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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)
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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
3.
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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 lowmolecular-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
4.
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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
5.
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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)
A. Sinus tachycardia
B. Atrial flutter with third degree block
C. Asystole
D. Torsades de pointes
6.
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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
B. Furosemide (Lasix)
C. Raloxifene (Evista)
D. Calcium carbonate
E. Vitamin D
7.
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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
B. Hyperthyroidism
C. Female gender
D. A nodule size of 2 cm
E. A freely movable nodule
8.
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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
9.
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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)
A. pH <7.2
B. Bloody appearance
C. Neutrophil count >300/mL
D. Positive cytology
E. Total protein >1 g/dL
10.
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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)
A. Escherichia coli
B. Rotavirus
C. Norwalk virus
D. Hepatitis A
E. Giardia species
11.
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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)
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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
13.
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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)
14.
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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
15.
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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
16.
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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
17.
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Neurologic Board Review Questions 02
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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
18.
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Patient-Based Systems Board Review Questions
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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
19.
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Population-Based Care Board Review Questions
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Which one of the following is recommended for routine
prenatal care? (check one)
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Psychogenic Board Review Questions 01
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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
21.
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Psychogenic Board Review Questions 02
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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
22.
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Psychogenic Board Review Questions 03
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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
23.
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Psychogenic Board Review Questions 04
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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 sustained-release 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)
24.
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Random Board Review Questions 01
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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
25.
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Random Board Review Questions 02
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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.
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
26.
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Random Board Review Questions 03
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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)
27.
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Random Board Review Questions 04
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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
28.
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Random Board Review Questions 05
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Which one of the following is most consistent with obsessivecompulsive 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
29.
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Random Board Review Questions 06
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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
30.
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Random Board Review Questions 07
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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
31.
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Random Board Review Questions 08
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You are asked to perform a preoperative evaluation on a 55year-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
32.
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Random Board Review Questions 09
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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
Hemoglobin........................... 7.0 g/dL (N 12.0-16.0)
Hematocrit............................ 20% (N 36-46)
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.
The most likely diagnosis is: (check one)
A. vitamin B12 deficiency
B. malaria
C. ehrlichiosis
D. sickle cell anemia
33.
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Random Board Review Questions 10
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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
34.
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Random Board Review Questions 11
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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.
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Random Board Review Questions 12
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The most appropriate advice for a 50-year-old 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
36.
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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)
A. Azithromycin (Zithromax)
B. Dicloxacillin
C. Levofloxacin (Levaquin)
D. Doxycycline
E. Cephalexin (Keflex)
37.
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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.
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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.
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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
40.
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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.
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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)
A. Warfarin (Coumadin)
B. Enoxaparin (Lovenox)
C. Clopidogrel (Plavix)
D. Pentoxifylline (Trental)
E. Atorvastatin (Lipitor)
42.
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Random Board Review Questions 19
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A 55-year-old male sees you for a follow-up 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.
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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.
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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)
45.
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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
46.
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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 anklebrachial index of 0.7 bilaterally, and decreased flow.
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Random Board Review Questions 24
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Which one of the following organisms is NOT killed by alcoholbased hand disinfectants? (check one)
A. Methicillin-resistant Staphylococcus aureus (MRSA)
B. Methicillin-sensitive Staphylococcus aureus
C. Pseudomonas aeruginosa
D. Klebsiella pneumoniae
E. Clostridium difficile
48.
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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
B. Torn rotator cuff
C. Impingement syndrome
D. Chronic posterior shoulder dislocation
E. Osteoarthritis
49.
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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
50.
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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
B. postictal prolactin levels
C. EEG monitoring
D. video-electroencephalography (vEEG) monitoring
E. brain MRI
51.
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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)
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
52.
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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)
=======================================================
Random Board Review Questions 30
=======================================================
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
54.
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Random Board Review Questions 31
=======================================================
A patient who takes fluoxetine (Prozac), 40 mg twice daily,
develops shivering, tremors, and diarrhea after taking an
over-the-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
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)
55.
=======================================================
Random Board Review Questions 32
=======================================================
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)
=======================================================
Random Board Review Questions 33
=======================================================
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)
57.
=======================================================
Random Board Review Questions 34
=======================================================
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
58.
=======================================================
Random Board Review Questions 35
=======================================================
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)
=======================================================
Random Board Review Questions 36
=======================================================
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)
A. Surgical correction of the hammer toe
B. Custom-made shoes to protect the hammer toe
C. Bunionectomy
D. A metatarsal pad
60.
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Random Board Review Questions 37
=======================================================
A patient presents with a pigmented skin lesion that could be a
melanoma. Its largest dimension is 0.5 cm.
=======================================================
Random Board Review Questions 38
=======================================================
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.
=======================================================
Random Board Review Questions 39
=======================================================
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)
A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia
63.
=======================================================
Random Board Review Questions 40
=======================================================
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
64.
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Random Board Review Questions 41
=======================================================
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 4300-10,800)3
D. An elevated uric acid level
65.
=======================================================
Random Board Review Questions 42
=======================================================
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)
66.
=======================================================
Random Board Review Questions 43
=======================================================
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
67.
