrombin time (PT) are
relatively poor predictors of bleeding risk.
Studies have shown that baseline
coagulation assays do not predict
postoperative bleeding in patients
undergoing general or vascular surgery
who have no history that suggests a
bleeding disorder. Obtaining a history for
evidence of prior bleeding problems is the
most sensitive and accurate method of
determining a patient's risk.
E. Pituitary failure. This patient's
symptoms and laboratory findings suggest
a significant lack of TSH despite low
levels of circulating thyroid hormone. This
is diagnostic of secondary hypothyroidism.
Such findings should prompt a workup for
a pituitary or hypothalamic deficiency that
is causing a lack of TSH production.
Primary hypothyroidism, such as
Hashimoto's thyroiditis, would be
evidenced by an elevated TSH and low (or
normal) T4 . Graves' disease is a cause of
hyperthyroidism, which would be expected
to increase T4 levels, although low TSH
with a normal T4 level may be present.
Some nonthyroid conditions such as
malnutrition may suppress T4 . In such
cases the TSH would be elevated or
normal. This patient has gained weight,
which does not coincide with malnutrition.
The patient does not have the thyroid
gland enlargement seen with goiter.

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A 40-year-old female with chronic plaque


psoriasis requests topical treatment. Which
one of the following topical therapies
would be most effective and have the
fewest adverse effects? (check one)
A. High-potency corticosteroids
B. Tazarotene (Tazorac)
C. Coal tar polytherapy
D. Anthralin

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A. High-potency corticosteroids. Chronic


plaque psoriasis is the most common type
of psoriasis and is characterized by
redness, thickness, and scaling. A variety
of treatments were found to be more
effective than placebo, but the best results
were produced by topical vitamin D
analogues and topical corticosteroids.
Vitamin D and high-potency
corticosteroids were equally effective
when compared head to head, but the
corticosteroids produced fewer local
reactions (SOR A).

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A 40-year-old male who recently


immigrated from central Africa presents to
a public health clinic where you are
working. He was referred by a physician in
the local emergency department, who
made a diagnosis of type 2 diabetes
mellitus. The patient has no history of
fever or night sweats, weight loss, or
cough. He does have a history of receiving
bacille Calmette-Gurin (BCG) vaccine in
the past. Screening tests for HIV and
hepatitis performed in the emergency
department were negative.
Which one of the following is true
regarding screening for latent tuberculosis
infection by in vitro interferon-gamma
release assay (IGRA) compared to
screening by the traditional targeted
tuberculin skin test (TST) in this patient?
(check one)

C. IGRA differentiates Mycobacterium


tuberculosis from nontuberculous
mycobacteria. In vitro interferon-gamma
release assays (IGRAs) are a new way of
screening for latent tuberculosis infection.
One of the advantages of IGRA is that it
targets antigens specific to Mycobacterium
tuberculosis. These proteins are absent
from the BCG vaccine strains and from
commonly encountered nontuberculous
mycobacteria. Unlike skin testing, the
results of IGRA are objective. It is
unnecessary for IGRA to be done in
tandem with skin testing, and it eliminates
the need for two-step testing in high-risk
patients. IGRAs are labor intensive,
however, and the blood sample must be
received by a qualified laboratory and
incubated with the test antigens within 816 hours of the time it was
drawn,depending upon the brand of
cuurently available IGRAs

A. Both tests require subjective


interpretation
B. BCG interferes with IGRA results
C. IGRA differentiates Mycobacterium
tuberculosis from nontuberculous
mycobacteria
D. IGRA results are valid if the sample is
analyzed within 24 hours
E. IGRA should be done in tandem with
TST

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A 40-year-old male with acute pancreatitis


has an alanine transaminase (ALT) level
that is five times normal. Which one of the
following is the most likely diagnosis?
(check one)
A. Gallstone pancreatitis
B. Pancreatic necrosis
C. Pancreatic pseudocyst
D. Hepatitis C
E. Alcohol-induced pancreatitis
A 40-year-old male with HIV infection
presents to the emergency department with
a 5-day history of progressive cough and
dyspnea on exertion. A chest radiograph
shows bilateral diffuse interstitial
infiltrates. Arterial blood gas levels show
an increased alveolar-arterial gradient and
a pO2 of 60 mm Hg. His CBC is normal
but his CD4 count is 150/mm3 .
In addition to
trimethoprim/sulfamethoxazole (Bactrim,
Septra), which one of the following
medications should be prescribed? (check
one)

A. Gallstone pancreatitis. In this setting, a


threefold or greater elevation of alanine
transaminase has a positive predictive
value of 95% for acute gallstone
pancreatitis. High levels of C-reactive
protein are associated with pancreatic
necrosis. Hepatitis C is identified by
antibody detection or polymerase chain
reaction testing. Other markers are
investigational.
E. Corticosteroids.
Trimethoprim/sulfamethoxazole is the
treatment of choice for acute Pneumocystis
pneumonia. Adjunctive corticosteroids
should also be started in any patient whose
initial pO2 on room air is <70 mm Hg.
Three prospective trials have shown that
there is a decrease in mortality and
frequency of respiratory failure when
corticosteroids are used in addition to
antibiotics. All of the other medications
listed are effective therapy for
Pneumocystis pneumonia, but they do not
need to be given with
trimethoprim/sulfamethoxazole.

A. Pentamidine (Pentam)
B. Dapsone
C. Atovaquone (Mepron)
D. Clindamycin (Cleocin) and primaquine
E. Corticosteroids

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A 40-year-old nurse presents with a 1-year


history of rhinitis, and a more recent onset
of episodic wheezing and dyspnea. Her
symptoms seem to improve when she is on
vacation. She does not smoke, although
she says that her husband does. Her FEV1
improves 20% with inhaled -agonists.
Which one of the following is the most
likely diagnosis?
(check one)
A. Occupational asthma
B. Sarcoidosis
C. COPD
D. Anxiety
E. Vocal cord dysfunction

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A. Occupational asthma. Occupational


asthma merits special consideration in all
cases of new adult asthma or recurrence of
childhood asthma after a significant
asymptomatic period (SOR C).
Occupational asthma is often preceded by
the development of rhinitis in the
workplace and should be considered in
patients whose symptoms improve away
from work. Reversibility with -agonist
use makes COPD less likely, in addition to
the fact that the patient is a nonsmoker.
Cystic fibrosis is not a likely diagnosis in a
patient this age with a long history of
being asymptomatic. Sarcoidosis would be
less likely to cause reversible airway
obstruction and intermittent symptoms.
Vocal cord dysfunction would not be
expected to respond to bronchodilators.

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A 40-year-old obese African-American


male presents with a history of excessive
daytime drowsiness. He readily falls
asleep when reading or watching
television. He admits to nearly crashing his
car twice in the past month because he
briefly fell asleep behind the wheel. Most
frightening to the patient have been
episodes characterized by sudden loss of
muscle tone, lasting about 1 minute,
associated with laughing. An overnight
sleep study shows decreased sleep latency
and no evidence of obstructive sleep
apnea.
Appropriate treatment includes which one
of the following? (check one)

A. Methylphenidate (Ritalin). The clinical


history and laboratory findings presented
are consistent with a diagnosis of
narcolepsy. Methylphenidate and other
stimulant drugs remain the pharmacologic
agents of choice in managing this disorder.
Since there is no evidence of obstructive
sleep apnea, weight reduction would not
be expected to address his sleep problem.
In general, sedatives, hypnotics, and
alcohol should be avoided. Periodic
daytime naps may help to reduce
symptoms.

A. Methylphenidate (Ritalin)
B. Zolpidem (Ambien) at bedtime
C. Carbidopa/levodopa (Sinemet)
D. Weight reduction
E. Avoidance of daytime napping
A 40-year-old runner complains of
gradually worsening pain on the lateral
aspect of his foot. He runs on asphalt, and
has increased his mileage from 2 miles/day
to 5 miles/day over the last 2 weeks.
Palpation causes pain over the lateral 5th
metatarsal. The pain is also reproduced
when he jumps on the affected leg. When
you ask about his shoes he tells you he
bought them several years ago.
Which one of the following is the most
likely diagnosis?
(check one)

B. Stress fracture. Running injuries are


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

A. Ligamentous sprain of the arch


B. Stress fracture
C. Plantar fasciitis
D. Osteoarthritis of the metatarsal joint
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A 40-year-old white female lawyer sees


you for the first time. When providing a
history, she describes several problems,
including anxiety, sleep disorders, fatigue,
persistent depressed mood, and decreased
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.
The most likely diagnosis at this time is:
(check one)
A. premenstrual syndrome
B. dysthymia
C. dementia
D. menopause
E. anorexia nervosa

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B. dysthymia. Psychological disorders,


including anxiety, depression, and
dysthymia, are frequently confused with
premenstrual syndrome (PMS), and must
be ruled out before initiating therapy.
Symptoms are cyclic in true PMS. The
most accurate way to make the diagnosis is
to have the patient keep a menstrual
calendar for at least two cycles, carefully
recording daily symptoms. Dysthymia
consists of a pattern of ongoing, mild
depressive symptoms that have been
present for 2 years or more and are less
severe than those of major depression.
This diagnosis is consistent with the
findings in the patient described here.

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A 40-year-old white female presents with


pain on inspiration and dyspnea since this
morning. She has no chronic medical
problems, takes no medications, has not
traveled, and has no history of trauma. On
examination the patient is afebrile, has a
heart rate of 90 beats/min and a respiratory
rate of 20/min, and her lungs are clear to
auscultation. The pain is worse in the
supine position. Which one of the
following would you do initially? (check
one)
A. Order a CBC with differential
B. Order a chest film and EKG
C. Prescribe ibuprofen
D. Prescribe omeprazole (Prilosec)
E. Prescribe a bronchodilator

A 41-year-old male trips on a curb while


running, sustaining an inversion ankle
injury. According to the Ottawa ankle
rules, which one of the following would be
an indication for radiographic evaluation?
(check one)
A. Tenderness at the anterior talofibular
ligament
B. Point tenderness over the cuboid
C. Inability to take four steps either
immediately after the injury or while in
your office
D. Bony tenderness at the anterior aspect
of the distal tibia
E. Point tenderness over the base of the
fourth metatarsal

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B. Order a chest film and EKG. This


patient has pleuritic chest pain, and the
fact that it is worse when supine and is
accompanied by dyspnea creates
additional concern. Supine pain could be
due to pericarditis, which may be evident
on an EKG. Dyspnea increases suspicion
for pneumonia, pulmonary embolism,
pneumothorax, and myocardial infarction,
and a chest film and EKG are
recommended to evaluate these
possibilities. The lack of any significant
medical history does not rule out any of
these problems. Once these problems have
been ruled out, a diagnosis of pleurisy
would be reasonable and can be treated
with an NSAID. A CBC would only
indicate the possibility that infection or
anemia is the cause of the problem.
Omeprazole or a bronchodilator would be
inappropriate treatment, as asthma and
reflux are not likely in this patient.
C. Inability to take four steps either
immediately after the injury or while in
your office. The Ottawa ankle rules have
been designed and validated to reduce
unnecessary radiographs. Radiographs
should be obtained for all patients with an
acute ankle injury who meet any of the
following criteria: inability to take four
steps, either immediately after the injury or
when being evaluated; localized
tenderness of the navicular bone or the
base of the fifth metatarsal; or localized
tenderness at the posterior edge or tip of
either malleolus.

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A 42-year-old African-American male


recently traveled to the Caribbean for a
scuba diving trip. Since his return he has
noted brief intermittent episodes of vertigo
not associated with nausea or vomiting. He
is concerned, however, because these
episodes occurred after sneezing or
coughing and then a couple of times after
straining while lifting something. He has
had no hearing loss, and no vertigo with
positional changes such as bending over or
turning over in bed. The most likely cause
of this patients vertigo is (check one)
A. vestibular neuronitis
B. Menieres disease
C. benign paroxysmal positional vertigo
D. a perilymphatic fistula
E. multiple sclerosis triggered by a rapid
change in climate

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D. a perilymphatic fistula. A perilymphatic


fistula between the middle and inner ear
may be caused by barotrauma from scuba
diving, as well as by direct blows, heavy
weight bearing, and excessive straining
(e.g., with sneezing or bowel movements.)
This patients recent trip involved two of
these potential factors. Vestibular
neuronitis is a more sudden, unremitting
syndrome. Menieres disease is manifested
by episodes of vertigo, associated with
hearing loss and often with nausea and
vomiting. Benign paroxysmal positional
vertigo is more likely in older individuals,
and is associated with postural change.
Multiple sclerosis requires symptoms in
multiple areas and is not thought to be
provoked by climate change. Reference:
Labuguen RH: Initial evaluation of
vertigo. Am Fam Physician
2006;73(2):244-251, 254.

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A 42-year-old asymptomatic female


presents 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 treatment option?
(check one)
A. Laparoscopic myomectomy
B. Hysterectomy
C. A gonadotropin-releasing hormone
(GnRH) agonist
D. An oral contraceptive
E. Observation

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E. Observation. Uterine fibroid tumors


(leiomyomas) are the most common
female reproductive tract tumors, with
some evidence suggesting that the
cumulative incidence in women ages 2545 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
expectant management being the treatment
of choice 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 to allow conclusions to be
made about 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 (oral contraceptives,
NSAIDs, progestins) in the treatment of
women with symptomatic fibroids.

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A 42-year-old female brings you the


results of a comprehensive metabolic
profile obtained through a health screening
program offered by her employer. She
fasted for 8 hours prior to the test, and her
blood glucose level was reported as 110
mg/dL. Her lipid values and her blood
pressure were normal, but her BMI is 30.5
kg/m 2 .
She currently views herself as relatively
healthy and reports no symptoms
consistent with diabetes mellitus during
your review of systems. Additional testing
reveals a hemoglobin A1c of 6.3%.
Based on this data, which one of the
following is most appropriate at this time?
(check one)
A. Order a C-peptide level
B. Order an islet cell antibody level
C. Recommend lifestyle modifications
only
D. Start low-dose glyburide (DiaBeta)
daily
E. Start low-dose insulin glargine (Lantus)
daily

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C. Recommend lifestyle modifications


only. The ADA recommends testing to
detect type 2 diabetes mellitus in
asymptomatic adults with a BMI 25 kg/m
2 and one or more additional risk factors.
Risk factors include physical inactivity,
hypertension, an HDL-cholesterol level
<35 mg/dL, a triglyceride level >250
mg/dL, a history of cardiovascular disease,
a hemoglobin A 1c5.7%, a history of
gestational diabetes or delivery of an
infant weighing >4 kg (9 lb), and a history
of polycystic ovary syndrome.
Diabetes mellitus can be diagnosed if the
patient's fasting blood glucose level is
126 mg/dL on two separate occasions. It
can also be diagnosed if a random blood
glucose level is 200 mg/dL if classic
symptoms of diabetes are present. A
fasting blood glucose level of 100-125
mg/dL, a glucose level of 140-199 mg/dL
2 hours following a 75-g glucose load, or a
hemoglobin A 1c of 5.7%-6.9% signifies
impaired glucose tolerance. Patients
meeting these criteria have a significantly
higher risk of progression to diabetes and
should be counseled about lifestyle
modifications such as weight loss and
exercise.

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A 42-year-old female is found to have a


thyroid nodule during her annual physical
examination. Her TSH level is normal.
Ultrasonography of her thyroid gland
shows a solitary nodule measuring 1.2 cm.
Which one of the following would be most
appropriate at this point? (check one)
A. A radionuclide thyroid scan
B. A fine-needle aspiration biopsy of the
nodule
C. Partial thyroidectomy
D. Total thyroidectomy
E. Reassurance
A 42-year-old female presents to the
emergency department with pleuritic chest
pain. Her probability of pulmonary
embolism is determined to be low.
Which one of the following should be
ordered to further evaluate this patient?
(check one)

B. A fine-needle aspiration biopsy of the


nodule. All patients who are found to have
a thyroid nodule on a physical examination
should have their TSH measured. Patients
with a suppressed TSH should be
evaluated with a radionuclide thyroid scan;
nodules that are "hot" (show increased
isotope uptake) are almost never malignant
and fine-needle aspiration biopsy is not
needed. For all other nodules, the next step
in the workup is a fine-needle aspiration
biopsy to determine whether the lesion is
malignant (SOR B).
C. ELISA-based D-dimer. Patients who
have a low or moderate pretest probability
of pulmonary embolism should have ddimer testing as the next step in
establishing a diagnosis.

A. Brain natriuretic peptide (BNP)


B. CT pulmonary angiography
C. ELISA-based D-dimer
D. A cardiac troponin level
E. A ventilation-perfusion lung scan

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A 42-year-old female presents with a 2day history of chest pain. She describes the
pain as sharp, located in the right upper
chest, and worsened by deep breathing or
coughing. She also complains of shortness
of breath. She was previously healthy and
has no recent history of travel. Her vital
signs are normal. A pleural friction rub is
noted on auscultation of the lungs. The
remainder of the examination is normal.
An EKG, cardiac enzymes, oxygen
saturation, and a D-dimer level are all
normal. Which one of the following would
be most appropriate at this point? (check
one)
A. No further testing
B. A chest radiograph
C. An antinuclear antibody test
D. Echocardiography
E. Pulmonary angiography

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B. A chest radiograph. This patient has


pleurisy. Patients presenting with pleuritic
chest pain may have life-threatening
disorders, and pulmonary embolism, acute
myocardial infarction, and pneumothorax
should be excluded. While 5%-20% of
patients with pulmonary embolism present
with pleuritic chest pain, this patient has
no risks for pulmonary embolism and the
normal D-dimer level obviates the need for
further evaluation. Moderate- to high-risk
patients may need a helical CT scan or
other diagnostic testing. An EKG and
chest radiograph are recommended in the
evaluation of acute/subacute pleuritic chest
pain. The chest radiograph will exclude
pneumothorax, pleural effusion, or
pneumonia. An echocardiogram would not
be indicated if the cardiac examination and
EKG are normal. An antinuclear antibody
level could be considered in recurrent
pleurisy or if other symptoms or signs of
lupus were present, but it would not be
indicated in this patient. Most cases of
acute pleurisy are viral and should be
treated with NSAIDs unless the workup
indicates another problem.

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A 42-year-old female with a history of


alcoholism and binge drinking presents
with a 3-hour history of severe epigastric
pain associated with nausea and vomiting.
Her pain radiates to her back and into her
lower abdomen. The patient appears to be
in moderate distress due to pain. She is
afebrile with a pulse rate of 110 beats/min
and a blood pressure of 98/66 mm Hg. Her
abdominal examination is remarkable for
epigastric tenderness, guarding, and mild
abdominal distention. Laboratory
evaluation reveals a serum lipase level of
562 U/L (N 22-51) and a serum amylase
level of 317 U/L (N 36-128).
You admit the patient to the hospital. Your
treatment plan includes volume repletion,
pain control, and close monitoring of her
hemodynamic status. After 48 hours of
treatment, she is hemodynamically stable.
Her serum lipase level is now 168 U/L.
She is awake and alert and in no distress,
but still requires parenteral pain
medication.