=======================================================
Random Board Review Questions 44
=======================================================
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)
B. Leuprolide (Lupron)
C. Prednisone
D. Metformin (Glucophage)
68.
=======================================================
Random Board Review Questions 45
=======================================================
A 26-month-old child presents with a 2-day 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
69.
=======================================================
Random Board Review Questions 46
=======================================================
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
70.
=======================================================
Random Board Review Questions 47
=======================================================
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)
=======================================================
Random Board Review Questions 48
=======================================================
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.
=======================================================
Random Board Review Questions 49
=======================================================
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)
73.
=======================================================
Random Board Review Questions 50
=======================================================
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.
=======================================================
Random Board Review Questions 51
=======================================================
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)
75.
=======================================================
Random Board Review Questions 52
=======================================================
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)
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
76.
=======================================================
Random Board Review Questions 53
=======================================================
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
77.
=======================================================
Random Board Review Questions 54
=======================================================
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
78.
=======================================================
Random Board Review Questions 55
=======================================================
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
79.
=======================================================
Random Board Review Questions 56
=======================================================
The most common presenting symptom of obstructive sleep
apnea is: (check one)
=======================================================
Random Board Review Questions 57
=======================================================
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 (ToprolXL), 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)
A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)
81.
=======================================================
Random Board Review Questions 58
=======================================================
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
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
82.
=======================================================
Random Board Review Questions 59
=======================================================
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
B. A chest radiograph
C. Low-dose CT of the chest
D. Sputum cytology
83.
=======================================================
Random Board Review Questions 60
=======================================================
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
84.
=======================================================
Random Board Review Questions 61
=======================================================
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%
85.
=======================================================
Random Board Review Questions 62
=======================================================
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 node
enlargement.This presentation is most consistent with:
(check one)
A. polyarteritis nodosa
B. Goodpasture's syndrome
C. sarcoidosis
D. pulmonary embolus
86.
=======================================================
Random Board Review Questions 63
=======================================================
A 4-week-old white male is brought to your office with a 2week history of increasing dyspnea, cough, and poor feeding.
The child appears nontoxic and is 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
87.
=======================================================
Random Board Review Questions 64
=======================================================
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
88.
=======================================================
Random Board Review Questions 65
=======================================================
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 (anti-HBs), 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
89.
=======================================================
Random Board Review Questions 66
=======================================================
A 14-year-old female sees you for follow-up 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 8.5-10.5). 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
B. Decreased serum phosphate
C. High-normal to increased serum chloride
D. Elevated alkaline phosphatase
E. Elevated parathyroid hormone
90.
=======================================================
Random Board Review Questions 67
=======================================================
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
91.
=======================================================
Random Board Review Questions 68
=======================================================
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)
A. KUB radiography
B. Transabdominal ultrasonography
C. Voiding cystourethrography
D. CT urography
E. Magnetic resonance urography
92.
=======================================================
Random Board Review Questions 69
=======================================================
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)
=======================================================
Random Board Review Questions 70
=======================================================
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
94.
=======================================================
Random Board Review Questions 71
=======================================================
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)
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)
95.
=======================================================
Random Board Review Questions 72
=======================================================
Sympathomimetic decongestants such as pseudoephedrine
and phenylephrine can be problematic in elderly patients
because they can: (check one)
=======================================================
Random Board Review Questions 73
=======================================================
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
97.
=======================================================
Random Board Review Questions 74
=======================================================
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 honey-colored, crusted
lesion seen now. Which one of the following would be the
most appropriate therapy? (check one)
A. Oral penicillin V
B. Oral erythromycin
C. Topical disinfectant (e.g., hydrogen peroxide)
D. Topical bacitracin
E. Topical mupirocin (Bactroban)
D. are homebound. Factors associated with a higher risk of heatrelated 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.
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.
98.
=======================================================
Random Board Review Questions 75
=======================================================
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 8.0-10.0), a BUN level of 36 mg/dL (N 6-20), and a
creatinine level of 2.2 mg/dL (N 0.6-1.1). 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
99.
=======================================================
Random Board Review Questions 76
=======================================================
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
100.
=======================================================
Random Board Review Questions 77
=======================================================
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
B. Amblyopia
C. Cataract
D. Esotropia
E. Heterophoria
101.
=======================================================
Random Board Review Questions 78
=======================================================
A 26-year-old female presents with a 1-year 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)
102.
=======================================================
Random Board Review Questions 79
=======================================================
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)
103.
=======================================================
Random Board Review Questions 80
=======================================================
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)
A. B-cell lymphoma
B. T-cell lymphoma
C. Multiple myeloma
D. Lung cancer
E. Colorectal cancer
104.
=======================================================
Random Board Review Questions 81
=======================================================
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
105.
=======================================================
Random Board Review Questions 82
=======================================================
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)
=======================================================
Random Board Review Questions 83
=======================================================
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
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
107.
=======================================================
Random Board Review Questions 84
=======================================================
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
108.
=======================================================
Random Board Review Questions 85
=======================================================
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
109.
=======================================================
Random Board Review Questions 86
=======================================================
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
110.