D. Intravenous total parenteral nutrition.


Although intravenous dextrose in normal
saline can initially be used for aggressive
rehydration, it does not meet the
nutritional needs of patients with acute
pancreatitis. Total enteral nutrition is
superior to total parenteral nutrition in
stable patients with acute pancreatitis, in
both mild and severe cases (SOR A).
When compared to total parenteral
nutrition in these patients, enteral nutrition
is associated with reduced rates of
mortality, multiple organ failure, systemic
infection, and operative interventions
(SOR A). Enteral nutrition likely
contributes to better outcomes by
inhibiting bacterial translocation from the
gut, thereby preventing the development of
infected necrosis. This patient is awake
and alert and presumably able to protect
her airway, so nasogastric tube feeding is
unnecessary to provide enteral nutrition.

Which one of the following is most


appropriate for meeting her fluid and
caloric needs at this time? (check one)
A. D5 normal saline intravenously at a
maintenance rate
B. Enteral feedings via nasogastric feeding
tube
C. A low-fat diet orally and oral fluids ad
libitum
D. Intravenous total parenteral nutrition

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A 42-year-old male presents with anterior


neck pain. His thyroid gland is markedly
tender on examination, but there is no
overlying erythema. He also has a bilateral
hand tremor. His erythrocyte
sedimentation rate is 82 mm/hr (N 1-13)
and his WBC count is 11,500/mm3 (N
4300-10,800). His free T4 is elevated,
TSH is suppressed, and radioactive iodine
uptake is abnormally low.
Which one of the following treatment
options would be most helpful at this
time? (check one)

C. Prednisone. This patient has signs and


symptoms of painful subacute thyroiditis,
including a painful thyroid gland,
hyperthyroidism, and an elevated
erythrocyte sedimentation rate. It is
unclear whether there is a viral etiology to
this self-limited disorder. Thyroid function
returns to normal in most patients after
several weeks, and may be followed by a
temporary hypothyroid state. Treatment is
symptomatic. Although NSAIDs can be
helpful for mild pain, high-dose
glucocorticoids provide quicker relief for
the more severe symptoms.

A. Levothyroxine (Synthroid) and


NSAIDs
B. Propylthiouracil
C. Prednisone
D. Nafcillin
E. Thyroidectomy

Levothyroxine is not indicated in this


hyperthyroid state. Neither thyroidectomy
nor antibiotics is indicated for this
problem.

A 42-year-old male seeks your advice


regarding smoking cessation. You
recommend a smoking cessation class, as
well as varenicline (Chantix).
You caution him that the most common
side effect is: (check one)

E. nausea. The most common adverse


event attributed to varenicline at a dosage
of 1 mg twice a day is nausea, occurring in
approximately 30%-50% of patients.
Taking the drug with food lessens the
nausea.

A. dermatitis
B. diarrhea
C. edema
D. hirsutism
E. nausea

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A 42-year-old male with a history of


intravenous drug use asks to be tested for
hepatitis C. The hepatitis C virus (HCV)
antibody enzyme immunoassay and
recombinant immunoblot assay are both
reported as positive. The quantitative HCV
RNA polymerase chain reaction test is
negative. These test results are most
consistent with: (check one)
A. very early HCV infection
B. current active HCV infection
C. a false-positive antibody test
D. past infection with HCV that is now
resolved
A 42-year-old male with well-controlled
type 2 diabetes mellitus presents with a 24hour history of influenza-like symptoms,
including the sudden onset of headache,
fever, myalgias, sore throat, and cough. It
is December, and there have been a few
documented cases of influenza recently in
the community.
The CDC recommends initiating treatment
in this situation: (check one)
A. on the basis of clinical symptoms alone
B. only if rapid influenza testing is
positive
C. only if the diagnosis is confirmed by
immunoassay testing
D. only if the diagnosis is confirmed by
reverse transcriptase polymerase chain
reaction (PCR) assay

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D. past infection with HCV that is now


resolved. The most widely used initial
assay for detecting hepatitis C virus
(HCV) antibody is the enzyme
immunoassay. A positive enzyme
immunoassay should be followed by a
confirmatory test such as the recombinant
immunoblot assay. If negative, it indicates
a false-positive antibody test. If positive,
the quantitative HCV RNA polymerase
chain reaction is used to measure the
amount of virus in the blood to distinguish
active from resolved HCV infection. In
this case, the results of the test indicate
that the patient had a past infection with
HCV that is now resolved.
A. on the basis of clinical symptoms alone.
Influenza is a highly contagious viral
illness spread by airborne droplets. This
patient's symptoms are highly suggestive
of typical influenza: a sudden onset of
malaise, myalgia, headache, fever, rhinitis,
sore throat, and cough. While influenza is
typically uncomplicated and self-limited, it
can result in severe complications,
including encephalitis, pneumonia,
respiratory failure, and death.
The effectiveness of treatment for
influenza is dependent on how early in the
course of the illness it is given. Because of
the recent global H1N1 influenza outbreak
that resulted in demand potentially
outstripping the supply of antiviral
medication, the Centers for Disease
Control and Prevention has modified its
recommendation as follows:
Antiviral treatment is recommended as
soon as possible for patients with
confirmed or suspected influenza who
have severe, complicated, or progressive
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illness or who require hospitalization.


Antiviral treatment is recommended as
soon as possible for outpatients with
confirmed or suspected influenza who are
at higher risk for influenza complications
based on their age or underlying medical
conditions. Clinical judgment should be an
important component of outpatient
treatment decisions.
Antiviral treatment also may be considered
on the basis of clinical judgment for any
outpatient with confirmed or suspected
influenza who does not have known risk
factors for severe illness, if treatment can
be initiated within 48 hours of illness
onset.
Many rapid influenza tests produce falsenegative results, and more accurate assays
can take more than 24 hours. Thus,
treatment of patients with a clinical picture
suggesting influenza is recommended,
even if a rapid test is negative. Delaying
treatment until further test results are
available is not recommended.

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A 42-year-old previously healthy white


female presents to your office with her
third episode of abdominal pain. This
episode began 2 hours ago, and the pain is
improving. She describes colicky right
upper quadrant and epigastric pain. On
examination you note mild right upper
quadrant tenderness, with otherwise
unremarkable findings. Renal function
tests are normal.
Which one of the following would be most
appropriate at this point?
(check one)
A. KUB films
B. Ultrasonography of the right upper
quadrant
C. Abdominal CT with intravenous
contrast
D. Abdominal CT with intravenous and
oral contrast
E. MRI of the abdomen

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B. Ultrasonography of the right upper


quadrant. Ultrasonography of the right
upper quadrant is recommended as the
initial imaging study for right upper
quadrant pain (SOR C). KUB films can
detect kidney stones but may miss
gallstones. CT also may miss gallstones,
and is more invasive than ultrasonography.
Abdominal CT with intravenous contrast
is the preferred test for right lower
quadrant pain, and abdominal CT with
intravenous and oral contrast is preferred
for left lower quadrant pain. MRI is
preferred for detecting tumors, and is
inappropriate as the initial imaging study
for right upper quadrant pain.

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A 42-year-old white female presents to


your office as a new patient. She states that
she has an 8-year history of abdominal
cramps and diarrhea. Her symptoms have
not responded to the usual treatments for
irritable bowel syndrome. She has no
rectal bleeding, anemia, weight loss, or
fever, and no family history of colon
cancer. Her medical history and a review
of symptoms is otherwise negative, and a
physical examination is normal.
Which one of the following would be the
most appropriate next step in evaluating
this patient?
(check one)

D. Serologic testing for celiac sprue. In


patients who have symptoms of irritable
bowel syndrome (IBS), the differential
diagnosis includes celiac sprue,
microscopic and collagenous colitis,
atypical Crohn's disease for patients with
diarrhea-predominant IBS, and chronic
constipation (without pain) for those with
constipation-predominant IBS. If there are
no warning signs, laboratory testing is
warranted only if indicated by the history.

A. A CBC
B. A TSH level
C. A complete metabolic panel
D. Serologic testing for celiac sprue
E. Stool testing for ova and parasites
A 42-year-old white male develops
respiratory distress 12 hours after he
sustained a closed head injury and a femur
fracture. A physical examination reveals a
respiratory rate of 40/min. He has a pO2 of
45 mm Hg (N 75-100), a pCO2 of 25 mm
Hg (N 35-45), and a blood pH of 7.46 (N 2
2 7.35-7.45). His hematocrit is 30.0% (N
37.0-49.0).
Of the following, the most likely diagnosis
is: (check one)

C. adult respiratory distress syndrome


(ARDS). Acute respiratory failure
following severe injury and critical illness
has received increasing attention over the
last decade. With advances in the
management of hemorrhagic shock and
support of circulatory and renal function in
injured patients, it has become apparent
that 1%-2% of significantly injured
patients develop acute respiratory failure
in the post-injury period.

A. respiratory depression due to central


nervous system damage
B. heart failure
C. adult respiratory distress syndrome
(ARDS)
D. hypovolemic shock
E. tension pneumothorax

Initially this lung injury was thought to be


related to a particular clinical situation.
This is implied by such names as "shock
lung" and "traumatic wet lung," which
have been applied to acute respiratory
insufficiency. It is now recognized that the
pulmonary problems that follow a variety
of insults have many similarities in their

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clinical presentation and physiologic and


pathologic findings. This has led to the
theory that the lung has a limited number
of ways of reacting to injury and that
several different types of acute, diffuse
lung injury result in a similar
pathophysiologic response. The common
denominator of this response appears to be
injury at the alveolar-capillary interface,
with resulting leakage of proteinaceous
fluid from the intravascular space into the
interstitium and subsequently into alveolar
spaces. It has become acceptable to
describe this entire spectrum of acute
diffuse injury as adult respiratory distress
syndrome (ARDS).
The syndrome of ARDS can occur under a
variety of circumstances and produces a
spectrum of clinical severity from mild
dysfunction to progressive, eventually
fatal, pulmonary failure. Fortunately, with
proper management, pulmonary failure is
far less frequent than milder abnormalities.

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A 43-year-old female complains of a


several-month history of unpleasant
sensations in her legs and an urge to move
her legs. These symptoms only occur at
night and improve when she gets up and
stretches. The sensations often awaken her,
and she feels very tired. She has no other
medical problems and takes no
medication. Laboratory tests reveal a
serum calcium level of 8.9 mg/dL (N 8.510.5), a serum potassium level of 4.1
mmol/L (N 3.5-5.0), a serum ferritin level
of 15 ng/mL (N 10-200), and a serum
magnesium level of 1.5 mEq/L (N 1.42.0).
Which one of the following may improve
her symptoms? (check one)

A. Iron supplementation. This patient has


restless legs syndrome, which includes
unpleasant sensations in the legs and can
cause sleep disturbances. The symptoms
are relieved by movement.
Recommendations for treatment include
lower-body resistance training and
avoiding or changing medications that may
exacerbate symptoms (e.g., antihistamines,
caffeine, SSRIs, tricyclic antidepressants,
etc.). It is also recommended that patients
with a serum ferritin level below 50 ng/mL
take an iron supplement (SOR C).
Magnesium supplementation does not
improve restless legs syndrome.
Ropinirole may be used if
nonpharmacologic therapies are
ineffective.

A. Iron supplementation
B. Magnesium supplementation
C. Antihistamines
D. Stopping calcium supplementation
E. Amitriptyline

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A 43-year-old female presents to your


office for evaluation of a chronic cough
that has been present for the past 6 months.
She is not a smoker, and is not aware of
any exposure to environmental irritants.
She does not have any systemic
complaints such as fever or weight loss,
and does not have any symptoms of
heartburn or regurgitation. She is not on
any regular medications.
Auscultation of the lungs and a chest
radiograph show no evidence of acute
disease. A trial of an inhaled
bronchodilator and antihistamine therapy
does not improve the patient's symptoms.
Which one of the following would be the
most appropriate next step?
(check one)
A. A methacholine inhalation challenge
test
B. Pulmonary function testing
C. CT of the chest
D. A trial of a proton pump inhibitor
E. 24-hour pH monitoring

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D. A trial of a proton pump inhibitor.


Gastroesophageal reflux disease (GERD)
is one of the most common causes of
chronic cough. Patients with chronic
cough have a high likelihood of having
GERD, even in the absence of
gastrointestinal symptoms (level of
evidence 3). In fact, up to 75% of patients
with a cough caused by GERD may have
no gastrointestinal symptoms. The cough
is thought to be triggered by
microaspiration of acidic gastric contents
into the larynx and upper bronchial tree.
The American College of Chest Physicians
states that patients with a chronic cough
should be given a trial of antisecretory
therapy (SOR B). Aggressive acid
reduction using a proton pump inhibitor
twice daily before meals for 3-4 months is
the best way to demonstrate a causal
relationship between GERD and extraesophageal symptoms (SOR B).
Methacholine inhalation testing is not
necessary in this patient, since
symptomatic asthma has been ruled out by
the lack of response to bronchodilator
therapy. Chest CT and pulmonary function
tests are not indicated given the lack of
findings from the history, physical
examination, and chest film to suggest
underlying pulmonary disease. An initial
therapeutic trial of proton pump inhibitors
is favored over 24-hour pH monitoring
because it is less uncomfortable to the
patient and has a better clinical correlation.

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A 43-year-old male complains of difficulty


washing his face and combing his hair
with his right hand. On examination a
nodule, band, and slight contracture are
noted in the palm proximal to the fourth
finger. This patient's symptoms are
associated with which one of the
following? (check one)
A. Hyperparathyroidism
B. Diabetes mellitus
C. Hyperthyroidism
D. Hypothyroidism
E. Adrenal insufficiency
A 44-year-old African-American female
reports diffuse aching, especially in her
upper legs and shoulders. The aching has
increased, and she now has trouble going
up and down stairs because of weakness.
She has no visual symptoms, and a
neurologic examination is normal except
for proximal muscle weakness. Laboratory
tests reveal elevated levels of serum
creatine kinase and aldolase. Her
symptoms improve significantly when she
is treated with corticosteroids. Which one
of the following is the most likely
diagnosis? (check one)
A. Duchenne's muscular dystrophy
B. Myasthenia gravis
C. Amyotrophic lateral sclerosis
D. Aseptic necrosis of the femoral head
E. Polymyositis

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B. Diabetes mellitus. The patient has


Dupuytren's disease, which is most
common in men over 40 years of age. It is
a progressive condition that causes the
fibrous fascia of the palmar surface to
shorten and thicken. It initially can be
managed with observation, but
corticosteroid injection and surgery may
be needed. The condition will regress in
10% of patients. There is a 3%-33%
prevalence of Dupuytren's contracture in
patients with diabetes mellitus; however,
these patients tend to have a mild form of
the disease with slow progression.
E. Polymyositis. The patient described has
an inflammatory myopathy of the
polymyositis/dermatomyositis group.
Proximal muscle involvement and
elevation of serum muscle enzymes such
as creatine kinase and aldolase are
characteristic. Corticosteroids are the
accepted treatment of choice. It is
extremely unlikely that Duchenne's
muscular dystrophy would present after
age 30. In amyotrophic lateral sclerosis, an
abnormal neurologic examination with
findings of upper motor neuron
dysfunction is characteristic. Patients with
myasthenia gravis characteristically have
optic involvement, often presenting as
diplopia. The predominant symptom of
aseptic necrosis of the femoral head is pain
rather than proximal muscle weakness.

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A 44-year-old female is distressed because


of incontinence. She reports frequent
episodes of an immediate need to urinate,
which cannot always be deferred. She
admits to urinating more than 10 times a
day, but denies any urine leakage with
coughing, laughing, or straining. Which
one of the following is the most
appropriate initial treatment for this
patient? (check one)
A. Solifenacin (Vesicare)
B. Oxybutynin (Ditropan XL)
C. Tamsulosin (Flomax)
D. Phenazopyridine (Pyridium)
E. Pelvic floor muscle training and bladder
training

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E. Pelvic floor muscle training and bladder


training. Nonpharmacologic therapy is
recommended for all patients with an
overactive bladder. Pelvic floor muscle
training (e.g., Kegel exercises) and bladder
training are proven effective in urge
incontinence or overactive bladder, as well
as in stress and mixed incontinence. In
motivated patients, training may be more
effective than medications such as
oxybutynin and newer muscarinic receptor
antagonists such as solifenacin.
Tamsulosin is used in benign prostatic
hypertrophy and phenazopyridine is a
urinary tract anesthetic that has not been
recommended for treating overactive
bladder.

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A 44-year-old female presents with a


complaint of increasingly dry eyes over
the past 3-4 months, and says she can no
longer wear contacts due to the discomfort
and itching. She also apologizes for
chewing gum during the visit, explaining
that it helps keep her mouth moist. On
examination you note decreased tear
production, decreased saliva production,
and new dental caries. She stopped taking
a daily over-the-counter allergy
medication about 1 month ago.
Which one of the following is the most
likely diagnosis? (check one)
A. Sarcoidosis
B. Sjgren's syndrome
C. Ocular rosacea
D. Allergic conjunctivitis
E. Medication side effect

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B. Sjgren's syndrome. Sjgren's


syndrome is one of the three most common
systemic autoimmune diseases. It results
from lymphocytic infiltration of exocrine
glands and leads to acinar gland
degeneration, necrosis, atrophy, and
decreased function. A positive anti-SS-A
or anti-SS-B antigen test or a positive
salivary gland biopsy is a criterion for
classification of this diagnosis. In addition
to ocular and oral complaints, clinical
manifestations include arthralgias,
thyroiditis, pulmonary disease, and GERD.
Most patients with sarcoidosis present
with shortness of breath or skin
manifestations, and patients with lupus
generally have fatigue and joint pain.
Ocular rosacea causes eye symptoms very
similar to those of Sjgren's syndrome, but
oral findings would not be expected. Drugs
such as anticholinergics can cause a dry
mouth, but this would be unlikely a month
after the medication was discontinued
(SOR B).

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A 44-year-old female who suffers from


obstructive sleep apnea complains of
gradual swelling in her legs over the last
several weeks. Her vital signs include a
BMI of 44.1 kg/m2 , a respiratory rate of
12/min, a blood pressure of 120/78 mm
Hg, and an O 2 saturation of 86% on room
air. An EKG and a chest radiograph are
normal. Pulmonary function testing shows
a restrictive pattern with no signs of
abnormal diffusion. Abnormal blood tests
include only a significantly elevated
bicarbonate level.
Which one of the following treatments is
most likely to reduce this patient's
mortality rate? (check one)
A. ACE inhibitors
B. Routine use of nebulized albuterol
(AccuNeb)
C. High-dose diuretic therapy
D. Continuous oxygen therapy
E. Continuous or bilevel positive airway
pressure (CPAP or Bi-PAP)

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E. Continuous or bilevel positive airway


pressure (CPAP or Bi-PAP). This patient
has obesity-hypoventilation syndrome,
often referred to as Pickwickian syndrome.
These patients are obese (BMI >30 kg/m 2
), have sleep apnea, and suffer from
chronic daytime hypoxia andcarbon
dioxide retention. They are at increased
risk for significant respiratory failure and
death compared to patients with otherwise
similar demographics. Treatment consists
of nighttime positive airway pressure in
the form of continuous (CPAP) or bi-level
(BiPAP) devices, as indicated by sleep
testing. The more hours per day that
patients can use this therapy, the less
carbon dioxide retention and less daytime
hypoxia will ensue. Several small studies
suggest that the increased mortality risk
from obesity-hypoventilation syndrome
can be decreased by adhering to this
therapy. The use of daytime oxygen can
improve oxygenation, but is not
considered adequate to restore the chronic
low respiratory drive that is characteristic
of this condition.

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A 45-year-old female presents to your


office because she has had a lump on her
neck for the past 2 weeks. She has no
recent or current respiratory symptoms,
fever, weight loss, or other constitutional
symptoms. She has a history of wellcontrolled hypertension, but is otherwise
healthy. On examination you note a
nontender, 2-cm, soft node in the anterior
cervical chain. The remainder of the
examination is unremarkable.
Which one of the following would be most
appropriate at this point?
(check one)
A. Immediate biopsy
B. Treatment with antibiotics, then a
biopsy if the problem does not resolve
C. Monitoring clinically for 4-6 weeks,
then a biopsy if the node persists or
enlarges
D. Serial ultrasonography to monitor for
changes in the node

C. Monitoring clinically for 4-6 weeks,


then a biopsy if the node persists or
enlarges. There is limited evidence to
guide clinicians in the management of an
isolated, enlarged cervical lymph node,
even though this is a common occurrence.
Evaluation and management is guided by
the presence or absence of inflammation,
the duration and size of the node, and
associated patient symptoms. In addition,
the presence of risk factors for malignancy
should be taken into account.
Immediate biopsy is warranted if the
patient does not have inflammatory
symptoms and the lymph node is >3 cm, if
the node is in the supraclavicular area, or if
the patient has coexistent constitutional
symptoms such as night sweats or weight
loss. Immediate evaluation is also
indicated if the patient has risk factors for
malignancy. Treatment with antibiotics is
warranted in patients who have
inflammatory symptoms such as pain,
erythema, fever, or a recent infection.
In a patient with no risk factors for
malignancy and no concerning symptoms,
monitoring the node for 4-6 weeks is
recommended. If the node continues to
enlarge or persists after this time, then
further evaluation is indicated. This may
include a biopsy or imaging with CT or
ultrasonography. The utility of serial
ultrasound examinations to monitor lymph
nodes has not been demonstrated.

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A 45-year-old female presents to your


office with a 1-month history of pain and
swelling posterior to the medial malleolus.
She does not recall any injury, but reports
that the pain is worse with weight bearing
and with inversion of the foot. Plantar
flexion against resistance elicits pain, and
the patient is unable to perform a singleleg heel raise.
Which one of the following is true
regarding this problem?
(check one)
A. The patient most likely has a medial
ankle sprain
B. NSAIDs will improve the long-term
outcome
C. Injecting a corticosteroid into the
tendon sheath of the involved tendon is
recommended
D. A lateral heel wedge should be
prescribed
E. Immobilization in a cast boot for 3
weeks is indicated

E. Immobilization in a cast boot for 3


weeks is indicated. The diagnosis of
tendinopathy of the posterior tibial tendon
is important, in that the tendon's function
is to perform plantar flexion of the foot,
invert the foot, and stabilize the medial
longitudinal arch. An injury can, over
time, elongate the midfoot and hindfoot
ligaments, causing a painful flatfoot
deformity.
The patient usually recalls no trauma,
although the injury may occur from
twisting the foot by stepping in a hole.
This is most commonly seen in women
over the age of 40. Without proper
treatment, progressive degeneration of the
tendon can occur, ultimately leading to
tendon rupture.
Pain and swelling of the tendon is often
noted, and is misdiagnosed as a medial
ankle sprain. With the patient standing on
tiptoe, the heel should deviate in a varus
alignment, but this does not occur on the
involved side. A single-leg toe raise should
reproduce the pain, and if the process has
progressed, this maneuver indicates
progression of the problem.
While treatment with acetaminophen or
NSAIDs provides short-term pain relief,
neither affects long-term outcome.
Corticosteroid injection into the synovial
sheath of the posterior tibial tendon is
associated with a high rate of tendon
rupture and is not recommended. The best
initial treatment is immobilization in a cast
boot or short leg cast for 2-3 weeks.

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A 45-year-old female presents with a 3month history of hoarseness that is not


improving. She works as a high-school
teacher. The most appropriate management
at this time would be: (check one)
A. voice therapy
B. azithromycin (Zithromax)
C. a trial of inhaled corticosteroids
D. a trial of a proton pump inhibitor
E. laryngoscopy

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E. laryngoscopy. Hoarseness most


commonly affects teachers and older
adults. The cause is usually benign, but
extended symptoms or certain risk factors
should prompt evaluation; specifically,
laryngoscopy is recommended when
hoarseness does not resolve within 3
months or when a serious underlying cause
is suspected (SOR C). The American
Academy of Otolaryngology/Head and
Neck Surgery Foundation guidelines state
that antireflux medications should not be
prescribed for patients with hoarseness
without reflux symptoms (SOR C).
Antibiotics should not be used, as the
condition is usually caused by acute
laryngitis or an upper respiratory infection,
and these are most likely to be viral.
Inhaled corticosteroids are a common
cause of hoarseness. Voice therapy should
be reserved for patients who have
undergone laryngoscopy first (SOR A).

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A 45-year-old female presents with a


complaint of pain and swelling in her right
index finger of 2 days' duration. She
reports that 5 days ago she had artificial
nails applied, which she removed
yesterday due to the pain. She used
hydrogen peroxide on the finger, but it did
not help. She denies any systemic
symptoms or fever. On examination there
is erythema and swelling in the lateral nail
fold of the right index finger, with purulent
material noted.
Which one of the following would be the
most appropriate treatment for this patient?
(check one)
A. Removal of the proximal nail fold
B. Topical corticosteroids
C. Topical antibiotics
D. Topical antifungals

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C. Topical antibiotics. This is a common


presentation for acute paronychia, which
typically is caused by local trauma to the
nail fold or cuticle, with resulting
inoculation and infection. Topical
antibiotics, with or without topical
corticosteroids, is one treatment option.
Other options include warm compresses,
oral antibiotics, and incision and drainage;
however, incision and drainage is not
always necessary. Removal of the
proximal nail fold is used to treat chronic
paronychia that is not responsive to other
treatments. Topical corticosteroids can be
used alone for chronic paronychia, but if
used for acute paronychia, they should be
combined with antibiotics since acute
paronychia is typically caused by a
bacterial infection. Topical antifungals are
a treatment option for chronic paronychia,
which can be associated with a fungal
infection, but not for acute paronychia.

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A 45-year-old female presents with a rash


on the central portion of her face. She
states that she has intermittent flushing and
intense erythema that feels as if her face is
stinging. She has noticed that her
symptoms can be worsened by sun
exposure, emotional stress, alcohol, or
eating spicy foods. She has been in good
health and has taken conjugated estrogens
(Premarin), 0.625 mg daily, since a
hysterectomy for benign reasons. A
general examination is normal except for
erythema of the cheeks and chin. No
pustules or comedone formation is noted
around her eyes, but telangiectasias are
present.
Which one of the following would be
appropriate in the management of this
problem?
(check one)
A. Increasing her estrogen dosage
B. Referral to a rheumatologist
C. Low-potency non-fluorinated topical
corticosteroids
D. Oral prednisone
E. Metronidazole gel (MetroGel)

E. Metronidazole gel (MetroGel). Rosacea


is a relatively common condition seen
most often in women between the ages of
30 and 60. Central facial erythema and
telangiectasias are prominent early
features that may progress to a chronic
infiltrate with papules and sometimes
sterile pustules. Facial edema also may
occur. Some patients develop rhinophyma
due to hypertrophy of the subcutaneous
glands of the nose. The usual presenting
symptoms are central facial erythema and
flushing that many patients find socially
embarrassing. Flushing can be triggered by
food, environmental, chemical, or
emotional triggers. Ocular problems occur
in half of patients with rosacea, often in
the form of an intermittent inflammatory
conjunctivitis with or without blepharitis.
Management includes avoidance of
precipitating factors and use of sunscreen.
Oral metronidazole, doxycycline, or
tetracycline also can be used, especially if
there are ocular symptoms. These are often
ineffective for the flushing, so low-dose
clonidine or a nonselective -blocker may
be added.
Topical treatments such as metronidazole
and benzoyl peroxide may also be
effective, particularly for mild cases. Other
illnesses to consider include acne,
photodermatitis, systemic lupus
erythematosus, seborrheic dermatitis,
carcinoid syndrome, and mastocytosis.

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A 45-year-old female with rheumatoid


arthritis has a hemoglobin level of 9.5
g/dL (N 11.5-16.0). Her arthritis is well
controlled with methotrexate. Further
evaluation reveals the following:
Hematocrit............29.0% (N 35.0-47.0)
Mean corpuscular volume............78 m3
(N 80-98)
Platelets............230,000/mm3 (N 150,000400,000)
WBCs............6900/mm3 (N 4000-11,000)
Differential............normal
Serum iron............15 g/dL (N 50-170)
Total iron binding capacity............150
g/dL (N 45-70)
Iron saturation............10% (N 15-50)
Serum ferritin............7 ng/mL (N 12-150)
Reticulocyte count............8 x 109/L (N 10100)
Stool guaiac............negative x 3
Which one of the following would be the
most appropriate next step?
(check one)
A. Evaluation for a source of blood loss
B. Hemoglobin electrophoresis to screen
for thalassemia
C. Stopping the methotrexate and
beginning an alternative treatment for
rheumatoid arthritis
D. No further evaluation

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A. Evaluation for a source of blood loss.


Anemia of chronic disease is characterized
by the underproduction of red cells, due to
low serum iron caused by the uptake of
iron by the reticuloendothelial system.
Total-body iron stores are increased but
the iron in storage is not available for red
cell production. This anemia is
normochromic and normocytic, and is
associated with a reduction in iron,
transferrin, and transferrin saturation.
Ferritin is either normal or increased,
reflecting both the increased iron within
the reticuloendothelial system and
increases due to immune activation (acute
phase reactant). In iron deficiency anemia,
total-body iron levels are low, leading to
hypochromia and microcytosis, low iron
levels, increased transferrin levels, and
reduced ferritin levels. This patient's
anemia is most likely multifactorial, with
anemia of chronic disease and drug effects
playing a role. However, she also has iron
deficiency, and searching for a source of
blood loss would be important. With
thalassemia, marked microcytosis is seen,
and with hemolysis, slight macrocytosis
and an increased reticulocyte count would
be expected.

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A 45-year-old Hispanic male with


schizophrenia presents with an
exacerbation of his COPD. He currently
takes only ziprasidone (Geodon). He asks
for a prescription for clarithromycin
(Biaxin) because it has worked well for
previous exacerbations.
Which one of the following effects of this
drug combination should you be alert for?
(check one)
A. Stevens-Johnson syndrome
B. Prolonged QT interval
C. Seizures
D. Diarrhea
E. Hypoglycemia

A 45-year-old male asks about using


nicotine replacement therapy (NRT) to
help him quit smoking. You tell him that
recent evidence shows that (check one)
A. NRT usually doubles a smokers chance
of quitting
B. NRT must be tapered off
C. NRT should be used for at least 6
months to be effective
D. nicotine patches are the most effective
form of NRT
E. using combinations of NRT reduces the
likelihood that a relapsed smoker will quit

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B. Prolonged QT interval. Ziprasidone is a


second-generation antipsychotic used in
the treatment of schizophrenia. These
drugs cause QT-interval prolongation,
which can in turn lead to torsades de
pointes and sudden cardiac death. This risk
is further increased when these drugs are
combined with certain antibiotics (e.g.,
clarithromycin), antiarrhythmics (class I
and III), and tricyclic antidepressants. The
FDA has issued a black box warning for
both first- and second-generation
antipsychotic drugs due to a 1.6- to 1.7fold increase in the risk of sudden cardiac
death and cerebrovascular accidents
associated with their use in the elderly
population (SOR A). None of the other
conditions listed is associated with this
drug combination.
A. NRT usually doubles a smokers chance
of quitting. A Cochrane meta-analysis of
nicotine replacement therapy (NRT) found
that it almost doubles a smokers chances
of quitting (SOR A). There was no benefit
to tapering NRT as compared to abrupt
discontinuation. Treatment for 8 weeks
was as effective as a longer course. No one
type of NRT is significantly more
effective, but combining several types may
aid a relapsed smoker in his or her next
quit attempt.

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A 45-year-old male has diabetes mellitus


and hypertension. He has no other medical
problems.
Which one of the following classes of
medications is the preferred first-line
therapy for the treatment of hypertension
in this patient? (check one)
A. Potassium-sparing diuretics
B. ACE inhibitors
C. -Receptor blockers
D. Calcium channel blockers
E. -Blockers

B. ACE inhibitors. The target blood


pressure in patients with diabetes mellitus
is <130/80 mm Hg (SOR A). ACE
inhibitors and angiotensin receptor
blockers (ARBs) are the preferred first-line
agents for the management of patients with
hypertension and diabetes mellitus (SOR
A). If the target blood pressure is not
achieved with an ACE inhibitor or ARB,
the addition of a thiazide diuretic is the
preferred second-line therapy for most
patients; potassium-sparing and loop
diuretics are not recommended (SOR B).
-Blockers are recommended for patients
with diabetes mellitus who also have a
history of myocardial infarction, heart
failure, coronary artery disease, or stable
angina (SOR A). Calcium channel
blockers should be reserved for patients
with diabetes mellitus who cannot tolerate
preferred antihypertensive agents, or for
those who need additional agents to
achieve their target blood pressure (SOR
A).

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A 45-year-old male is seen in the


emergency department with a 2-hour
history of substernal chest pain. An EKG
shows an ST-segment elevation of 0.3 mV
in leads V4-V6.
In addition to evaluation for reperfusion
therapy, which one of the following would
be appropriate?
(check one)
A. Enteric aspirin, 81 mg
B. Intravenous metoprolol (Lopressor)
C. Oral clopidogrel (Plavix)
D. Warfarin (Coumadin), after blood is
drawn to establish his baseline INR
E. Delaying treatment pending results of
two sets of cardiac enzyme measurements

A 45-year-old male presents with a 4month history of low back pain that he
says is not alleviated with either ibuprofen
or acetaminophen. On examination he has
no evidence of weakness or focal
tenderness. Laboratory studies, including a
CBC, erythrocyte sedimentation rate, Creactive protein, and complete metabolic
profile, are all normal. MRI of the
lumbosacral region shows mild bulging of
the L4-L5 disc without impingement on
the thecal sac.
Which one of the following has been
shown to be beneficial in this situation?
(check one)
A. Traction
B. Ultrasound
C. Epidural corticosteroid injection
D. A back brace
E. Acupuncture
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C. Oral clopidogrel (Plavix). This patient


has an ST-segment elevation myocardial
infarction (STEMI). STEMI is defined as
an ST-segment elevation of greater than
0.1 mV in at least two contiguous
precordial or adjacent limb leads. The
most important goal is to begin fibrinolysis
less than 30 minutes after the first contact
with the health system. The patient should
be given oral clopidogrel, and should also
chew 162-325 mg of aspirin.
Enteric aspirin has a delayed effect.
Intravenous -blockers such as metoprolol
should not be routinely given, and warfarin
is not indicated. Delaying treatment until
cardiac enzyme results are available in a
patient with a definite myocardial
infarction is not appropriate.
E. Acupuncture. Most chronic back pain
(up to 70%) is nonspecific or idiopathic in
origin. Treatment options that have the
best evidence for effectiveness include
analgesics (acetaminophen, tramadol,
NSAIDs), multidisciplinary rehabilitation,
and acupuncture (all SOR A).
Other treatments likely to be beneficial
include herbal medications, tricyclics,
antidepressants, exercise therapy, behavior
therapy, massage, spinal therapy, opioids,
and short-term muscle relaxants (all SOR
B). There is conflicting data regarding the
effectiveness of back school, low-level
laser therapy, lumbar supports, viniyoga,
antiepileptic medications, prolotherapy,
short-wave diathermy, traction,
transcutaneous electrical nerve
stimulation, ultrasound, and epidural
corticosteroid injections (all SOR C).
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A 45-year-old male presents with a


complaint of recent headaches. He has had
four headaches this week, and his
description indicates that they are
moderate to severe, bilateral, frontal, and
nonthrobbing. There is no associated aura.
He has had similar episodes of recurring
headachesin the past.
Based on this limited history, which one of
the following headache types can be
eliminated from the differential diagnosis?
(check one)

D. Cluster headache. Cluster headache can


be removed from the differential because it
is always unilateral, although the affected
side can vary. The remainder of these
headache types can be bilateral, frontal,
and nonthrobbing. Brain tumor headaches
may be similar in character to previous
headaches, but are often more severe or
frequent.

A. Tension-type headache
B. Sinus headache
C. Migraine headache
D. Cluster headache
E. Headache of intracranial neoplasm

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A 45-year-old male sees you for a routine


annual visit and is found to have atrial
fibrillation, with a ventricular rate of 70-75
beats/min. He is otherwise healthy, and a
laboratory workup and echocardiogram are
normal.
Which one of the following would be the
most appropriate management? (check
one)
A. Aspirin, 325 mg daily
B. Warfarin (Coumadin), with a target
INR of 2.0-3.0
C. Clopidogrel (Plavix), 75 mg daily
D. Amiodarone (Cordarone), 200 mg daily
E. Observation only

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A. Aspirin, 325 mg daily. Atrial


fibrillation is the most common
arrhythmia, and its prevalence increases
with age. The major risk with atrial
fibrillation is stroke, and a patient's risk
can be determined by the CHADS 2 score.
CHADS stands for Congestive heart
failure, Hypertension, Age >75, Diabetes
mellitus, and previous Stroke or transient
ischemic attack. Each of these is worth 1
point except for stroke, which is worth 2
points. A patient with 4 or more points is
at high risk, and 2-3 points indicates
moderate risk. Having 1 point indicates
low risk, and this patient has 0 points.
Low-risk patients should be treated with
aspirin, 81-325 mg daily (SOR B).
Moderate-or high-risk patients should be
treated with warfarin. Amiodarone is used
for rate control, and clopidogrel is used for
vascular events not related to atrial
fibrillation.