=======================================================
Random Board Review Questions 87
=======================================================
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 1-week 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)
A. Formula intolerance
B. Meningitis
C. Viral gastroenteritis
D. Pyloric stenosis
E. Inappropriate feeding
111.
=======================================================
Random Board Review Questions 88
=======================================================
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)
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
112.
=======================================================
Random Board Review Questions 89
=======================================================
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)
=======================================================
Random Board Review Questions 90
=======================================================
The most common stress fracture in children involves which one of the
following bones? (check one)
A. Calcaneus
B. Tibia
C. Fibula
D. Tarsal navicular
E. Metatarsal
114.
=======================================================
Random Board Review Questions 91
=======================================================
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
115.
=======================================================
Random Board Review Questions 92
=======================================================
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)
A. Enalapril
B. Furosemide
C. Labetalol
D. Insulin
E. Heparin
116.
=======================================================
Random Board Review Questions 93
=======================================================
When draining a felon, which one of the following incisions is
recommended? (check one)
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
117.
118.
=======================================================
Reproductive (Female) Board Review Questions 01
=======================================================
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
=======================================================
Reproductive (Female) Board Review Questions 02
=======================================================
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
B. Pelvic abscess
C. Pelvic inflammatory disease
D. Ruptured ovarian cyst
119.
=======================================================
Reproductive (Female) Board Review Questions 03
=======================================================
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)
=======================================================
Reproductive (Female) Board Review Questions 04
=======================================================
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
121.
=======================================================
Reproductive (Female) Board Review Questions 05
=======================================================
The definition of post-term pregnancy is a pregnancy that has
reached: (check one)
A. 40 weeks' gestation
B. 41 weeks' gestation
C. 42 weeks' gestation
D. 43 weeks' gestation
122.
=======================================================
Reproductive (Female) Board Review Questions 06
=======================================================
A 22-year-old gravida 2 para 1 presents to your office with a 1day 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
B. Completed abortion
C. Threatened abortion
D. Incomplete abortion
E. Missed abortion
123.
=======================================================
Reproductive (Female) Board Review Questions 07
=======================================================
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
124.
=======================================================
Respiratory Board Review Questions 01
=======================================================
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
125.
=======================================================
Respiratory Board Review Questions 03
=======================================================
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)
=======================================================
Respiratory Board Review Questions 04
=======================================================
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
127.
=======================================================
Special Sensory Board Review Questions
=======================================================
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. Streptococcus pneumoniae
B. Pseudomonas aeruginosa
C. Corynebacterium ulcerans
D. Staphylococcus epidermidis
E. Escherichia coli
128.
A 2-week-old
female is brought
to the office for a
well child visit. The
physical
examination is
completely normal
except for a
clunking sensation
and feeling of
movement when
adducting the hip
and applying
posterior pressure.
Which one of the
following would
be the most
appropriate next
step? (check one)
A. Referral for
orthopedic
consultation
B. Reassurance
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
A. Referral for orthopedic consultation. Developmental dysplasia of the hip encompasses both subluxation and
dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females,
breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts
are divided 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.
129.
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. Intravenous vancomycin. This patient has systemic symptoms that suggest a severe
underlying infection. Community-acquired 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
131.
132.
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.
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.
134.
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).
136.
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
B. Necrotizing
enterocolitis
C. Hypertrophic
pyloric stenosis
D. Intussusception
E. Midgut volvulus
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 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 6-11 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 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.
137.
A. Reassurance
B. Foot stretching exercises
C. Use of orthotics
D. Use of night splints
E. Surgery
138.
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.
139.
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.
141.
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 selflimited 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.
144.
145.
146.
A. Acetaminophen overdose
B. Antiphospholipid syndrome with lupus anticoagulant
C. Munchausen syndrome by proxy
D. Henoch-Schnlein purpura
E. Traumatic injury (child abuse)
147.
148.
151.
A. Sub-Saharan Africa
B. Southeast Asia
C. The Middle East
D. Caribbean islands
E. Andean South America
152.
153.
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.
155.
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 vesiculoulcerative 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.
A. herpangina
B. hand, foot, and mouth disease
C. aphthous stomatitis
D. herpetic gingivostomatitis
E. streptococcal pharyngitis
156.
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.
157.
A. An electroencephalogram
B. Polysomnography
C. Atomoxetine
D. Methylphenidate (Ritalin)
159.
160.
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 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
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.
162.
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.
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.
164.
166.
168.
169.
170.
...
171.
173.
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.
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.
175.
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 Legg-Calv-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 false-negative
result.
177.
A. Metronidazole (Flagyl)
B. Ciprofloxacin (Cipro)
C. Azithromycin (Zithromax)
D. Mebendazole
E. Metoclopramide (Reglan)
179.
A. Azithromycin (Zithromax)
B. Ceftriaxone (Rocephin)
C. Amoxicillin/clavulanate (Augmentin)
D. Doxycycline
E. Clindamycin (Cleocin)
180.
...
181.
182.
183.
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.
184.
185.
186.
A 12-year-old female is brought to your office with an 8day 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 Creactive 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
188.
189.
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 high-risk 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.
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 communityacquired 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.
191.
A. Molluscum contagiosum
B. Human papillomavirus
C. Herpes gladiatorum
D. Tinea corporis
E. Mat burn
192.
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-Calv-Perthes disease are more common in younger
children.
194.
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.
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 4H project
195.
B. Oral corticosteroids. The treatment of choice for occasional acute symptoms of asthma is an inhaled 2adrenergic 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 2-selective agonists are less effective and
have a slower onset of action than the same drugs given by inhalation.
196.
197.
198.
199.
A 14-year-old African-American
female presents for a routine
evaluation. On examination, you
note a rubbery, well-defined,
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
200.
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.
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.
Cognitive-behavioral 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.
201.
203.
204.
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.
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.
205.
E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up. 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 community-acquired
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.
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.
207.
208.
210.
211.
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
C. Anterior cruciate ligament tear. 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 straightplane 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 sports-related 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 highriding 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 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.
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.
212.
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.
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.
214.
216.
217.
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 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. 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.
218.
219.
220.
221.
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
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. Closedcircuit 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
222.
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
223.
224.
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
infectious mononucleosis.
Appropriate management
includes which one of the
following? (check one)
225.
E. Avoidance of contact sports. Infectious mononucleosis presents most commonly with a sore throat,
fatigue, myalgias, and lymphadenopathy, and is most prevalent 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.
A. A corticosteroid
B. An antihistamine
C. An antiviral agent
D. Strict bed rest
E. Avoidance of contact
sports
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.
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.
A. Prediabetes
B. Type 1 diabetes mellitus
C. Type 2 diabetes mellitus
D. Maturity-onset diabetes
of the young
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.
226.
228.
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)
229.
230.
231.
232.
233.
234.
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.
236.
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.
239.
240.
242.
A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion
243.
A. Emergency contraception does not interfere with an established, postimplantation pregnancy. An FDA Advisory Committee has recommended over-thecounter 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.
244.
245.
246.
247.
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
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 5-25 ng/mL.
248.
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.
250.
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.
252.
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.
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.
254.
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.
255.
A 23-month-old child is brought to your office with a 2day 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
257.
A. Operative delivery
B. First pregnancy and delivery
C. Preeclampsia
D. A previous history of depression
258.
...
260.
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.
C. The fetus is AT RISK for hemolytic disease only if the biological father is Rh-positive. 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 antigen-positive 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.
262.
263.
A. A wood splinter
B. A glass splinter
C. A plastic splinter
D. A sea urchin spine
264.
265.
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
266.
A. Clonazepam (Klonopin)
B. Thioridazine
C. Chlorpromazine
D. Aripiprazole (Abilify)
E. Olanzapine (Zyprexa)
267.
268.
269.
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.
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.
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.
271.
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
antibiotic-associated 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).
273.
274.
275.
A. fibromyalgia syndrome
B. Sheehan's syndrome (postpartum
hypopituitarism)
C. polymyositis
D. myasthenia gravis
E. stroke
276.
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.
277.
A. Oseltamivir (Tamiflu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment
278.
A. Open reduction
B. Placement of a pin to prevent further
displacement
C. A short arm-thumb spica cast
D. An ulnar gutter splint
279.
280.
282.
A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder
284.
285.
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 firstline 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.
...
287.
A. A CBC
B. Urinalysis
C. Plain abdominal films
D. Abdominal/pelvic ultrasonography
E. Abdominal/pelvic CT
288.
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.
289.
290.
291.
292.
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.
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).
294.
A 25-year-old male who came to your office for a preemployment 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 16hour 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)
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.
296.
297.
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 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 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.
298.
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.
A. Pheochromocytoma
B. Panic attack
C. Hypochondriasis
D. Hypoglycemia
E. Hyperthyroidism
299.
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.
300.
301.
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.
302.
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 meta-analyses 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 cost-effectiveness 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.
304.
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.
306.
A. -Glutamyltransferase (GGT)
B. Bile acids
C. Direct bilirubin
D. Indirect bilirubin
E. Prothrombin time
307.
308.
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.
311.
...
312.
314.
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 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
316.
317.
318.
319.
320.
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. Insulin
B. Metformin (Glucophage)
C. Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen)
D. Glipizide (Glucotrol)
E. Spironolactone (Aldactone)
322.
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
323.
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.
324.
A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E. Cefixime (Suprax)
325.
326.
327.
328.
329.
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.
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
syndromethe 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).
331.
333.
334.
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
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.
335.
337.
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.
339.
340.
A. Bracing
B. Taping
C. NSAIDs
D. Arthroscopic surgery
E. Physical therapy
341.
342.
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, deep-vein 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 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.
344.
345.
346.
347.
A. a hypercoagulable state
B. a compressive anomaly in the thoracic outlet
C. use of injection drugs
D. Budd-Chiari syndrome
348.
349.
D. Levofloxacin (Levaquin). For previously healthy patients with communityacquired 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).
350.
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
351.
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.
352.
353.
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.
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.
354.
A. CT of the abdomen
B. MRI of the abdomen
C. Ultrasonography of the abdomen
D. A small bowel series
E. Intravenous pyelography
355.
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.