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A 45-year-old male sees you for follow-up


after a pre-employment physical
examination reveals blood in his urine. He
brings a copy of a urinalysis report that
shows 3-5 RBCs/hpf. He has not seen any
gross blood himself. He is asymptomatic,
is on no medications, and does not smoke.
You perform a physical examination, with
normal findings. A repeat urinalysis
confirms the presence of red blood cells
but is otherwise normal. Which one of the
following would be most appropriate at
this point? (check one)
A. Observation and reassurance
B. A repeat urinalysis in 6 months
C. Urine cytology only
D. Ultrasonography of the kidneys and
urine cytology only
E. Ultrasonography of the kidneys, urine
cytology, and cystoscopy

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E. Ultrasonography of the kidneys, urine


cytology, and cystoscopy. The American
Urological Association (AUA) defines
clinically significant microscopic
hematuria as 3 RBCs/hpf. Microscopic
hematuria is frequently an incidental
finding, but may be associated with
urologic malignancy in up to 10% of
adults. The upper urinary tract should be
evaluated in this patient. There are no clear
evidence-based imaging guidelines for
upper tract evaluation; therefore,
intravenous urography, ultrasonography,
or CT can be considered. Ultrasonography
is the least expensive and safest choice
because it does not expose the patient to
intravenous radiographic contrast media.
Urine cytology and cystoscopy are used
routinely to evaluate the lower urinary
tract. The AUA recommends that patients
with microscopic hematuria have
radiographic assessment of the upper
urinary tract, followed by urine cytology
studies. The AUA also recommends that
all patients older than 40 and those who
are younger but have risk factors for
bladder cancer undergo cystoscopy to
complete the evaluation. Cystoscopy is the
only reliable method of detecting
transitional cell carcinoma of the bladder
and urethra.

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A 45-year-old male was admitted to the


hospital for nausea resulting from
chemotherapy for colon cancer. He has no
other chronic diseases and takes no routine
medications. He was mildly dehydrated on
admission and has been receiving
intravenous fluids (D5 -normal saline
with potassium chloride) at slightly higher
than maintenance rates through an
indwelling port for the last 24 hours. The
nausea is being controlled by antiemetics,
and his condition is improving. Results of
routine blood work at the time of
admission and from the following morning
are shown below.
Admission Following Morning
Glucose 109 mg/dL (N 65-110) 371
mg/dL
BUN 13 mg/dL (N 7-21) 9 mg/dL
Creatinine 0.9 mg/dL (N 0.6-1.6) 0.9
mg/dL
Sodium 143 mmol/L (N 136-144) 129
mmol/L
Potassium 3.7 mmol/L (N 3.6-5.1) 6.6
mmol/L
Chloride 110 mmol/L (N 101-111) 108
mmol/L
Total CO2 20 mmol/L (N 22-32) 22
mmol/L
Which one of the following would be the
most appropriate next step?
(check one)

B. Order blood work taken from a


peripheral vein. Physicians should avoid
reacting to laboratory values without
considering the clinical scenario. This
patient presented with mild dehydration
and normal laboratory values. Although he
is improving clinically, his laboratory
values show multiple unexpected results.
The most noticeable is the severely
elevated glucose, because he has no
history of diabetes mellitus or use of
medications that could cause this effect.
Similarly, the elevated potassium and
decreased sodium suggest profound
electrolyte abnormalities. Most likely, the
laboratory technician drew blood from the
patients indwelling port without discarding
the first several milliliters. Thus, the blood
was contaminated with intravenous fluids,
resulting in the erroneous results. A repeat
blood test from a peripheral vein should
give more accurate results.

A. Start an intravenous insulin drip


B. Order blood work taken from a
peripheral vein
C. Restrict the patient's free water intake
D. Switch from normal saline to
hypertonic saline
E. Treat with diuretics

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A 45-year-old male with chronic


nonmalignant back pain is on a chronic
narcotic regimen. Which one of the
following behaviors is LEAST likely to be
associated with pseudoaddiction, as
opposed to true addiction? (check one)
A. Requesting a specific drug
B. Aggressive complaining about needing
more medication
C. Hoarding drugs during periods of
reduced symptoms
D. Requesting medication exactly at
prescribed times when hospitalized
E. Concurrent abuse of alcohol or illicit
drugs

E. Concurrent abuse of alcohol or illicit


drugs. The use of narcotics for chronic
nonmalignant pain is becoming more
commonplace. Guidelines have been
developed to help direct the use of these
medications when clinically appropriate.
However, even when given appropriately,
the use of opioid medications for pain
relief can cause both the physician and the
patient to be concerned about the
possibility of addiction.
Addiction is a neurobiologic,
multifactorial disease characterized by
impaired control, compulsive drug use,
and continued use despite harm.
Pseudoaddiction is a term used to describe
patient behaviors that may occur when
pain is undertreated. Patients with
unrelieved pain may become focused on
obtaining specific medications, seem to
watch the clock, or engage in other
behaviors that appear to be due to
inappropriate drug seeking.
Pseudoaddiction can be distinguished from
true addiction because the behaviors will
resolve when the pain is effectively
treated.
The concurrent use of alcohol and/or illicit
drugs complicates the management of
chronic pain in patients. If these are known
problems, patients should be referred for
psychiatric or pain specialty evaluation
before the decision is made to use opioids.
Agreements for use of chronic opioids
should include the expectation that alcohol
and illicit drugs will not be used
concurrently, and doing so suggests
addiction rather than pseudoaddiction.

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A 45-year-old white female with elevated


cholesterol and coronary artery disease
comes in for a periodic fasting lipid panel
and liver enzyme levels. She began statin
therapy about 2 months ago and reports no
problems. Laboratory testing reveals an
LDL-cholesterol level of 70 mg/dL, an
HDL-cholesterol level of 55 mg/dL, an
alanine aminotransferase (ALT) level of
69 U/L (N 7-30), and an aspartate
aminotransferase (AST) level of 60 U/L
(N 9-25).
Which one of the following would be most
appropriate at this time? (check one)

A. Continue the current therapy with


routine monitoring. The patient is at her
LDL and HDL goals and has no
complaints, so she should be continued on
her current regimen with routine
monitoring (SOR C). Research has proven
that up to a threefold increase above the
upper limit of normal in liver enzymes is
acceptable for patients on statins. Too
often, slight elevations in liver enzymes
lead to unnecessary dosage decreases,
discontinuation of statin therapy, or
additional testing.

A. Continue the current therapy with


routine monitoring
B. Decrease the dosage of the statin and
monitor liver enzymes
C. Discontinue the statin and monitor liver
enzymes
D. Discontinue the statin and begin niacin
E. Substitute another statin

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A 45-year-old white male develops


disabling tremulousness, loss of voice, and
a marked sense of forceful and rapid
heartbeat whenever he must speak to a
large group.
Which one of the following drugs is likely
to be of most value in enabling him to give
presentations at sales and stockholders'
meetings? (check one)
A. Desipramine (Norpramin)
B. Propranolol (Inderal)
C. Alprazolam (Xanax)
D. Amantadine (Symmetrel)
E. Buspirone (BuSpar)

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B. Propranolol (Inderal). This patient has a


specific situational anxiety disorder or
social phobia called performance anxiety
or speech phobia, characterized by marked
and sometimes disabling symptoms of
catecholamine excess during specific
performance situations, such as public
speaking. Rates of speech phobia may
exceed 50% in the population, but it is
unclear whether such fear and avoidance
of public speaking warrants a psychiatric
diagnosis.
Specific phobias such as speech phobia
respond moderately well to -blockers
used prior to a performance. These drugs
block peripheral anxiety symptoms such as
tachycardia and tremulousness that can
escalate subjective anxiety and impair
performance. Drugs that are primarily
psychotropics or antiparkinsonian agents
are much less likely to be of value in this
specific anxiety disorder, and may cause
undesirable sedation and dry mouth.

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A 45-year-old white male is admitted to


the intensive-care unit after being pinned
in a car wreck for 2 hours. He has
sustained several broken bones and crush
injuries to both thighs. On admission his
urine is clear but the next morning it is
burgundy colored. Some fresh urine is
drawn from his Foley catheter and sent for
analysis, with the following results:
Specific gravity............1.020
pH............6.0
Protein............30 mg/dL (N 1-14)
Glucose............negative
Hemoglobin............4+
Urobilinogen............0.1 Ehrlich Units (N
0.1-1.0)
Bile............negative
RBCs............1-2/hpf
WBCs............0-2/hpf
Occasional hyaline casts
You immediately order a CBC which
shows his hematocrit to have dropped 4
percentage points overnight. Visual
inspection of the serum shows it is light
yellow. The color of his urine is most
likely due to
(check one)

A. myoglobinuria. A positive dipstick for


hemoglobin without any RBCs noted in
the urine sediment indicates either free
hemoglobin or myoglobin in the urine.
Since the specimen in this case was a fresh
sample, significant RBC hemolysis within
the urine would not be expected. If a
transfusion reaction occurs, haptoglobin
binds enough free hemoglobin in the
serum to give it a pink coloration. Only
when haptoglobin is saturated will the free
hemoglobin be excreted in the urine.
Myoglobin is released when skeletal
muscle is destroyed by trauma, infarction,
or intrinsic muscle disease. If the
hematuria were due to trauma there would
be many RBCs visible on microscopic
examination of the urine. Free hemoglobin
resorption from hematomas does not
occur. Porphyria may cause urine to be
burgundy colored, but it is not associated
with a positive urine test for hemoglobin.

A. myoglobinuria
B. hematuria from trauma to the urinary
tract
C. a transfusion reaction with hemolysis of
RBCs and free hemoglobin into the urine
D. hemoglobinuria resulting from
reabsorption of hemoglobin from
hematomas
E. acute porphyria provoked by trauma

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A 45-year-old white male presents with


severe intermittent right flank pain that
radiates into his right groin area. You
suspect a ureteral stone. Which one of the
following would most reliably confirm
your suspected diagnosis? (check one)
A. A helical CT scan of the abdomen and
pelvis without contrast
B. Intravenous pyelography
C. Abdominal ultrasonography
D. A KUB plain film of the abdomen
E. A urinalysis

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A. A helical CT scan of the abdomen and


pelvis without contrast. An unenhanced
helical CT scan of the abdomen and pelvis
is the best study for confirming the
diagnosis of a urinary tract stone in a
patient with acute flank pain, supplanting
the former gold standard, intravenous
pyelography. A CT scan may also reveal
other pathology, such as appendicitis,
diverticulitis, or abdominal aortic
aneurysm. Although abdominal
ultrasonography has a very high
specificity, it is still not better than CT,
and its sensitivity is much lower; thus, its
use is usually confined to pregnant patients
with a suspected stone. Plain abdominal
radiographs may show the stone if it is
radiopaque, and are useful for following
patients with radiopaque stones. CT will
reveal a radiopaque stone. While most
patients with stones will have hematuria,
its absence does not rule out a stone.

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A 45-year-old white male undergoes a


health screening at his church. He has a
carotid Doppler study, abdominal
ultrasonography, heel densitometry, and a
multiphasic blood panel. He receives a
report indicating that all of the studies are
normal, but a 0.7-cm thyroid nodule was
noted. The TSH level is normal. He
schedules a visit with you and brings you
the report. A neck examination and ENT
examination are normal, and you do not
detect a nodule. You recommend (check
one)

C. repeat ultrasonography in 6-12 months.


This is a classic incidentaloma. Nodules
are detected in up to 50% of thyroid
sonograms and carry a low risk of
malignancy (<5%). If the TSH level is
normal, nuclear scanning and further
thyroid studies are not necessary. Nodules
smaller than 1 cm are difficult to biopsy
and thyroid surgery is not indicated for
what is almost certainly benign disease. It
is reasonable to follow small nodules with
clinical examinations and periodic
sonograms.

A. a radionuclide thyroid scan


B. T3, T4, and calcitonin levels
C. repeat ultrasonography in 6-12 months
D. a fine-needle biopsy
E. hemithyroidectomy
A 46-year-old female presents to your
office for follow-up of elevated blood
pressure on a pre-employment
examination. She is asymptomatic, and her
physical examination is normal with the
exception of a blood pressure of 160/100
mm Hg. Screening blood work reveals a
potassium level of 3.1 mEq/L (N 3.7-5.2).
You consider screening for primary
hyperaldosteronism. (check one)
A. 24-hour urine aldosterone levels
B. An ACTH infusion test
C. Adrenal venous sampling
D. CT of the abdomen
E. A serum aldosterone-to-renin ratio

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E. A serum aldosterone-to-renin ratio.


Primary hyperaldosteronism is relatively
common in patients with stage 2
hypertension (160/100 mm Hg or higher)
or treatment-resistant hypertension. It has
been estimated that 20% of patients
referred to a hypertension specialist suffer
from this condition. Experts recommend
screening for this condition using a ratio of
morning plasma aldosterone to plasma
renin. A ratio >20:1 with an aldosterone
level >15 ng/dL suggests the diagnosis.
The level of these two values is affected
by several factors, including medications
(especially most blood pressure
medicines), time of day, position of the
patient, and age.
Patients who are identified as possibly
having this condition should be referred to
an endocrinologist for further confirmatory
testing.
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A 46-year-old white female complains of a


3-month history of hoarseness and
nocturnal wheezing. On further
questioning, she tells you that she has to
clear her throat repeatedly and feels like
she has something stuck in her throat.
These symptoms are most likely related to:
(check one)
A. thyroid disease
B. gastroesophageal reflux disease
C. sinusitis
D. tracheal stenosis
A 47-year-old female presents to your
office complaining of hot flashes and cold
sweats of several months' duration. She is
premenopausal. Which one of the
following is accurate advice for this
patient regarding vasomotor symptoms?
(check one)
A. They usually peak around the time of
menopause, then decline after menopause
B. Without treatment, they usually get
worse each year after menopause
C. They are always caused by estrogen
deficiency
D. Estrogen alone is recommended for
therapy

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B. gastroesophageal reflux disease. Acid


laryngitis is a group of respiratory
symptoms related to gastroesophageal
reflux disease. The symptoms of
hoarseness (especially in the morning), a
repeated need to clear the throat, and
nocturnal or early morning wheezing may
occur singly or in varying combinations,
and are believed to be caused by gastric
contents irritating the larynx and
hypopharynx. Thyroid disease, sinusitis,
and tracheal stenosis can produce one or
more of the symptoms described, but not
all of them.
A. They usually peak around the time of
menopause, then decline after menopause.
Vasomotor symptoms slowly increase
until perimenopause, at which time they
peak. The symptoms then tend to diminish
after menopause. Numerous other
pathologic and functional vasomotor
etiologies may mimic hot flashes. Estrogen
is effective in treating hot flashes but
generally should not be given alone, as it
increases the risk for endometrial cancer.

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A 47-year-old female presents to your


office with a complaint of hair loss. On
examination she has a localized 2-cm
round area of complete hair loss on the top
of her scalp. Further studies do not reveal
an underlying metabolic or infectious
disorder.
Which one of the following is the most
appropriate initial treatment?
(check one)
A. Topical minoxidil (Rogaine)
B. Topical immunotherapy
C. Intralesional triamcinolone (Kenalog)
D. Oral finasteride (Proscar)
E. Oral spironolactone (Aldactone)

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C. Intralesional triamcinolone (Kenalog).


These findings are consistent with alopecia
areata, which is thought to be caused by a
localized autoimmune reaction to hair
follicles. It occasionally spreads to involve
the entire scalp (alopecia totalis) or the
entire body (alopecia universalis).
Spontaneous recovery usually occurs
within 6-12 months, although areas of
regrowth may be pigmented differently.
Recovery is less likely if the condition
persists for longer than a year, worsens, or
begins before puberty. The initial
treatment of choice for patients older than
10 years of age, in cases where alopecia
areata affects less than 50% of the scalp, is
intralesional corticosteroid injections.
Minoxidil is an alternative for children
younger than 10 years of age or for
patients in whom alopecia areata affects
more than 50% of the scalp. While topical
immunotherapy is the most effective
treatment for chronic severe alopecia
areata, it has the potential for severe side
effects and should not be used as a firstline agent. Finasteride inhibits 5 reductase type 2, resulting in a decrease in
dihydrotestosterone levels, and is used in
the treatment of androgenic alopecia
(male-pattern baldness). Similarly,
spironolactone is sometimes used for
androgenic alopecia because it is an
aldosterone antagonist with antiandrogenic
effects.

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A 47-year-old female presents with


progressive difficulty hearing. She is
employed as an office worker, has no
significant past medical history, and takes
no medications. Physical examination
shows no gross abnormalities of her outer
ears. The external ear canals are free of
cerumen, and the tympanic membranes
move well to insufflation. Weber's test and
the Rinne test have results that are
compatible with a conductive hearing loss.
Which one of the following is the most
likely cause of this patient's hearing loss?
(check one)
A. Noise-induced hearing loss
B. Meniere's disease
C. Otosclerosis
D. Acoustic neuroma
E. Perilymphatic fistula
A 47-year-old gravida 3 para 3 is seen for
a physical examination. She has had a total
abdominal hysterectomy for benign uterine
fibroids. Which one of the following is the
recommended interval for Papanicolaou
(Pap) screening in this patient? (check
one)
A. Every 5 years
B. Every 3 years
C. Every 2 years
D. Annually
E. Routine screening is not necessary

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C. Otosclerosis. Otosclerosis typically


presents between the third and fifth
decades, and is more common in women.
The chief feature of otosclerosis is a
progressive conductive hearing loss.
Occasionally, when lesions impinge on the
stapes footplate, a sensorineural loss may
occur. All of the other choices are
exclusively sensorineural in character.
Meniere's disease also causes fluctuating
hearing loss. Noise-induced hearing loss
frequently and characteristically is
accompanied by tinnitus. Perilymphatic
fistula is associated with sudden unilateral
hearing loss with tinnitus and vertigo.
Acoustic neuroma is associated with
tinnitus and gradual hearing impairment.

E. Routine screening is not necessary.


Most American women who have
undergone hysterectomy are not at risk of
cervical cancer, as they underwent the
procedure for benign disease and no longer
have a cervix. U.S. Preventive Services
Task Force recommendations issued in
1996 stated that routine Papanicolaou
(Pap) screening is unnecessary for these
women. Nevertheless, data from the
Behavioral Risk Factor Surveillance
System (1992-2002) indicated that in the
previous 3 years, some 69% of women
with a previous history of hysterectomy
for benign causes had undergone
screening.

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A 47-year-old male is preparing for a 3day trip to central Mexico to present the
keynote address for an international law
symposium. He asks you for an antibiotic
to be taken prophylactically to prevent
bacterial diarrhea.
Which one of the following would you
recommend? (check one)
A. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. Rifaximin (Xifaxan)
C. Doxycycline
D. Nitrofurantoin (Macrobid)

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B. Rifaximin (Xifaxan). While


prophylactic antibiotics are not generally
recommended for prevention of traveler's
diarrhea, they may be useful under special
circumstances for certain high-risk hosts,
such as the immunocompromised, or for
those embarking on critical short trips for
which even a short period of diarrhea
might cause undue hardship. Rifaximin, a
nonabsorbable antibiotic, has been shown
to reduce the risk for traveler's diarrhea by
77%. Trimethoprim/sulfamethoxazole and
doxycycline are no longer considered
effective antimicrobial agents against
enteric bacterial pathogens. Increasing
resistance to the fluoroquinolones,
especially among Campylobacter species,
is limiting their use as prophylactic agents.