A. Visual loss
B. Hearing loss
C. Vertigo
D. A cerebrovascular accident
E. Cerebral herniation
356.
A. Amoxicillin
B. Azithromycin (Zithromax)
C. Cephalexin (Keflex)
D. Ciprofloxacin (Cipro)
E. Doxycycline
357.
358.
A. Biofeedback
B. Ma huang
C. Oxygen
D. Epley canalith respositioning maneuver
E. Phototherapy
359.
A. Radioactive iodine
B. Propylthiouracil
C. Methimazole (Tapazole)
D. Thyroid hormone replacement plus propylthiouracil
E. Thyroidectomy
360.
361.
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
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
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 non-breastfeeding 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 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 this
diagnosis include fatigue, constipation, menstrual irregularity, weight changes, and cold intolerance.
362.
363.
A. Risperidone (Risperdal)
B. Clorazepate (Tranxene)
C. Clonazepam (Klonopin)
D. Imipramine (Tofranil)
E. Fluoxetine (Prozac)
364.
365.
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.
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.
367.
A. Traumatic iritis
B. Corneal abrasion
C. Intraocular foreign body
D. Bacterial corneal ulcer
E. Retinal detachment
368.
369.
370.
372.
373.
C. Obtain a repeat chest radiograph in 24-48 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. Follow-up should include a chest radiograph to assess stability at 2448 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.
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).
374.
375.
A. Doxycycline
B. Trimethoprim/sulfamethoxazole (Bactrim,
Septra)
C. Clindamycin (Cleocin)
D. Ciprofloxacin (Cipro)
E. Cephalexin (Keflex)
376.
...
377.
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.
A. sinusitis
B. a brain tumor
C. muscle tension headache
D. cluster headache
E. migraine headache
378.
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.
379.
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
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.
380.
A. Nifedipine (Procardia)
B. Enalaprilat intravenously
C. Lorazepam (Ativan) intravenously
D. Metoprolol (Toprol) intravenously
E. Thrombolytic therapy
381.
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.
382.
383.
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.
A. Somatization disorder
B. Conversion disorder
C. Hypochondriasis
D. Malingering
384.
D. She should be offered testing because sexual transmission is possible. Key risk
factors for hepatitis C infection are long-term 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 coinfection 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.
385.
A 36-year-old female presents with a severalweek 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
386.
387.
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.
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.
388.
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.
391.
A. Pyogenic granuloma
B. Leishmaniasis
C. Atypical mycobacterial infection
D. Squamous cell carcinoma
E. Epidermal inclusion cysts
392.
A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)
393.
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.
394.
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 3045 minutes before bedtime
395.
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.
396.
397.
398.
399.
A. Hepatitis C
B. Wilson's disease
C. Sickle cell anemia
D. Gilbert's syndrome
E. Drug toxicity
400.
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
401.
402.
A. oral trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. oral nitrofurantoin (Macrodantin)
C. oral levofloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceftriaxone (Rocephin)
403.
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
404.
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 live-culture yogurt have thus far not been
established as useful. Daily use of peppermint oil has been shown to relieve
symptoms.
405.
406.
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 2-hour
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 2hour glucose level on an oral glucose tolerance test.
A 40-year-old female comes to your office with a 1month 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.
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.
A. Taping/strapping
B. Over-the-counter heel inserts
C. Extracorporeal shock wave therapy
D. A corticosteroid injection
E. A fiberglass walking cast
407.
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.
A. Bleeding time
B. Prothrombin time (PT)
C. Activated partial thromboplastin
time (aPTT)
D. Bleeding history
408.
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.
410.
A. Gallstone pancreatitis
B. Pancreatic necrosis
C. Pancreatic pseudocyst
D. Hepatitis C
E. Alcohol-induced pancreatitis
412.
413.
414.
A. Methylphenidate (Ritalin)
B. Zolpidem (Ambien) at bedtime
C. Carbidopa/levodopa (Sinemet)
D. Weight reduction
E. Avoidance of daytime napping
415.
416.
A. premenstrual syndrome
B. dysthymia
C. dementia
D. menopause
E. anorexia nervosa
417.
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.
419.
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
420.
421.
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).
424.
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.
A. No further testing
B. A chest radiograph
C. An antinuclear antibody test
D. Echocardiography
E. Pulmonary angiography
425.
426.
A. dermatitis
B. diarrhea
C. edema
D. hirsutism
E. nausea
428.
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.
429.
430.
431.
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
432.
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.
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 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.
433.
435.
436.
438.
439.
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.
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.
441.
442.
443.
444.
445.
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.
446.
A. Stevens-Johnson syndrome
B. Prolonged QT interval
C. Seizures
D. Diarrhea
E. Hypoglycemia
447.
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).
449.
450.
451.
452.
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.
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.
454.
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.
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.
456.
458.
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
459.
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.
460.
A 46-year-old female presents to your office for followup 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
462.
A. thyroid disease
B. gastroesophageal reflux disease
C. sinusitis
D. tracheal stenosis
463.
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.
464.
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 first-line 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.
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.
466.
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.
A. Every 5 years
B. Every 3 years
C. Every 2 years
D. Annually
E. Routine screening is not
necessary
467.