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A 47-year-old male who lives at sea level


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

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A. Administration of oxygen and


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

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A 47-year-old male with chronic kidney


disease is being treated with epoetin alfa
(Procrit). His hemoglobin level is 11.3
g/dL (N 13.0-18.0). Which one of the
following would be most appropriate with
regard to his epoetin alfa regimen? (check
one)
A. Increase the dosage until the
hemoglobin level is >12.0 g/dL
B. Increase the frequency of injections,
using the same dose
C. Decrease the frequency of injections,
using the same dose
D. Continue the current regimen
A 48-year-old male who weighs 159 kg
(351 lb) is admitted to the hospital with a
left leg deepvein thrombosis and
pulmonary embolism. Treatment is begun
with enoxaparin (Lovenox).
Which one of the following would be most
appropriate for monitoring the adequacy of
anticoagulation in this patient?
(check one)
A. Anti-factor Xa levels
B. Activated partial thromboplastin time
(aPTT)
C. Daily INRs
D. Daily factor VIII levels

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D. Continue the current regimen. In


patients with renal failure, the risk for
death and serious cardiovascular events is
increased with higher hemoglobin levels
(13.5 g/dL), and it is therefore
recommended that levels be maintained at
10-12 g/dL. Studies have also
demonstrated less mortality and morbidity
when the dosage of epoetin alfa is set to
achieve a target hemoglobin of <12 g/dL.

A. Anti-factor Xa levels. In severely obese


patients (>330 lb) and those with renal
failure, low molecular weight heparin
therapy should be monitored with antifactor Xa levels obtained 4 hours after
injection. Most other patients do not need
monitoring. The INR is used to monitor
warfarin therapy, and the activated partial
thromboplastin time (aPTT) is used to
monitor therapy with unfractionated
heparin. Factor VIII levels are not used to
monitor anticoagulation therapy.

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A 48-year-old white female comes to see


you because of abnormal vaginal bleeding.
Her periods are lasting 3-5 days longer
than usual, bleeding is heavier, and she has
experienced some intermenstrual bleeding.
Her physical examination is unremarkable,
except for a parous cervix with dark blood
at the os and in the vagina. She has no
orthostatic hypotension, and her
hemoglobin level is 11.5 g/dL. A
pregnancy test is negative.
Which one of the following is the most
important next step in management?
(check one)

B. An endometrial biopsy. A patient over


the age of 35 who experiences abnormal
vaginal bleeding must have an endometrial
assessment to exclude endometrial
hyperplasia or cancer. An endometrial
biopsy is currently the preferred method
for identifying endometrial disease. A
laboratory evaluation for thyroid
dysfunction or hemorrhagic diathesis is
appropriate if no cancer is present on an
endometrial biopsy and medical therapy
fails to halt the bleeding. The other options
listed can be used as medical therapy to
control the bleeding once the
histopathologic diagnosis has been made.

A. Laboratory tests to rule out thyroid


dysfunction
B. An endometrial biopsy
C. Oral contraceptives, 4 times a day for 57 days
D. Cyclic combination therapy with
conjugated estrogens (Premarin) and
medroxy-progesterone (Provera) each
month
E. Administration of a gonadotropinreleasing hormone analog such as
leuprolide acetate (Eligard Lupron Depot)

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A 48-year-old white female complains of


anxiety and difficulty concentrating at
home and at work. She reports that the
symptoms have increased over the last 2
months because of her daughter's marital
difficulties. She has had similar symptoms
along with intermittent depression since
she was a teenager. She admits to a loss of
pleasure in work and recreational
activities. Which one of the following is
LEAST likely to help her coexistent
depressive symptoms? (check one)
A. Buspirone (BuSpar)
B. Nortriptyline (Aventyl)
C. Escitalopram (Lexapro)
D. Venlafaxine (Effexor)
E. Paroxetine (Paxil)

A 49-year-old white female comes to your


office complaining of painful, cold finger
tips which turn white when she is hanging
out her laundry. While there is no
approved treatment for this condition at
this time, which one of the following drugs
has been shown to be useful? (check one)
A. Propranolol (Inderal)
B. Nifedipine (Procardia)
C. Ergotamine/caffeine (Cafergot)
D. Methysergide (Sansert)

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A. Buspirone (BuSpar). Buspirone is


indicated for the treatment of anxiety. Its
advantages include the absence of
addictive potential and sedation; like
antidepressants, the onset of benefit is
often delayed for several weeks. However,
it is not an established antidepressant. Its
use with other agents for depression has
yielded questionable benefit, and used
alone it is not an effective therapy for
depression. The other agents listed have
both antidepressant and antianxiety effects
and were originally marketed for their
antidepressant effect. Nortriptyline shares
the risks of tricyclic agents, but historically
it was one of the better tolerated tricyclics.
The newer agents have serotoninnorepinephrine reuptake inhibition (SSRI
activity). They have shown benefit in the
treatment of anxiety as well as depression.
B. Nifedipine (Procardia). At present there
is no approved treatment for Raynaud's
disease. However, patients with this
disorder reportedly experience subjective
symptomatic improvement with calcium
channel antagonists, with nifedipine being
the calcium channel blocker of choice. Blockers can produce arterial insufficiency
of the Raynaud type, so propranolol and
atenolol are contraindicated. Drugs such as
ergotamine preparations and methysergide
can produce cold sensitivity, and should
therefore be avoided in patients with
Raynaud's disease.

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A 50-year-old female complains of a 6month history of the insidious onset of


right shoulder pain and decreased range of
motion. She does not respond to consistent
use of prescription strength antiinflammatory medication. Radiographs are
negative.
Treatment of this patient's condition
should include:
(check one)

A. physical therapy with home exercises.


This patient most likely has either
adhesive capsulitis or a degenerative
rotator cuff tendinopathy. It is important to
rule out osteoarthritis with radiographs.
Treatment typically includes NSAIDs,
subacromial cortisone injections, and
physical therapy. These problems take
months to treat and should not be referred
quickly for surgical evaluation, unless the
diagnosis is in question.

A. physical therapy with home exercises


B. early surgical referral
C. a short course of oral
methylprednisolone
D. corticosteroid injection of the
acromioclavicular joint
A 50-year-old female presents with a 2day history of four vesicles on her upper
eyelid, but no pain or swelling. She has not
experienced any eye trauma, has had no
vision changes, and has no other skin
changes.
Which one of the following would be the
most appropriate next step in treating this
patient?
(check one)

A. Referral to an ophthalmologist. This


patient likely has herpes zoster
ophthalmicus. In addition to treatment
with a systemic antiviral agent, it is
important that the patient see an
ophthalmologist to be evaluated for
corneal disease and iritis, as vision can be
lost. This is a viral infection, so
corticosteroids could worsen the infection.
Mupirocin or metronidazole would not
resolve the infection.

A. Referral to an ophthalmologist
B. A methylprednisolone (Medrol) dose
pack
C. A topical corticosteroid
D. Topical mupirocin (Bactroban)
E. Topical metronidazole (MetroGel)

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A 50-year-old female presents with right


eye pain. On examination, you find no
redness, but when you test her extraocular
muscles she reports marked pain with eye
movement.
This finding suggests that her eye pain is
caused by: (check one)

D. an orbital problem. Pain with eye


movement suggests an orbital condition.
Orbital inflammation, infection, or tumor
invasion can lead to such eye pain. Other
findings suggestive of an orbital cause of
eye pain include diplopia or proptosis. If
an orbital lesion is suspected, imaging
studies should be performed.

A. an intracranial process
B. an ocular condition
C. a retinal problem
D. an orbital problem
E. an optic nerve problem
A 50-year-old female with a history of
paroxysmal atrial fibrillation has been
successfully treated for depression with
sertraline (Zoloft). However, she has
persistent insomnia, and a 10-day trial of
zolpidem (Ambien) has yielded minimal
improvement. The most appropriate
addition to her current medication would
be: (check one)
A. Trazodone (Desyrel) each evening
B. Lorazepam (Ativan) daily
C. Zaleplon (Sonata) at night
D. Amitriptyline (Elavil) at night

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A. Trazodone (Desyrel) each evening.


Trazodone has been found useful for its
sedative and hypnotic effects, and is often
used in combination with another
antidepressant. Benzodiazepines are not
recommended for long-term use. Zaleplon
is more short-acting than zolpidem and
therefore would not be more effective.
Amitriptyline could be used for its
antidepressant and sedative effects, but its
chronotropic side effects make it less
preferable for someone with a disposition
to cardiac arrhythmia.

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A 50-year-old female with significant


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

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E. Cervical spine imaging. While all of the


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

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A 50-year-old Hispanic male has a solitary


5-mm pulmonary nodule on a chest
radiograph. His only medical problem is
severe osteoarthritis. He quit smoking 10
years ago.
Which one of the following would be the
most appropriate follow-up for the
pulmonary nodule? (check one)
A. Positron emission tomography (PET)
B. Chest CT
C. A repeat chest radiograph in 6 weeks
D. A repeat chest radiograph in 6 months
E. Referral for a biopsy

B. Chest CT. Solitary pulmonary nodules


are common radiologic findings, and the
differential diagnosis includes both benign
and malignant causes. The American
College of Chest Physicians guidelines for
evaluation of pulmonary nodules are based
on size and patient risk factors for cancer.
Lesions 8 mm in diameter with a
"ground-glass" appearance, an irregular
border, and a doubling time of 1 month to
1 year suggest malignancy, but smaller
lesions should also be evaluated,
especially in a patient with a history of
smoking.
CT is the imaging modality of choice to
reevaluate pulmonary nodules seen on a
radiograph (SOR C). PET is an appropriate
next step when the cancer pretest
probability and imaging results are
discordant (SOR C). Patients with notable
nodule growth during follow-up should
undergo a biopsy (SOR C).

A 50-year-old male comes to your office


for a "doctor's excuse" for days of work he
missed last week. He attended a picnic
where he and other guests developed
nausea and vomiting 2 hours after eating.
Within 48 hours, the symptoms had
resolved.
The most likely etiology of the illness is
which one of the following?
(check one)
A. Staphylococcus
B. Clostridium botulinum
C. Clostridium perfringens
D. Clostridium difficile
E. Actinomycosis

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A. Staphylococcus. This is a typical


presentation of staphylococcal food
poisoning. The symptoms usually begin 16 hours after ingestion and resolve within
24-48 hours. Foodborne botulism is most
commonly found in homecanned foods,
and symptoms begin 18-36 hours after
ingestion. Clostridium perfringens is
transmitted in feces and water, and
symptoms begin 6-24 hours after
ingestion. Clostridium difficile is
associated with antibiotic use.
Actinomycosis causes local abscesses, not
gastroenteritis.

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A 50-year-old male has a pre-employment


chest radiograph showing a pulmonary
nodule. There are no previous studies
available.
Which one of the following would raise
the most suspicion that this is a malignant
lesion if found on the radiograph? . (check
one)
A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
A 50-year-old male is brought to the
emergency department because of a
syncopal episode.Prior to the episode, he
felt bad for 30 minutes, then developed
nausea followed by vomiting. During a
second bout of vomiting he blacked out
and fell to the floor. His wife did not
observe any seizure activity, and he was
unconscious only for a few seconds. His
history is otherwise negative, his past
medical history is unremarkable, and he
currently takes no medications. A physical
examination is normal.
Which one of the following would be the
most helpful next step?
(check one)
A. CT of the head
B. Carotid ultrasonography
C. A CBC and complete metabolic profile
D. Echocardiography
E. An EKG

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A. The absence of calcification.


Pulmonary nodules are a common finding
on routine studies, including plain chest
radiographs, and require evaluation.
Radiographic features of benign nodules
include a diameter <5 mm, a smooth
border, a solid appearance, concentric
calcification, and a doubling time of less
than 1 month or more than 1 year. Features
of malignant nodules include a size >10
mm, an irregular border, a "ground glass"
appearance, either no calcification or an
eccentric calcification, and a doubling time
of 1 month to 1 year (SOR B).
E. An EKG. The workup of patients with
syncope begins with a history and a
physical examination to identify those at
risk for a poor outcome. Patients who have
a prodrome of 5 seconds or less may have
a cardiac arrhythmia. Patients with longer
prodromes, nausea, or vomiting are likely
to have vasovagal syncope, which is a
benign process. Patients who pass out after
standing for 2 minutes are likely to have
orthostatic hypotension. In most cases, the
recommended test is an EKG. If the EKG
is normal, dysrhythmias are not a likely
cause of the syncopal episode. Laboratory
testing and advanced studies such as CT or
echocardiography are not necessary unless
there are specific findings in either the
history or the physical examination.

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A 50-year-old male is brought to the


emergency department with shortness of
breath, chest tightness, tremulousness, and
diaphoresis. Aside from tachypnea, the
physical examination is normal. Arterial
blood gases on room air show a pO2 of 98
mm Hg (N 80-100), a pCO2 of 24 mm Hg
(N 35-45), and a pH of 7.57 (N 7.38-7.44).
The most likely cause of the patient's
blood gas abnormalities is: (check one)
A. carbon monoxide poisoning
B. anxiety disorder with hyperventilation
C. an acute exacerbation of asthma
D. pulmonary embolus
E. pneumothorax

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B. anxiety disorder with hyperventilation.


The elevated pH, normal oxygen
saturation, and low pCO2 are
characteristic of acute respiratory
alkalosis, as seen with acute
hyperventilation states. In patients with a
pulmonary embolism, pO2 and pCO2 are
decreased, while the pH is elevated,
indicating the acute nature of the disorder.
With the other diagnoses, findings on the
physical examination would be different
than those seen in this patient. Vital signs
would be normal with carbon monoxide
poisoning, and patients with an asthma
exacerbation have a prominent cough and
wheezing, and possibly other
abnormalities. Tension pneumothorax
causes severe cardiac and respiratory
distress, with significant physical findings
including tachycardia, hypotension, and
decreased mental activity.

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A 50-year-old male presents with a 1-day


history of fever and chest pain. The chest
pain is worse when he is in a supine
position and with deep inspiration, and
improves when he leans forward. He has
no shortness of breath and has never had
this problem before. His vital signs are
normal except for a temperature of 37.8C
(100.0F). He has no other medical
problems or allergies, and takes no
medications. An EKG reveals widespread
ST-segment elevation, upright T waves,
and PR-segment depression. His troponin
level is normal. An echocardiogram is
pending.
Which one of the following would be the
most appropriate treatment for this patient?
(check one)
A. Aspirin
B. Prednisone
C. Heparin
D. Enoxaparin (Lovenox)

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A. Aspirin. This patient demonstrates


classic clinical features of acute
pericarditis. Although the EKG findings
appear specific for the early stages of
pericarditis, myocardial infarction would
also be included in the differential
diagnosis. However, unlike with acute
pericarditis, the EKG in myocardial
infarction typically demonstrates ST
elevation that is localized and convex,
often has Q waves, and rarely shows PRsegment depression. A friction rub can be
heard in up to 85% of patients with acute
pericarditis. An echocardiogram is often
performed to determine the type and
amount of effusion. Conventional therapy
for acute pericarditis includes NSAIDs,
such as aspirin and ibuprofen. Recent
studies demonstrate that adding colchicine
to aspirin may be beneficial in reducing
the persistence and recurrence of
symptoms.

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A 50-year-old male who is a heavy smoker


asks you about vitamin supplementation to
prevent cancer and cardiovascular disease.
The patient is unwilling to stop smoking.
According to the 2003 recommendations
of the U.S. Preventive Services Task
Force, which one of the following is true
regarding vitamin supplementation in
adults who are middle-age or older?
(check one)
A. Large supplemental doses of ~17betacarotene may increase the risk of lung
cancer in heavy smokers
B. Beta-carotene supplementation
decreases the risk of cardiovascular
disease and cancer in nonsmokers
C. Supplementation with vitamins A, C,
and E plus folic acid decreases the risk of
cardiovascular disease
D. Supplementation with antioxidant
combination vitamins plus folic acid
decreases the risk of cancer
A 50-year-old male with a history of
methamphetamine abuse requests
medication to treat this problem.
According to evidence-based studies,
which one of the following would be most
likely to help this patient overcome
methamphetamine dependence? (check
one)
A. Fluoxetine (Prozac)
B. Amlodipine (Norvasc)
C. Imipramine
D. Bupropion (Wellbutrin)
E. Cognitive therapy

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A. Large supplemental doses of ~17betacarotene may increase the risk of lung


cancer in heavy smokers. The U.S.
Preventive Services Task Force found that
beta-carotene supplementation provides no
benefit in the prevention of cancer in
middle-aged and older adults. In two trials
limited to heavy smokers, supplementation
with beta-carotene was associated with a
higher incidence of lung cancer and allcause mortality. In general, little evidence
was found to determine whether
supplementation of any of the mentioned
vitamins reduces the risk of cardiovascular
disease or cancer.

E. Cognitive therapy. Methamphetamine


dependence is very difficult to treat. No
medications have been approved by the
FDA for the treatment of this problem, nor
have any studies shown consistent benefit
to date. The standard therapy for
methamphetamine dependence is
outpatient behavioral therapies, especially
with case management included. Therapy
must be individualized. Support groups
and 12-step drug-treatment programs may
be helpful.

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A 50-year-old white female comes to you


because she has found a breast mass. Your
examination reveals a firm, fixed,
nontender, 2-cm mass. No axillary nodes
are palpable, nor is there any nipple
discharge. You send her for a
mammogram, and fine-needle aspiration is
performed to obtain cells for cytologic
examination. The mammogram is read as
"suspicious" and the fine-needle cytology
report reads, "a few benign ductal
epithelioid cells and adipose tissue."
Which one of the following would be the
most appropriate next step? (check one)
A. A repeat mammogram in 3 months
B. Repeat fine-needle aspiration in 3
months
C. An excisional biopsy of the mass
D. Referral for breast irradiation
E. Referral to a surgeon for simple
mastectomy

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C. An excisional biopsy of the mass. In the


ideal setting, the accuracy of fine-needle
aspiration may be over 90%. Clinical
information is critical for interpreting the
results of fine-needle aspiration, especially
given the fact that the tissue sample is
more limited than with a tissue biopsy. It
is crucial to determine whether the
findings on fine-needle aspiration explain
the clinical findings. Although the report
from the mammogram and the biopsy are
not ominous in this patient, they do not
explain the clinical findings. Immediate
repeat fine-needle aspiration or,
preferably, a tissue biopsy is indicated.
Proceeding directly to therapy, whether
surgery or irradiation, is inappropriate
because the diagnosis is not clearly
established. Likewise, any delay in
establishing the diagnosis is not
appropriate.

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A 51-year-old immigrant from Vietnam


presents with a 3-week history of
nocturnal fever, sweats, cough, and weight
loss. A chest radiograph reveals a right
upper lobe cavitary infiltrate. A PPD
produces 17 mm of induration, and acidfast bacilli are present on a smear of
induced sputum.
While awaiting formal laboratory
identification of the bacterium, which one
of the following would be most
appropriate? (check one)
A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin),
and pyrazinamide

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E. INH, ethambutol, rifampin (Rifadin),


and pyrazinamide. Leading authorities,
including experts from the American
Thoracic Society, CDC, and Infectious
Diseases Society of America, mandate
aggressive initial four-drug treatment
when tuberculosis is suspected. Delays in
diagnosis and treatment not only increase
the possibility of disease transmission, but
also lead to higher morbidity and
mortality. Standard regimens including
INH, ethambutol, rifampin, and
pyrazinamide are recommended, although
one regimen does not include
pyrazinamide but extends coverage with
the other antibiotics. Treatment regimens
can be modified once culture results are
available.

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A 52-year-old female presents to the


emergency department with a complaint of
chest pain. The symptoms began 2 hours
ago while she was shopping. She describes
the pain as a tightness on the left side of
her chest that radiates to her left shoulder.
She has some shortness of breath with the
pain, but no nausea or diaphoresis. Her
past medical history is significant for panic
disorder.Her vital signs and a physical
examination are within normal
limits.Which one of the following would
be the most appropriate next step in the
management of this patient? (check one)
A. Admit to a monitored bed for further
evaluation
B. Obtain a CBC, a blood chemistry
profile, liver function tests, and an EKG
C. Administer a short-acting
benzodiazepine and observe for 60
minutes
D. Consult with a cardiologist for
immediate heart catheterization
E. Obtain a troponin I measurement and an
EKG

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E. Obtain a troponin I measurement and an


EKG. This patient has symptoms that
suggest acute coronary syndrome, which
includes chest pain with activity that
radiates to the shoulder. An EKG is
essential early in the evaluation of a
patient with chest pain, and the initial
evaluation should also include a troponin I
measurement. The patient should neither
be admitted nor given a benzodiazepine
until the EKG is performed. The diagnosis
of acute coronary syndrome should be
established prior to heart catheterization.
Other laboratory tests may be appropriate,
but they are not the most important initial
tests.

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A 52-year-old female with a 60-pack-year


history of cigarette smoking and known
COPD presents with a 1-week history of
increasing purulent sputum production and
shortness of breath on exertion. Which one
of the following is true regarding the
management of this problem? (check one)
A. Antibiotics should be prescribed
B. Intravenous corticosteroids are superior
to oral corticosteroids
C. Inhaled corticosteroids should be
started or the dosage increased
D. Levalbuterol (Xopenex) is superior to
albuterol
E. Acetylcysteine should be given if the
patient is hospitalized
A 52-year-old Hispanic female with
diabetes mellitus and stage 3 chronic
kidney disease sees you for follow-up after
tests show an estimated glomerular
filtration rate of 56 mL/min. Which one of
the following medications should she
avoid to prevent further deterioration in
renal function? (check one)
A. Lisinopril (Prinivil, Zestril)
B. Folic acid
C. Low-dose aspirin
D. Candesartan (Atacand)
E. Ibuprofen

A. Antibiotics should be prescribed.


Antibiotic use in moderately or severely ill
patients with a COPD exacerbation
reduces the risk of treatment failure or
death, and may also help patients with
mild exacerbations. Brief courses of
systemic corticosteroids shorten hospital
stays and decrease treatment failures.
Studies have not shown a difference
between oral and intravenous
corticosteroids. Inhaled corticosteroids are
not helpful in the management of an acute
exacerbation. Levalbuterol and albuterol
have similar benefits and adverse effects.
Acetylcysteine, a mucolytic agent, has not
been shown to be helpful for routine
treatment of COPD exacerbations.
E. Ibuprofen. Patients with chronic kidney
disease (CKD) and those at risk for CKD
because of conditions such as hypertension
and diabetes have an increased risk of
deterioration in renal function from
NSAID use. NSAIDs induce renal injury
by acutely reducing renal blood flow and,
in some patients, by causing interstitial
nephritis. Because many of these drugs are
available over the counter, patients often
assume they are safe for anyone.
Physicians should counsel all patients with
CKD, as well as those at increased risk for
CKD, to avoid NSAIDs.
ACE inhibitors and angiotensin II receptor
blockers are renoprotective and their use is
recommended in all diabetics. The use of
low-dose aspirin and folic acid is
recommended in all patients with diabetes,
due to the vasculoprotective properties of
these drugs. High-dose aspirin should be
avoided because it acts as an NSAID.

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A 52-year-old hypertensive male has had


two previous myocardial infarctions. In
spite of his best efforts, he has not
achieved significant weight loss and he
finds it difficult to follow a heart-healthy
diet. He takes rosuvastatin (Crestor), 20
mg/day, and his last lipid profile showed a
total cholesterol level of 218 mg/dL, a
triglyceride level of 190 mg/dL, an HDLcholesterol level of 45 mg/dL, and an
LDL-cholesterol level of 118 mg/dL.

A. Increase the rosuvastatin dosage. This


patient's goal LDL-cholesterol level is 70
mg/dL, and he is not at the maximum
dosage of a potent statin. There is no data
that shows that adding a different statin
will be beneficial, and outcomes data for
the other actions is lacking. For patients
not at their goal LDL-cholesterol level, the
maximum dosage of a statin should be
reached before alternative therapy is
chosen.

Which one of the following would be the


most appropriate change in management?
(check one)
A. Increase the rosuvastatin dosage
B. Add atorvastatin (Lipitor)
C. Add niacin
D. Add fenofibrate (Lipofen, Tricor)
E. Add ezetimibe (Zetia)

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A 52-year-old male has had a chronic


course of multiple vague and exaggerated
symptoms for which no cause has been
found despite extensive testing. Which one
of the following is the most effective
management approach for this patient?
(check one)
A. Reassure the patient that his symptoms
are not real
B. Schedule the patient for regular
appointments every 2-4 weeks
C. Prescribe opioids for the pain
D. Order additional diagnostic tests
E. Advise the patient to go to the
emergency department if the symptoms
occur after office hours

B. Schedule the patient for regular


appointments every 2-4 weeks. The
management of somatizing patients can be
difficult. One strategy that has been shown
to be effective is to schedule regular office
visits so that the patient does not need to
develop new symptoms in order to receive
medical attention. Regular visits have been
shown to significantly reduce the cost and
chaos of caring for patients with
somatization disorder and to help
progressively diminish emergency visits
and telephone calls. In addition, it is
important to describe the patient's
diagnosis with compassion and avoid
suggesting that it's "all in your head."
Continued diagnostic testing and referrals
in the absence of new symptoms or
findings is unwarranted. Visits to the
emergency department often result in
inconsistent care and mixed messages
from physicians who are seeing the patient
for the first time, and unnecessary and
often repetitive tests may be ordered.
Opiates have significant side effects such
as constipation, sedation, impaired
cognition, and risk of addiction.

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A 52-year-old male presents with a small


nodule in his palm just proximal to the
fourth metacarpophalangeal joint. It has
grown larger since it first appeared, and he
now has mild flexion of the finger, which
he is unable to straighten. He reports that
his father had similar problems with his
fingers. On examination you note pitting
of the skin over the nodule.
The most likely diagnosis is:
(check one)
A. degenerative joint disease
B. trigger finger
C. Dupuytren's contracture
D. a ganglion
E. flexor tenosynovitis

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C. Dupuytren's contracture. Dupuytren's


contracture is characterized by changes in
the palmar fascia, with progressive
thickening and nodule formation that can
progress to a contracture of the associated
finger. The fourth finger is most
commonly affected. Pitting or dimpling
can occur over the nodule because of the
connection with the skin.
Degenerative joint disease is not
associated with a palmar nodule. Trigger
finger is related to the tendon, not the
palmar fascia, and causes the finger to lock
and release. Ganglions also affect the
tendons or joints, are not located in the
fascia, and are not associated with
contractures. Flexor tenosynovitis, an
inflammation, is associated with pain,
which is not usually seen with Dupuytren's
contracture.

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A 52-year-old male with stable coronary


artery disease and controlled hypertension
sees you for a routine visit and asks for
advice regarding prevention of altitude
illness for his upcoming trip to Bhutan to
celebrate his anniversary. His medical
chart indicates that he had a reaction to a
sulfa drug in the past.
Which one of the following would be most
appropriate? (check one)
A. Advise the patient to not make the trip
B. Recommend ginkgo biloba
C. Prescribe acetazolamide
D. Prescribe dexamethasone

A 52-year-old patient is concerned about a


biopsy result from a recent screening
colonoscopy. Which one of the following
types of colon polyp is most likely to
become malignant? (check one)
A. Hyperplastic polyp
B. Hamartomatous polyp
C. Tubular adenoma
D. Villous adenoma
E. Tubulovillous adenoma
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D. Prescribe dexamethasone. Altitude


illness is common, affecting 25%-85% of
travelers to high altitudes. The most
common manifestation is acute mountain
sickness, heralded by malaise and
headache. Risk factors include young age,
residence at a low altitude, rapid ascent,
strenuous physical exertion, and a previous
history of altitude illness. However,
activity restriction is not necessary for
patients with coronary artery disease who
are traveling to high altitudes (SOR C).
Ginkgo biloba has been evaluated for both
prevention and treatment of acute
mountain sickness and high-altitude
cerebral edema, and it is not
recommended. Acetazolamide is an
effective prophylactic agent (SOR B), but
is contraindicated in patients with a sulfa
allergy. If used, it should be started a
minimum of one day before ascent and
continued until the patient acclimatizes at
the highest planned elevation.
Dexamethasone is an effective
prophylactic and treatment agent (SOR B),
and it is not contraindicated for those with
a sulfa allergy. It would be the best option
for this patient.
D. Villous adenoma. Hamartomatous (or
juvenile) polyps and hyperplastic polyps
are benign lesions and are not considered
to be premalignant. Adenomas, on the
other hand, have the potential to become
malignant. Sessile adenomas and lesions
>1.0 cm have a higher risk for becoming
malignant. Of the three types of adenomas
(tubular, tubulovillous, and villous),
villous adenomas are the most likely to
develop into an adenocarcinoma.
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A 52-year-old white male has chronic


musculoskeletal pain. He has been using
frequent doses of Extra-Strength Tylenol
with good results. He is concerned that he
may be taking too much and asks what his
maximum daily dosage of acetaminophen
should be. He weighs 70 kg (154 lb).
(check one)
A. 2000 mg
B. 3000 mg
C. 4000 mg
D. 5000 mg
E. 6000 mg
A 52-year-old white male is being
considered for pharmacologic treatment of
hyperlipidemia because of an LDL
cholesterol level of 180 mg/dL. Before
beginning medication for his
hyperlipidemia, he should be screened for:
(check one)
A. Hyperthyroidism
B. Hypothyroidism
C. Addison's disease
D. Cushing's disease
E. Pernicious anemia

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C. 4000 mg. The maximum daily dosage


for all acetaminophen preparations is 4000
mg. Acetaminophen is used in more
combination products than any other drug,
for a number of different indications. An
FDA panel has recommended that stronger
warnings about hepatotoxicity be added to
the label information for acetaminophen.
Because it is used so frequently and is
present in so many different preparations,
care must be taken not to exceed the
maximum 24-hour dosage in order to
avoid hepatotoxicity.
B. Hypothyroidism. According to the
Summary of the National Cholesterol
Education Program (NCEP) Adult
Treatment Panel III Report of 2001, any
person with elevated LDL cholesterol or
any other form of hyperlipidemia should
undergo clinical or laboratory assessment
to rule out secondary dyslipidemia before
initiation of lipid-lowering therapy. Causes
of secondary dyslipidemia include diabetes
mellitus, hypothyroidism, obstructive liver
disease, chronic renal failure, and some
medications.

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A 52-year-old white male is being


considered for pharmacologic treatment of
hyperlipidemia because of an LDLcholesterol level of 180 mg/dL. Before
beginning medication for his
hyperlipidemia, he should be screened for:
(check one)
A. hyperthyroidism
B. hypothyroidism
C. Addison's disease
D. Cushing's disease
E. pernicious anemia

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B. hypothyroidism. According to the


National Cholesterol Education Program
Adult Treatment Panel III Report of 2001,
any
person with elevated LDL cholesterol or
any other form of hyperlipidemia should
undergo clinical or
laboratory assessment to rule out
secondary dyslipidemia before initiation of
lipid-lowering therapy.
Causes of secondary dyslipidemia include
diabetes mellitus, hypothyroidism,
obstructive liver disease,
chronic renal failure, and some
medications.

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A 53-year-old male presents for a routine


well-care visit. He has no health
complaints. His wife has accompanied
him, however, and is quite concerned
about changes she has noticed over the last
1-2 years. She says that he has become
quite apathetic and seems to have lost
interest in his job and his hobbies. He has
been accused of making sexually harassing
comments and inappropriate touching at
work, and he no longer helps with
household chores at home. He often has
difficulty expressing himself and his
speech can lack meaning. The physical
examination is normal.
Based on the history provided by the wife,
you should suspect a diagnosis of : (check
one)
A. Alzheimer's disease
B. major depressive disorder
C. frontotemporal dementia
D. dementia with Lewy bodies
E. schizophrenia

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C. frontotemporal dementia. This patient


meets the criteria for frontotemporal
dementia (FTD), a common cause of
dementia in patients younger than 65, with
an insidious onset. Unlike with
Alzheimer's disease, memory is often
relatively preserved, even though insight is
commonly impaired.
There are three subtypes of frontotemporal
dementia: behavioral variant FTD,
semantic dementia, and progressive
nonfluent aphasia. This patient would be
diagnosed with the behavioral variant due
to his loss of executive functioning leading
to personality change (apathy) and
inappropriate behavior (SOR C). Speech
output is often distorted in frontotemporal
dementia, although the particular changes
differ between the three variants.
Patients with FTD often are mistakenly
thought to have major depressive disorder
due to their apathy and diminished interest
in activities. However, patients with
depression do not usually exhibit
inappropriate behavior and lack of
restraint. Dementia with Lewy bodies and
Alzheimer's dementia are both
characterized predominantly by memory
loss. Alzheimer's dementia is most
common after age 65, whereas FTD occurs
most often at a younger age. Lewy body
dementia is associated with parkinsonian
motor features. Patients diagnosed with
schizophrenia exhibit apathy and
personality changes such as those seen in
FTD. However, the age of onset is much
earlier, usually in the teens and twenties in
men and the twenties and thirties in
women.
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A 53-year-old male presents for follow-up


after a routine screening colonoscopy. He
is healthy and takes no medications, and
his family history is negative for colon
cancer. During a thorough, relatively easy
colonoscopy to the cecum, two rectal
polyps measuring 0.7 mm were removed,
both of which were found to be
hyperplastic on pathologic analysis. His
next surveillance colonoscopy should be in
(check one)
A. 1 year
B. 3 years
C. 5 years
D. 7 years
E. 10 years

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E. 10 years. Risk factors for proximal


neoplasia include high-grade dysplasia,
three or more adenomas, adenomas with
villous features, and an adenoma 1 cm in
size. For patients with one or more of these
findings, follow-up colonoscopy in 3 years
is recommended. The clinical benefit of
follow-up surveillance colonoscopy in
patients with one or two small adenomas
has never been demonstrated. Distal
hyperplastic polyps are not markers for
proximal or advanced neoplasia. Patients
with this finding on colonoscopy should be
considered to have a normal colonoscopy
and the interval until the next colonoscopy
should be 10 years.

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A 53-year-old male presents with a 1-day


history of swelling in his upper arm,
shown in Figure 1.
The swelling appeared after a sudden
painful "pop" as he was lifting a heavy
box. A physical examination reveals a soft
to firm, nontender mass in the anterior
aspect of the arm, and weakness of
forearm supination. Shoulder radiographs
are normal.
Which one of the following is the most
likely diagnosis? (check one)
A. Acute anterior shoulder dislocation
B. Lateral epicondylitis
C. Biceps tendinitis
D. Biceps tendon rupture

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D. Biceps tendon rupture. Biceps tendon


rupture is one of the most common
musculotendinous ruptures. Patients
typically present with a visible lump in the
upper arm following an audible, painful
"pop." The injury typically results from
application of an eccentric load to a flexed
elbow. Risk factors for biceps tendon
rupture include age >40, deconditioning,
contralateral biceps tendon rupture, a
history of rotator cuff tear, rheumatoid
arthritis, and cigarette smoking. Weakness
in forearm supination and elbow flexion
may be present. The biceps squeeze test
and the hook test are both sensitive and
specific for diagnosing the condition.
Acute anterior shoulder dislocation is
typically very painful, with restricted
shoulder movements. Lateral epicondylitis
results in pain and tenderness over a
localized area of the proximal lateral
forearm. Biceps tendinitis results in a deep
throbbing pain over the anterior shoulder,
accompanied by bicipital groove
tenderness.

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A 53-year-old male presents with a 3month history of despondency, insomnia,


and irritability with family and coworkers. During your interview you also
discover that he is drinking heavily at
times and has several firearms at home. He
thinks his life is "useless," noting that he
"would be better off dead." The most
appropriate action at this time would be to:
(check one)
A. Prescribe an SSRI
B. Arrange immediate hospitalization
C. Have the patient agree to a suicide
prevention contract
D. Avoid direct questions regarding
suicidal thoughts

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B. Arrange immediate hospitalization.


More than 50% of suicides are associated
with a major depressive episode and 25%
are associated with a substance abuse
disorder. Suicide rates increase with age
and are higher among men. Increased
suicide rates also occur in patients with
significant medical illnesses. Because
discussing suicidal ideation may relieve
the patient's anxiety, the physician should
directly ask depressed patients about any
suicidal thoughts. There are no known
reliable tools for assessing suicide risk, so
the assessment is subjective. The initial
management of suicidal ideation should
establish safety, often by hospitalization.
The suicide prevention contract is of
unproven clinical and legal usefulness.
Antidepressant medication has not been
shown to reduce suicide rates, especially
on a short-term basis.

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A 53-year-old white female visits your


office for her annual examination. During
the last year she has stopped having
menstrual periods and has had moderately
severe sleep disturbance. She has been
waking up at night with sweats. She denies
other problems or complaints. She has a
previous history of depression and her
family history is significant for
osteoporosis, heart disease, and
Alzheimer's disease in older members of
her family. There is no family history of
breast cancer. The patient is concerned
about her future and current health and
wants to know the benefits and risks of
hormone replacement therapy (HRT).
Which one of the following statements
about HRT is correct? (check one)

D. It improves vaginal dryness. Hormone


replacement therapy (HRT) improves the
urogenital symptoms of menopause, such
as vaginal dryness and dyspareunia.
However, recent research regarding HRT
has not shown a benefit for reducing
coronary events, slowing the progression
of Alzheimer's disease, improving
depression, or improving urinary
incontinence.