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.
468.
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.
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
469.
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.
470.
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 anti-factor 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.
A. Anti-factor Xa levels
B. Activated partial thromboplastin time (aPTT)
C. Daily INRs
D. Daily factor VIII levels
471.
472.
A. Buspirone (BuSpar)
B. Nortriptyline (Aventyl)
C. Escitalopram (Lexapro)
D. Venlafaxine (Effexor)
E. Paroxetine (Paxil)
473.
A. Propranolol (Inderal)
B. Nifedipine (Procardia)
C. Ergotamine/caffeine (Cafergot)
D. Methysergide (Sansert)
474.
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.
475.
A. Referral to an ophthalmologist
B. A methylprednisolone (Medrol) dose pack
C. A topical corticosteroid
D. Topical mupirocin (Bactroban)
E. Topical metronidazole (MetroGel)
476.
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 longterm 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.
478.
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.
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.
480.
A. Staphylococcus
B. Clostridium botulinum
C. Clostridium perfringens
D. Clostridium difficile
E. Actinomycosis
481.
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.
483.
484.
A. Aspirin
B. Prednisone
C. Heparin
D. Enoxaparin (Lovenox)
485.
486.
A. Fluoxetine (Prozac)
B. Amlodipine (Norvasc)
C. Imipramine
D. Bupropion (Wellbutrin)
E. Cognitive therapy
487.
C. An excisional biopsy of the mass. In the ideal setting, the accuracy of fineneedle 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.
489.
491.
492.
494.
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.
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.
495.
496.
A. Hyperplastic polyp
B. Hamartomatous polyp
C. Tubular adenoma
D. Villous adenoma
E. Tubulovillous adenoma
497.
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.
A. 2000 mg
B. 3000 mg
C. 4000 mg
D. 5000 mg
E. 6000 mg
498.
499.
500.
501.
502.
503.
504.
505.
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.
508.
A 54-year-old male comes to your office with a 2day 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 over-thecounter 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). 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 firstline treatment for acute attacks. Compression as an adjunctive therapy may
help control pain and swelling.
A. Allopurinol (Zyloprim)
B. Colchicine (Colcrys)
C. Elastic compression bandages
D. Indomethacin
E. Prednisone
509.
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.
511.
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
512.
513.
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.
514.
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.
516.
A. Hydrochlorothiazide
B. Losartan (Cozaar)
C. Metoprolol (Lopressor)
D. Simvastatin (Zocor)
E. Acetaminophen
517.
A. Metformin (Glucophage)
B. Exenatide (Byetta)
C. Acarbose (Precose)
D. Insulin glargine (Lantus)
E. Pioglitazone (Actos)
518.
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 methicillin-resistant Staphylococcus. A patient who
does not have a prosthetic valve should be started on vancomycin and
gentamicin, with monitoring of serum levels. Enterococcus and methicillinresistant 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.
519.
A. 48%
B. 65%
C. 76%
D. 84%
E. 92%
520.
521.
522.
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.
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.
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.
524.
525.
526.
527.
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
attackmost 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.
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
528.
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.
529.
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. 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.
A. Sesamoid fracture
B. Gout
C. Morton's neuroma
D. Cellulitis
531.
532.
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.
534.
535.
A. LDL cholesterol
B. HDL cholesterol
C. non-HDL cholesterol
D. triglycerides
E. fasting blood glucose
536.
537.
E. tarsal tunnel syndrome. Entrapment of the posterior tibial nerve or its branches as the
nerve courses behind the medial malleolus results in a neuritis known as tarsal tunnel
syndrome. Causes of compression within the tarsal tunnel include varices of the posterior
tibial vein, tenosynovitis of the flexor tendon, structural alteration of the tunnel secondary to
trauma, and direct compression of the nerve. Pronation of the foot causes pain and
paresthesias in the medial aspect of the ankle and heel, and sometimes the plantar surface
of the foot. The usual site for a stress fracture is the shaft of the second, third, or fourth
metatarsals. A herniated nucleus pulposus would produce reflex and sensory changes.
Plantar fasciitis is the most common cause of heel pain in runners and often presents with
pain at the beginning of the workout. The pain decreases during running only to recur
afterward. Diabetic neuropathy is usually bilateral and often produces paresthesias and
burning at night, with absent or decreased deep tendon reflexes.
A. a stress fracture
B. a herniated nucleus pulposus at L5
or S1
C. plantar fasciitis
D. diabetic neuropathy
E. tarsal tunnel syndrome
538.
539.
540.
541.
542.
543.
A. CT of the abdomen and pelvis. Based on the history and physical examination,
this patient most likely has acute diverticulitis. CT has a very high sensitivity and
specificity for this diagnosis, provides information on the extent and stage of the
disease, and may suggest other diagnoses. Ultrasonography may be helpful in
suggesting other diagnoses, but it is not as specific or as sensitive for diverticulitis
as CT.