A. It protects against coronary heart


disease
B. It slows progression of Alzheimer's
disease
C. It improves symptoms of depression
D. It improves vaginal dryness
E. It improves urinary incontinence

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A 54-year-old female has pain and


swelling of the right knee. Examination of
the synovial fluid reveals a leukocyte
count of 5000/mm3 , and crystals that
appear as short, blunt rods, rhomboids, and
cuboids when viewed under polarized
light.
The most likely diagnosis is: (check one)
A. gonococcal arthritis
B. tuberculous arthritis
C. rheumatoid arthritis
D. pseudogout
E. gout
A 54-year-old female presents with a 2month history of intense vulvar itching
that has not improved with topical
antifungal treatment. On examination you
note areas of white, thickened, excoriated
skin. Concerned about malignancy you
perform punch biopsies, which reveal
lichen sclerosus.
The treatment of choice for this condition
is topical application of: (check one)

D. pseudogout. Microscopic examination


of synovial fluid in a patient suffering an
acute attack of pseudogout shows large
numbers of polymorphonuclear
leukocytes. Calcium pyrophosphate
dihydrate crystals are frequently found
extracellularly and in polymorphonuclear
leukocytes. When viewed with polarized
light, the crystals appear as short, blunt
rods, rhomboids, and cuboids. The
diagnosis is made by finding typical
crystals under compensated polarized light
and is supported by radiographic evidence
of chondrocalcinosis.
B. fluorinated corticosteroids. Lichen
sclerosus is a chronic, progressive,
inflammatory skin condition found in the
anogenital region. It is characterized by
intense vulvar itching. The treatment of
choice is high-potency topical
corticosteroids. Testosterone has been
found to be no more effective than
petrolatum. Fluorouracil is an
antineoplastic agent most frequently used
to treat actinic skin changes or superficial
basal cell carcinomas.

A. conjugated estrogens
B. fluorinated corticosteroids
C. petrolatum
D. 2% testosterone
E. fluorouracil (Efudex)

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A 54-year-old female takes levothyroxine


(Synthroid), 0.125 mg/day, for central
hypothyroidism secondary to a pituitary
adenoma. The nurse practitioner in your
office orders a TSH level, which is found
to be 0.1 mIU/mL (N 0.5-5.0). Which one
of the following would you recommend?
(check one)
A. Decrease the dosage of levothyroxine
B. Increase the dosage of levothyroxine
C. Order a free T4 level
D. Order a TRH stimulation test
E. Repeat the TSH level in 3 months

A 54-year-old male comes to your office


with a 2-day history of swelling, erythema,
and pain in his right first
metatarsophalangeal joint. This is the third
time this year he has had this problem. He
has treated previous episodes with overthe-counter pain medicines, ice packs, and
elevation. Your evaluation suggests gout
as the diagnosis.
Which one of the following treatments for
gout is most likely to worsen his current
symptoms? (check one)
A. Allopurinol (Zyloprim)
B. Colchicine (Colcrys)
C. Elastic compression bandages
D. Indomethacin
E. Prednisone

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C. Order a free T4 level. Although


uncommon, pituitary disease can cause
secondary hypothyroidism. The
characteristic laboratory findings are a low
serum free T4 and a low TSH. A free T4
level is needed to evaluate the proper
dosage of replacement therapy in
secondary hypothyroidism. The TSH level
is not useful for determining the adequacy
of thyroid replacement in secondary
hypothyroidism since the pituitary is
malfunctioning. In the initial evaluation of
secondary hypothyroidism, a TRH
stimulation test would be useful if TSH
failed to rise in response to stimulation. It
is not necessary in this case, since the
diagnosis has already been made.
A. Allopurinol (Zyloprim). All of the
treatments listed are commonly used in the
management of gout with good success.
Allopurinol decreases the production of
uric acid and is effective in reducing the
frequency of acute gouty flare-ups.
However, it should not be started during
an acute attack since fluctuating levels of
uric acid can actually worsen inflammation
and intensify the patient's pain and
swelling. Colchicine inhibits white blood
cells from enveloping urate crystals and is
effective during acute attacks, as are
NSAIDs such as indomethacin.
Corticosteroids such as prednisone are also
considered a first-line treatment for acute
attacks. Compression as an adjunctive
therapy may help control pain and
swelling.

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A 54-year-old male presents to the


emergency department with an acute onset
of chest pain. His cardiac risk factors
include hypertension, hyperlipidemia, and
a positive family history. His temperature
is 37.0C (98.6F), pulse rate 80
beats/min, blood pressure 155/86 mm Hg,
and respiratory rate 22/min. His oxygen
saturation is 95% on room air. An EKG
shows rare unifocal PVCs and nonspecific
ST-T-wave changes. Initial cardiac
markers are negative.
Which one of the following would be most
appropriate at this point?
(check one)

C. PA and lateral chest films. PA and


lateral chest radiographs are still valuable
in the early evaluation of patients with
chest pain. While they do not confirm or
rule out the presence of myocardial
ischemia, other causes of chest pain may
be evident, such as pneumothorax,
pneumonia, or heart failure. The chest film
may also provide clues about other
possible diagnoses, such as pulmonary
embolism, aortic disease, or neoplasia. The
other tests listed often have a role in the
evaluation of chest pain, but none has
supplanted the plain chest film as the best
initial imaging study.

A. Helical (spiral) CT of the chest


B. Echocardiography
C. PA and lateral chest films
D. A ventilation-perfusion scan
E. Magnetic resonance angiography
A 54-year-old white female has been
taking amoxicillin for 1 week for sinusitis.
She has developed diarrhea and has had 68 stools per day for the past 2 days.
Examination shows the patient to be well
hydrated with normal vital signs and a
normal physical examination. The stool is
positive for occult blood, and a stool
screen for Clostridium difficile toxin is
positive. The most appropriate treatment at
this time would be (check one)
A. vancomycin (Vancocin) intravenously
B. metronidazole (Flagyl) orally
C. trimethoprim/sulfamethoxazole
(Bactrim, Septra) orally
D. ciprofloxacin (Cipro) orally

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B. metronidazole (Flagyl) orally. Many


antibiotics can induce pseudomembranous
colitis. Although oral vancomycin was
once the initial drug of choice for C.
difficile, oral metronidazole is now the
first-line agent because of cost
considerations and because of concerns
about the development of vancomycinresistant organisms. If the patient has
refractory symptoms despite treatment
with oral metronidazole, then oral
vancomycin would be appropriate.
Vancomycin given orally is not absorbed,
leading to high intraluminal levels of the
drug.

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A 54-year-old white male presents with


drooping of his right eyelid for 3 weeks.
On examination, he has ptosis of the right
upper lid, miosis of the right pupil, and
decreased sweating on the right side of his
face. Extraocular muscle movements are
intact. In addition to a complete history
and physical examination, which one of
the following would be most appropriate at
this point? (check one)
A. A chest radiograph
B. MRI of the brain and orbits
C. 131I thyroid scanning
D. A fasting blood glucose level
E. An acetylcholine receptor antibody
level

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A. A chest radiograph. The clinical triad of


Horner's syndrome-ipsilateral ptosis,
miosis, and decreased facial sweatingsuggests decreased sympathetic
innervation due to involvement of the
stellate ganglion, a complication of
Pancoast's superior sulcus tumors of the
lung. Radiographs or MRI of the
pulmonary apices and paracervical area is
indicated. Horner's syndrome may
accompany intracranial pathology, such as
the lateral medullary syndrome
(Wallenbergs syndrome), but is associated
with multiple other neurologic symptoms,
so MRI of the brain is not indicated at this
point. The acetylcholine receptor antibody
level is a test for myasthenia gravis, which
can also present with ptosis, but not with
full-blown Horner's syndrome. Diabetes
mellitus and thyroid disease do not
commonly present with Horner's
syndrome.

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A 55-year-old African-American male


with osteoarthritis of the knees asks for
advice on improving the function of his
knees and controlling arthritis pain. Which
one of the following would be appropriate
advice? (check one)
A. Topical capsaicin (Zostrix) applied
twice daily will improve both pain and
function
B. Glucosamine will improve both pain
and function
C. A therapeutic exercise program will
improve both pain and function
D. An intra-articular corticosteroid
injection will provide at least 6 months of
pain relief
E. NSAIDs will slow the progression of
the disease
A 55-year-old female has severe
symptoms of gastroesophageal reflux
disease. Upper endoscopy with a biopsy
shows severe esophagitis and Barrett's
esophagus.
Which one of the following is true
regarding this patient?
(check one)

C. A therapeutic exercise program will


improve both pain and function. A
therapeutic exercise program will reduce
both pain and disability in patients with
osteoarthritis of the knee (SOR A). There
is no evidence to support the use of
capsaicin cream, but NSAIDs will reduce
pain and there are proven therapies that
will improve function of the patients knee.
While intra-articular corticosteroids are
effective in relieving pain in the short term
(up to 4 weeks), there is no evidence for
long-term efficacy. There is not good
evidence to support the use of glucosamine
for treating osteoarthritis of the knee. One
systematic review found it no more
effective than placebo.

D. Her risk of developing esophageal


adenocarcinoma is <1%. The actual risk of
adenocarcinoma from Barrett's esophagus
is less than 1%. Endoscopy does nothing
to reduce the risk of death. Patients with
Barrett's esophagus can have minimal
symptoms.

A. The severity of her symptoms is due to


the presence of Barrett's esophagus
B. Follow-up screening endoscopy will
reduce her risk of death from esophageal
cancer
C. Her risk of developing esophageal
adenocarcinoma is >90%
D. Her risk of developing esophageal
adenocarcinoma is <1%

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A 55-year-old female presents to an


urgent-care facility with a complaint of
weakness of several weeks' duration. She
has no other symptoms. She has been
healthy except for a history of
hypertension that has been difficult to
control despite the use of
hydrochlorothiazide, 25 mg daily;
lisinopril (Prinivil, Zestril), 40 mg daily;
amlodipine (Norvasc), 10 mg daily; and
doxazosin (Cardura), 8 mg daily.
On examination her blood pressure is
164/102 mm Hg, with the optic fundi
showing grade 2 changes. She has normal
pulses, a normal cardiac examination, and
no abdominal bruits. A CBC is normal and
a blood chemistry panel is also normal
except for a serum potassium level of 3.1
mmol/L (N 3.5-5.5).
Which one of the following would be best
for confirming the most likely diagnosis in
this patient? (check one)

E. A plasma aldosterone/renin ratio.


Difficult-to-control hypertension has many
possible causes, including nonadherence or
the use of alcohol, NSAIDs, certain
antidepressants, or sympathomimetics.
Secondary hypertension can be caused by
relatively common problems such as
chronic kidney disease, obstructive sleep
apnea, or primary hyperaldosteronism, as
in the case described here.
As many as 20% of patients referred to
specialists for poorly controlled
hypertension have primary
hyperaldosteronism. It is more common in
women and often is asymptomatic. A
significant number of these individuals
will not be hypokalemic. Screening can be
done with a morning plasma
aldosterone/renin ratio. If the ratio is 20 or
more and the aldosterone level is >15
ng/dL, then primary hyperaldosteronism is
likely and referral for confirmatory testing
should be considered.

A. Magnetic resonance angiography of the


renal arteries
B. A renal biopsy
C. 24-hour urine for metanephrines
D. Early morning fasting cortisol
E. A plasma aldosterone/renin ratio

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A 55-year-old female sees you because of


a constant leakage of small amounts of
urine. Her obstetric/gynecologic history
includes two pregnancies, with vaginal
deliveries. Her current medications include
hydrochlorothiazide, metformin
(Glucophage), and glyburide (DiaBeta).
On examination she has mild diabetic
retinopathy, decreased sensation to
monofilament testing on her feet, and
suprapubic fullness.
The most appropriate initial treatment for
this problem would be:
(check one)
A. tolterodine (Detrol LA)
B. duloxetine (Cymbalta)
C. estrogen replacement therapy
D. bladder neck needle suspension
E. a set schedule for urination

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E. a set schedule for urination. There are


four types of urinary incontinence in
women: functional incontinence, which
occurs when the patient's inability to
ambulate or transfer results in loss of
urine; urinary stress incontinence, which is
a result of pelvic relaxation and is
manifested as involuntary loss of urine
with increases in abdominal pressure such
as that which occurs with laughing,
sneezing, or coughing; detrusor instability
or overactive bladder, which is when the
urge to urinate is quickly followed by loss
of urine, usually a large volume; and
neurogenic bladder, which is marked by
constant leakage of small amounts of
urine.
Neurogenic bladder can be caused by
diabetes mellitus, multiple sclerosis, or
spinal cord injury, and is usually initially
treated with a strict voluntary urination
schedule, which may be coupled with
Crede's maneuver. It can be treated further
by adding bethanechol to the regimen.
Many patients have to be taught
intermittent self-catheterization of the
bladder. Ultimately, the patient may
require resection of the internal sphincter
of the bladder neck.

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A 55-year-old female who has


hypertension, hyperlipidemia, and
osteoarthritis of the knees develops acute
gout and is found to have hyperuricemia.
Discontinuation of which one of the
following medications may improve her
hyperuricemia? (check one)

A. Hydrochlorothiazide. Diuretics such as


hydrochlorothiazide are known to increase
serum uric acid levels, but losartan has
been shown to decrease uric acid.
Metoprolol, simvastatin, and
acetaminophen have no specific effect on
serum uric acid levels.

A. Hydrochlorothiazide
B. Losartan (Cozaar)
C. Metoprolol (Lopressor)
D. Simvastatin (Zocor)
E. Acetaminophen
A 55-year-old female with diabetes
mellitus, hypertension, and hyperlipidemia
presents to your office for routine followup. Her serum creatinine level is 1.5
mg/dL (estimated creatinine clearance 50
mL/min).
Which one of the following diabetes
medications would be contraindicated in
this patient? (check one)
A. Metformin (Glucophage)
B. Exenatide (Byetta)
C. Acarbose (Precose)
D. Insulin glargine (Lantus)
E. Pioglitazone (Actos)

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A. Metformin (Glucophage). Metformin is


contraindicated in patients with chronic
kidney disease. It should be stopped in
females with
a creatinine level 1.4 mg/dL and in males
with a creatinine level 1.5 mg/dL.
Pioglitazone should not be used in patients
with hepatic disease. Acarbose should be
avoided in patients with cirrhosis or a
creatinine level >2.0 mg/dL. Exenatide is
not recommended in patients with a
creatinine clearance <30 mL/min. Insulin
glargine can be used in patients with renal
disease at any stage, but the dosage may
need to be decreased.

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A 55-year-old hospitalized white male


with a history of rheumatic aortic and
mitral valve disease has a 3-day history of
fever, back pain, and myalgias. No definite
focus of infection is found on your initial
examination. His WBC count is
24,000/mm3(N 4300-10,800) with 40%
polymorphonuclear leukocytes and 40%
band forms. The following day, two blood
cultures have grown gram-positive cocci in
clusters.
Until the specific organism sensitivity is
known, the most appropriate antibiotic
treatment would be: (check one)
A. ciprofloxacin (Cipro)
B. nafcillin
C. streptomycin and penicillin
D. ceftriaxone (Rocephin)
E. vancomycin and gentamicin
A 55-year-old male consults you because
he wants to begin an exercise program. He
is asymptomatic, but because of his family
history you determine that he should
undergo a stress test with
echocardiography.
Which one of the following would be
considered a normal ejection fraction in
this patient?
(check one)
A. 48%
B. 65%
C. 76%
D. 84%
E. 92%

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E. vancomycin and gentamicin. This


patient has endocarditis caused by a grampositive coccus. Until sensitivities of the
organism are known, treatment should
include intravenous antibiotic coverage for
Enterococcus, Streptococcus, and
methicillin-sensitive and methicillinresistant Staphylococcus. A patient who
does not have a prosthetic valve should be
started on vancomycin and gentamicin,
with monitoring of serum levels.
Enterococcus and methicillin-resistant
Staphylococcus are often resistant to
cephalosporins. If the organism proves to
be Staphylococcus sensitive to nafcillin,
the patient can be switched to a regimen of
nafcillin and gentamicin.

B. 65%. The ejection fraction value is an


important measure of left ventricular
function, especially with regard to
previous cardiac events, medications,
exercise tolerance, and preoperative risk.
The normal predicted value is 55%-75%
when measured by echocardiography in a
healthy asymptomatic patient. There is no
gender difference, but there is a decline
with age. It may be as low as 15% in
patients with left ventricular dysfunction.
Ischemic and valvular heart disease may
significantly reduce the ejection fraction.

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A 55-year-old male has New York Heart


Association Class II heart failure. He
becomes dyspneic with significant
exertion. His only medication is an ACE
inhibitor. Which one of the following
additional medications has been shown to
improve longevity in this situation? (check
one)
A. Digitalis
B. Warfarin (Coumadin)
C. -Blockers
D. Amiodarone (Cordarone)
E. Non-dihydropyridine calcium channel
blockers

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C. -Blockers. -Blockers are


recommended to reduce mortality in
symptomatic patients with heart failure
(SOR A). The role that digoxin will
ultimately play in heart failure is unclear.
The Digitalis Investigation Group study
revealed a trend toward increased
mortality among women with heart failure
who were taking digoxin, but digoxin
levels were higher among women than
men. There is no evidence that warfarin
decreases mortality in patients with heart
failure. There is also no evidence that
amiodarone decreases mortality from heart
failure in patients with no history of atrial
fibrillation. Calcium channel blockers
should be used with caution in patients
with heart failure because they can cause
peripheral vasodilation, decreased heart
rate, decreased cardiac contractility, and
decreased cardiac conduction.

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A 55-year-old male is brought to the


emergency department because of
confusion and seizures. He has a history of
hypertension and obstructive sleep apnea
due to obesity. He is not conscious and no
other history is available. An examination
shows no focal neurologic findings, but a
general examination is limited because of
his size. Breath sounds are diminished, and
heart sounds are difficult to hear. He has
venous insufficiency changes on his lower
extremities, with brawny-type edema.
Laboratory testing reveals a sodium level
of 116 mmol/L (N 135-145), but normal
renal and liver functions. A chest
radiograph shows mild cardiomegaly. A
BNP level is pending, but immediate
treatment is felt to be indicated.
Which one of the following is the
treatment of choice for this patient?
(check one)

D. Hypertonic saline. This patient has


severe hyponatremia manifested by
confusion and seizures, a life-threatening
situation warranting urgent treatment with
hypertonic (3%) saline. The serum sodium
level should be raised by only 1-2 mmol/L
per hour, to prevent serious neurologic
complications. Saline should be used only
until the seizures stop. Some authorities
recommend concomitant use of
furosemide, especially in patients who are
likely to be volume overloaded, as this
patient is, but it should not be used alone.
The arginine vasopressin antagonist
conivaptan is approved for the treatment of
euvolemic or hypervolemic hyponatremia,
but not in patients who are obtunded or in
a coma, or who are having seizures.