Limited-contrast studies of the distal colon and rectum may occasionally be useful
in distinguishing between diverticulitis and carcinoma, but would not be the
initial procedure of choice. Water-soluble contrast material is used in this situation
instead of barium. Colonoscopy to detect other diseases, such as cancer or
inflammatory bowel disease, is deferred until the acute process has resolved,
usually for 6 weeks. The risk of perforation or exacerbation of the disease is
greater if colonoscopy is performed acutely. Diagnostic laparoscopy is rarely
needed in this situation. Laparoscopic or open surgery to drain an abscess or
resect diseased tissue is reserved for patients who do not respond to medical
therapy. Elective sigmoid resection may be considered after recovery in cases of
recurrent episodes.
545.
A 57-year-old African-American
female has a partial resection of
the colon for cancer. The
surgical specimen has clean
margins, and there is no lymph
node involvement. There is no
evidence of metastasis. You
recommend periodic
colonoscopy for surveillance,
and also plan to monitor which
one of the following tumor
markers for recurrence? (check
one)
A. Prostate-specific antigen
(PSA)
B. Cancer antigen 27.29 (CA 2729)
C. Cancer antigen 125 (CA-125)
D. Carcinoembryonic antigen
(CEA)
E. Alpha-fetoprotein
546.
A. Primary hyperparathyroidism. This woman most likely has primary hyperparathyroidism due
to a parathyroid adenoma or hyperplasia. Secondary hyperparathyroidism is unlikely with
normal renal function, a normal vitamin D level, and hypercalcemia. Likewise, tertiary
hyperparathyroidism is unlikely with normal renal function. The parathyroid hormone level is
suppressed with hypercalcemia associated with bone metastases. Parathyroid hormone-related
protein, produced by cancer cells in humoral hypercalcemia of malignancy, is not detected by the
assay for parathyroid hormone.
547.
549.
550.
C. Simvastatin (Zocor). Peripheral arterial disease (PAD) is a common malady that has
several proven treatments. The outcomes of these treatments can be separated into two
primary categories: reducing PAD symptoms and preventing death due to systemic
cardiovascular events (CVEs), especially myocardial infarction. Routine exercise up to nearmaximal pain on a regular basis has been shown to be one of the most effective
treatments for symptoms of PAD. Smoking cessation and aspirin are also standard
recommendations, and can both prevent CVEs and slow the rate of progression of PAD
symptoms.
Statin drugs (specifically simvastatin and atorvastatin) have been shown to be beneficial
for treatment of PAD symptoms and prevention of CVEs through the reduction of
cholesterol, but they also appear to have other properties that help reduce leg pain in
patients with PAD. Although lowering abnormally high blood pressure is recommended in
PAD patients, only ACE inhibitors have been shown to reduce symptoms of PAD directly.
Furthermore, the combination of atenolol and nifedipine has actually been shown to
worsen symptoms of PAD. The addition of warfarin to aspirin has no additional benefit in
either reduction of PAD symptoms or prevention of CVEs, but it may have a role in
preventing clots in patients who have undergone revascularization.
A. CT angiography would reliably either confirm or rule out PE. This patient has a high
clinical probability for pulmonary embolism (PE). About 40% of patients with PE will have
positive findings for deep-vein thrombosis in the lower extremities on compression
ultrasonography. A normal ventilation-perfusion lung scan rules out PE, but inconclusive
findings are frequent and are not reassuring. A normal D-dimer level reliably rules out the
diagnosis of venous thromboembolism in patients at low or moderate risk of pulmonary
embolism, but the negative predictive value of this test is low for high-probability patients.
A positive D-dimer test does not confirm the diagnosis; it indicates the need for further
testing, and is thus not necessary for this patient. A multidetector CT angiogram or
ventilation-perfusion lung scan should be the next test, as these are reliable to confirm or
rule out PE.
551.
552.
554.
555.
D. 10 years. The evidence supports a 10-year interval for colonoscopy in patients less
than 80 years old. For patients with a family history of colon cancer a 5-year interval is
recommended, or 3 years if benign polyps are found. Screening in patients over 80
years old is controversial. References: 1) Kasper DL, Braunwald E, Fauci AS, et al (eds):
Harrisons Principles of Internal Medicine, ed 16. McGraw-Hill, 2005, pp 1737-1738. 2)
Singh H, Turne D, Xue L, et al: Risk of developing colorectal cancer following a negative
colonoscopy examination: Evidence for a 10-year interval between colonoscopies. JAMA
2006;295(20):2366-2373.
C. An MRI scan. Although leukocyte scans are sensitive for the diagnosis of foot ulcers,
MRI is now considered the imaging study of choice when osteomyelitis is suspected; the
sensitivity and specificity of MRI in diabetic patients are 90% or greater.
A. Angiography
B. A CT scan
C. An MRI scan
D. A PET scan
E. A leukocyte scan
556.
A. free testosterone
B. total testosterone
C. sex hormone-binding globulin
D. LH
E. FSH
557.
558.
B. Spironolactone (Aldactone). In patients with grade 2 ascites (visible clinically by abdominal distention,
not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction.
Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide
(SOR A). Chlorthalidone, a thiazide diuretic, is not recommended. Large-volume paracentesis is the
recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is
followed by salt restriction and diuretics.