A. Valsartan (Diovan)
B. Furosemide
C. Vasopressin (Pitressin)
D. Hypertonic saline
E. Conivaptan (Vaprisol)

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A 55-year-old male is brought to the


emergency department with a complaint of
pain in the right eye and reduced vision of
about 10 minutes' duration. His eye was
injured while he was hitting a metal stake
with a sledge hammer. He was not wearing
safety goggles. On examination you note a
subconjunctival hemorrhage completely
surrounding the cornea. The iris is
irregular.
Which one of the following is
contraindicated prior to emergency
transfer to an ophthalmologist? (check
one)
A. Administering an analgesic
B. Attempting tonometry
C. A visual acuity test
D. Use of an eye shield
E. Administering an antiemetic

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B. Attempting tonometry. The injury and


findings described raise the possibility of
globe rupture due to a fragment of steel
penetrating through the cornea and pupil
and into the globe. Relief of pain with an
analgesic is appropriate before transfer.
Because of a risk of extruding intraocular
fluid, tonometry should not be attempted if
globe rupture is suspected. A rapid
assessment of gross visual acuity (e.g.,
counting fingers, seeing light versus dark)
may be performed. An eye shield should
be placed over the affected eye to avoid
putting pressure on the eye during
transport to the ophthalmologist. Because
the Valsalva effect from vomiting may
lead to extrusion of intraocular contents,
an antiemetic would be appropriate before
transfer as well.

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A 55-year-old male is found to have three


hyperplastic polyps on a routine screening
colonoscopy. He has no personal or family
history of colon cancer.
This patient's next colonoscopy should be
in:
(check one)
A. 1 year
B. 3 years
C. 5 years
D. 10 years

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D. 10 years. Colonoscopy is the gold


standard for screening for colon cancer.
Because of differences in recommended
screening intervals, the American Cancer
Society and the U.S. Multi-Society Task
Force on Colorectal Cancer issued
recommendations for follow-up in 2006 to
bring some uniformity to the guidelines.
Patients with hyperplastic polyps are
considered to have normal colonoscopy
findings and can be followed up in 10
years, unless they have hyperplastic
polyposis syndrome. Patients with one or
two small adenomas (<1 cm, with no- or
low-grade dysplasia) are considered at low
risk and can be followed up in 5-10 years,
depending on family history, previous
colonoscopy findings, and patient and
physician preference. Patients with three
or more small adenomas, or one adenoma
>1 cm in size should be followed up in 3
years if the adenomas are completely
removed. Patients who have had a sessile
adenoma removed piecemeal should have
repeat colonoscopy in 2-6 months to make
sure that the polyp has been completely
removed. Other factors that influence the
screening interval include the quality of
the preparation and the ability of the
physician to see the entire colon. Although
this patient had three hyperplastic polyps
removed, he is at low risk for colon cancer
and should have repeat screening at the
normal 10-year interval.

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09/11/2014

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A 55-year-old male presents for an


evaluation of heel pain. He has a relatively
sedentary office job, but exercises daily by
jogging 3 miles. He has pain in the right
heel at the medial aspect of the calcaneus
and is tender on examination. The pain is
worse with the first few steps of the
morning. Which one of the following
would be the most appropriate initial
treatment for this patient? (check one)
A. Corticosteroid injection
B. Extracorporeal shockwave therapy
C. Surgical referral for bone spur removal
D. Non-weight bearing for 1 month
E. Stretching exercises for the Achilles
tendon

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E. Stretching exercises for the Achilles


tendon. Plantar fasciitis is an overuse
injury due to microtrauma of the plantar
fascia where it attaches at the medial
calcaneal tubercle. The patient experiences
heel or arch pain, which often is worse
upon arising and taking the first few steps
of the morning. Examination reveals
tenderness at the site and pain with
dorsiflexion of the toes. Stress fractures
often cause pain at rest that intensifies with
weight bearing. Treatment strategies
include relative rest, ice, NSAIDs, and
prefabricated shoe inserts that provide arch
support, as well as heel cord and plantar
fascia stretching. Currently, there is
evidence against the use of extracorporeal
shockwave therapy. If conservative
therapy fails, a corticosteroid injection
may be useful. Surgery is reserved for
patients refractory to 6-12 months of
uninterrupted conservative therapy.

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A 55-year-old male presents to your office


for evaluation of increasing dyspnea with
exertion over the past 2 weeks. He has
smoked 2 packs of cigarettes per day since
the age of 20. He has had a chronic cough
for years, along with daily sputum
production. He was given an albuterol
inhaler for wheezing in the past, which he
uses intermittently. On examination he has
a severe decrease in breath sounds, no
evidence of jugular venous distention, no
cardiac murmur, and no peripheral edema.
A chest film shows hyperinflation, but no
infiltrates or pleural effusion. Office
spirometry shows that his FEV1 is only
55% of the predicted value.
You consider using inhaled corticosteroids
as part of the treatment regimen for this
patient. This has been shown to: (check
one)
A. increase cataract formation
B. increase the incidence of fracture
C. increase the risk of pneumonia
D. slow the progression of the disease
E. improve overall mortality from the
disease

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C. increase the risk of pneumonia. COPD


has several symptoms, including poor
exercise tolerance, chronic cough, sputum
production, dyspnea, and signs of rightsided heart failure. The most common
etiology is cigarette smoking. A patient
with any combination of two of these
findings, such as a 70-pack-year history of
smoking, decreased breath sounds, or a
history of COPD, likely has airflow
obstruction, defined as an FEV1 60% of
the predicted value. In stable COPD,
treatment is reserved for patients who have
symptoms and airflow obstruction.
Treatment options for monotherapy are all
similar in effectiveness and include longacting inhaled anticholinergics, longacting -agonists, and inhaled
corticosteroids.
Inhaled corticosteroids will not reduce
mortality or affect long-term progression
of COPD. However, they do reduce the
number of exacerbations and the rate of
decline in the quality of life. There appears
to be no increase in cataract formation or
rate of fracture. These agents do have side
effects, including candidal infection of the
oropharynx, hoarseness, and an increased
risk of developing pneumonia.

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A 55-year-old male presents with a 2-year


history of persistent, worsening neck
stiffness. Over the past month, the stiffness
has been associated with left thumb
tingling.
After completing a thorough history and
physical examination, which one of the
following studies would be the most
appropriate next step in further evaluating
the patient's complaints? (check one)
A. Lateral neck radiography
B. A cervical spine series
C. Neck MRI
D. CT myelography
E. Diskography

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B. A cervical spine series. Based on the


American College of Radiology's
Appropriateness Criteria for chronic neck
pain, a complete cervical spine series that
includes five views is the correct study in a
patient of any age with chronic neck pain
and no history of trauma, malignancy, or
surgery. If the radiographs are normal and
the patient has neurologic signs or
symptoms, the next step would be MRI. If
MRI is contraindicated, CT myelography
should be offered (SOR B). A single
lateral radiograph is not sufficient.
Diskography is not recommended in
patients with chronic neck pain (SOR C).

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A 55-year-old male who had a recent


episode of atrial fibrillation that converted
in the emergency department is
asymptomatic and currently in sinus
rhythm. He is in good health otherwise and
has no history of hypertension, diabetes
mellitus, heart failure, transient ischemic
attack, or stroke.
Which one of the following would be best
for preventing a stroke in this patient?
(check one)
A. Aspirin
B. Clopidogrel (Plavix), 75 mg daily
C. Warfarin (Coumadin), with a goal INR
of 1.5-2.5
D. Warfarin, with a goal INR of 2.0-3.0
E. Warfarin, with a goal INR of 2.5-3.5

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A. Aspirin. The absolute rate of stroke


depends on age and comorbid conditions.
The stroke risk index CHADS , used to
quantify risk of stroke for patients who
have atrial fibrillation and to aid in the
selection of antithrombotic therapy, is a
mnemonic for individual stroke risk
factors: C (congestive heart failure), H
(hypertension), A (age 75), D (diabetes
mellitus), and S (secondary prevention for
prior ischemic stroke or transient attack
most experts include patients with a
systemic embolic event). Each of these
clinical parameters is assigned one point,
except for secondary prevention, which is
assigned 2 points. Patients are considered
to be at low risk with a score of 0, at
intermediate risk with a score of 1 or 2,
and at high risk with a score 3. Experts
typically prefer treatment with aspirin
rather than warfarin when the risk 2 of
stroke is low. The patient in this question
has a CHADS score of 0, which is low
risk. Treatment with aspirin is therefore
appropriate.

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A 55-year-old male who has a long history


of marginally-controlled hypertension
presents with gradually increasing
shortness of breath and reduced exercise
tolerance. His physical examination is
normal except for a blood pressure of
140/90 mm Hg, bilateral basilar rales, and
trace pitting edema. Which one of the
following ancillary studies would be the
preferred diagnostic tool for evaluating
this patient? (check one)
A. 12-lead electrocardiography
B. Posteroanterior and lateral chest
radiographs
C. 2-dimensional echocardiography with
Doppler
D. Radionuclide ventriculography
E. Cardiac MRI
A 55-year-old obese male with
hypertension and daytime somnolence is
found to have severe obstructive sleep
apnea, with an apnea-hypopnea index of
32 on an overnight polysomnogram.
Which one of the following is considered
to be first-line therapy for this patient's
condition?
(check one)

C. 2-dimensional echocardiography with


Doppler. The most useful diagnostic tool
for evaluating patients with heart failure is
two-dimensional echocardiography with
Doppler to assess left ventricular ejection
fraction (LVEF), left ventricular size,
ventricular compliance, wall thickness,
and valve function. The test should be
performed during the initial evaluation.
Radionuclide ventriculography can be
used to assess LVEF and volumes, and
MRI or CT also may provide information
in selected patients. Chest radiography
(posteroanterior and lateral) and 12-lead
electrocardiography should be performed
in all patients presenting with heart failure,
but should not be used as the primary basis
for determining which abnormalities are
responsible for the heart failure.
A. Continuous positive airway pressure
(CPAP). Patients with severe sleep apnea
(apnea-hypopnea index >29) and
concomitant cardiovascular disease benefit
the most from treatment for obstructive
sleep apnea. Because it is relatively easy to
implement and has proven efficacy,
continuous positive airway pressure
(CPAP) is considered first-line therapy for
severe apnea.

A. Continuous positive airway pressure


(CPAP)
B. An oral dental appliance
C. Uvulopalatopharyngoplasty
D. Sleep positioning therapy
E. Tracheostomy

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09/11/2014

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A 55-year-old overweight male presents


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

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A. Sesamoid fracture. Pain involving the


big toe is a common problem. The first
metatarsophalangeal (MTP) joint has two
sesamoid bones, and injuries to these
bones account for 12% of big-toe injuries.
Overuse, a sharp blow, and sudden
dorsiflexion are the most common
mechanisms of injury. Gout commonly
involves the first MTP joint, but the onset
is sudden, with warmth, redness, and
swelling, and pain on movement of the
joint is common. Morton's neuroma
commonly occurs between the third and
fourth toes, causes numbness involving the
digital nerve in the area, and usually is
caused by the nerve being pinched
between metatarsal heads in the center of
the foot. Cellulitis of the foot is common,
and can result from inoculation through a
subtle crack in the skin. However, there
would be redness and swelling, and the
process is usually more generalized.
Sesamoiditis is often hard to differentiate
from a true sesamoid fracture.
Radiographs should be obtained, but at
times they are nondiagnostic. Treatment,
fortunately, is similar, unless the fracture
is open or widely displaced. Limiting
weight bearing and flexion to control
discomfort is the first step. More complex
treatments may be needed if the problem
does not resolve in 4-6 weeks.

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A 55-year-old white female presents with


redness at the scar from a lumpectomy
performed for stage I cancer of her right
breast 4 months ago. The patient has
completed radiation treatments to the
breast. She is afebrile and there is no
axillary adenopathy. There is no wound
drainage, crepitance, or bullous lesions.
Which one of the following organisms
would be the most likely cause of cellulitis
in this patient? (check one)
A. Non-group A Streptococcus
B. Pneumococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Pasteurella multocida

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A. Non-group A Streptococcus. Cellulitis


in patients after breast lumpectomy is
thought to be related to lymphedema.
Axillary dissection and radiation
predispose to these infections. Non-group
A hemolytic Streptococcus is the most
common organism associated with this
infection. The onset is often several weeks
to several months after surgery.
Pneumococcus is more frequently a cause
of periorbital cellulitis. It is also seen in
patients who have bacteremia with
immunocompromised status.
Immunocompromising conditions would
include diabetes mellitus, alcoholism,
lupus, nephritic syndrome, and some
hematologic cancers. Clostridium and
Escherichia coli are more frequently
associated with crepitant cellulitis and
tissue necrosis. Pasteurella multocida
cellulitis is most frequently associated with
animal bites, especially cat bites.

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09/11/2014

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A 55-year-old white male comes to your


office with weakness and a headache. He
also describes an annoying pruritus that
occurs frequently after he takes a hot
shower. The physical examination is
remarkable for the presence of an enlarged
spleen. He has a hemoglobin level of 21
g/dL (N 12-16) and a hematocrit of 63%
(N 36-48). To confirm your clinical
diagnosis, you obtain additional studies.
Which one of the following would be most
consistent with the most likely diagnosis in
this patient? (check one)
A. A low serum erythropoietin level
B. A low platelet count
C. A low arterial oxygen concentration
D. An elevated carboxyhemoglobin level

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A. A low serum erythropoietin level. The


patient described in this case has
polycythemia vera. Pruritus after a hot
shower (aquagenic pruritus) and the
presence of splenomegaly helps to
clinically distinguish polycythemia vera
from other causes of erythrocytosis
(hematocrit >55%). Specific criteria for
the diagnosis of polycythemia vera include
an elevated red cell mass, a normal arterial
oxygen saturation (>92%), and the
presence of splenomegaly. In addition,
patients usually exhibit thrombocytosis
(platelet count >400,000/mm3 ),
leukocytosis (WBC>12,000/mm3 ), a low
serum erythropoietin level, and an elevated
leukocyte alkaline phosphatase score. High
carboxyhemoglobin levels are associated
with secondary polycythemia.

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A 55-year-old white male notices a


nodular thickening over the flexor tendons
in his medial palm. He has no difficulty
using his hand, and he is able to lay his
palm flat on a tabletop. You suspect
Dupuytren's disease.
Which one of the following is true
regarding this condition?
(check one)
A. There is a strong association with
diabetes mellitus
B. Surgical intervention is recommended
at this point to prevent progression to
contracture
C. Once a contracture develops, it is
irreversible and no treatment is indicated
D. A single cortisone injection often leads
to disease regression in mild to moderate
cases
E. A search for an occult malignancy is
indicated

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A. There is a strong association with


diabetes mellitus. Dupuytren's disease is
characterized by shortening and thickening
of the palmar fascia. It is initially
asymptomatic, but may progress and cause
difficulty with function of the hand, and
may eventually lead to contracture. Early
asymptomatic disease does not require
treatment. A series of cortisone injections
over a period of months may lead to
disease regression, and is useful in patients
with mild to moderate symptoms. Surgery
is indicated if a metacarpal joint
contracture reaches 30, or with a
proximal interphalangeal joint contracture
of any degree. If surgery is delayed,
irreversible joint contracture may occur.
There is a strong association between
diabetes mellitus and Dupuytren's disease,
with up to a third of diabetic patients
having evidence of the disease. It is also
associated with alcohol use and smoking.
Patients requiring surgery have an
increased risk of dying from cancer,
probably related to smoking, alcohol use,
or diabetes mellitus, but a search for
cancer at the time of diagnosis is not
indicated.

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A 55-year-old white male sees you for a


routine annual visit. His fasting blood
glucose level is 187 mg/dL. Repeat testing
1 week later reveals a fasting glucose level
of 155 mg/dL and an HbA1c of 9.4%. His
BMI is 30 kg/m2. He does not seem to
have any symptoms of diabetes mellitus.
In addition to lifestyle changes, which one
of the following would you prescribe
initially? (check one)
A. Metformin (Glucophage)
B. Glyburide (DiaBeta, Micronase)
C. Poiglitazone (Actos)
D. Bedtime long-acting insulin (Lantus,
Levamir)
E. Bedtime long-acting insulin and rapidacting insulin (NovoLog, Humalog) with
each meal

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A. Metformin (Glucophage). Metformin is


widely accepted as the first-line drug for
type 2 diabetes mellitus. It is relatively
effective, safe, and inexpensive, and has
been used widely for many years. Unlike
other oral hypoglycemics and insulin, it
does not cause weight gain. It should be
started at the same time as lifestyle
modifications, rather than waiting to see if
a diet and exercise regimen alone will
work. If metformin is not effective, a
sulfonylurea, a thiazolidinedione, or
insulin can be added, with the choice
based on the severity of the
hyperglycemia.

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A 55-year-old white male sees you for


follow-up after a recent lipid panel
revealed no improvement in his
hyperlipidemia. His total cholesterol level
is 275 mg/dL, with an LDL-cholesterol
level of 180 mg/dL, an HDL-cholesterol
level of 35 mg/dL, and a triglyceride level
of 275 mg/dL. These numbers are similar
to two previous lipid panels obtained over
the last several months, despite attempts at
lifestyle changes. He has adequately
treated essential hypertension, with a
blood pressure of 125/83 mm Hg. There is
no history of diabetes mellitus or tobacco
use, and no family history of premature
coronary heart disease. A physical
examination is unremarkable except for a
BMI of 33 kg/m2 and a waist
circumference of 107 cm (42 in). His
fasting blood glucose level is 107 mg/dL.
After discussion with the patient, you
decide to start prescription drug therapy.
The initial target of this therapy should be
to reach his goal level of (check one)

A. LDL cholesterol. This patient meets the


criteria for metabolic syndrome. In
addition to lifestyle changes,
pharmacologic treatment for his
hyperlipidemia should be considered. The
initial goal of this therapy should be to
reach his LDL-cholesterol goal, usually
using a statin. After achievement of this
goal, non-HDL cholesterol is the
secondary target for therapy. Non-HDL
cholesterol is calculated by subtracting
HDL cholesterol from total cholesterol.
The non-HDL cholesterol goal is 30
mg/dL higher than the LDL-cholesterol
goal.

A. LDL cholesterol
B. HDL cholesterol
C. non-HDL cholesterol
D. triglycerides
E. fasting blood glucose

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A 55-year-old white male smoker has had


daily severe gastroesophageal reflux
symptoms unrelieved by intensive medical
therapy with proton pump inhibitors. A
recent biopsy performed during upper
endoscopy identified Barrett's esophagus.
Which one of the following is true about
this condition? (check one)
A. It will reg