A 59-year-old white
female has a blood
pressure consistently at
or above 140/90 mm Hg.
Her only other
significant medical
problem is diabetes
mellitus, which is
controlled by diet.
Which one of the
following is the most
clearly established
advantage of
angiotensin receptor
blockers (ARBs) when
compared with ACE
inhibitors in patients
such as this? (check
one)
A. Reduced risk of
persistent cough
B. Reduced risk of
headache
C. Reduced risk of heart
failure
D. Improved control of
blood pressure
E. Improved lipid
profile
A. Reduced risk of persistent cough. In multiple studies, angiotensin receptor blockers (ARBs) have been
shown to be less likely to cause a chronic cough when compared with ACE inhibitors. Although this is not a
life-threatening danger, it is a side effect that can be persistent and lead to discontinuation of medication.
Angioedema, a more dangerous side effect, was thought to be ACE-inhibitor specific. However, it is rare
and there is not yet good evidence that ARBs are safer. There have been case reports of angioedema
associated with ARB use. The incidence of headache is similar for the two drug classes. ARBs have not been
proven superior to ACE inhibitors in blood pressure control, effects on lipid profiles, or prevention of heart
failure, and there is substantially more data on ACE inhibitors for the prevention of heart failure and
proteinuria.
560.
A. Propranolol (Inderal)
B. Verapamil (Calan, Isoptin)
C. Clonidine (Catapres)
D. Hydrochlorothiazide/triamterene
(Dyazide)
E. Enalapril (Vasotec)
561.
A. Serum electrolytes
B. A serum creatinine level
C. A CBC
D. A lipid panel
E. A thyroid panel
563.
A. <100 mg/dL. Most physicians realize that the goal LDL level for patients with
diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize
that this goal extends to people with CAD-equivalent diseases, including
peripheral artery disease, symptomatic carotid artery disease, and abdominal
aortic aneurysm.
564.
565.
567.
570.
D. Aspirin, 162-325 mg/day, plus clopidogrel, both for 12 months. In patients with a
drug-eluting stent, combined therapy with clopidrogel and aspirin is recommended
for 12 months because of the increased risk of late stent thrombosis. After this time,
aspirin at a dosage of 75-165 mg/day is recommended. The minimum duration of
combined therapy is 1 month for a bare metal stent, 3 months for a sirolimus-eluting
stent, and 6 months for other drug-eluting stents.
573.
576.
578.
A. Monitoring oxygenation status with pulse oximetry. Maintaining adequate tissue oxygenation
is an important component of the emergency management of stroke. Hypoxia leads to
anaerobic metabolism and depletion of energy stores, increasing brain injury. While there is no
reason to routinely administer supplemental oxygen, the potential need for oxygen should be
assessed using pulse oximetry or blood gas measurement. Overzealous use of antihypertensive
drugs is contraindicated, since this can further reduce cerebral perfusion. In general, these
drugs should not be used unless mean blood pressure is >130 mm Hg or systolic blood pressure
is >220 mm Hg. Antithrombotic drugs such as heparin must be used with caution, and only after
intracerebral hemorrhage has been ruled out by baseline CT followed by repeat CT within 4872 hours. Hypovolemia can exacerbate cerebral hypoperfusion, so there is no need to restrict
fluid intake. Optimization of cardiac output is a high priority in the immediate hours after a
stroke. Based on data from randomized clinical trials, corticosteroids are not recommended for
the management of cerebral edema and increased intracranial pressure after a stroke.
580.
A. Pelvic ultrasonography
B. An exercise stress test
C. Psychiatric consultation
D. Gastric emptying scintigraphy
E. Colonoscopy
581.
A. Primary hyperparathyroidism
B. Malignancy
C. Familial hypocalciuric hypercalcemia
D. Hypoparathyroidism
E. Hyperthyroidism
582.
583.
584.
B. Elevated methylmalonic acid. This patient has several clinical features of vitamin B12 deficiency. Some
patients with significant vitamin B12 deficiency have levels in the lower range of normal, as this patient
does. Vitamin B12 is a cofactor in the synthesis of both methionine and succinyl coenzyme A, and
vitamin B12 deficiency leads to the accumulation of methylmalonic acid and homocysteine, which are
the precursors of these compounds. An elevated level of these substances is therefore more sensitive
than a low vitamin B12 level for vitamin B12 deficiency. Homocysteine is also elevated in folic acid
deficiency, however, so a methylmalonic acid level is recommended if vitamin B12 deficiency is a
concern and serum vitamin B12 levels are 150-400 pg/mL. A reduced haptoglobin level is useful to
confirm hemolytic anemia. An elevated free erythrocyte protoporphyrin level may occur in lead
poisoning or iron deficiency. An elevated angiotensin converting enzyme level is found in sarcoidosis.
A. Elevated angiotensin
converting enzyme
B. Elevated methylmalonic
acid
C. Elevated free
erythrocyte
protoporphyrin
D. Low haptoglobin
E. Low homocysteine
585.
B. Decreased vitamin B12 absorption. Although proton pump inhibitors are the most effective
treatment for patients with asymptomatic gastroesophageal reflux disease, there are several potential
problems with prolonged therapy. Omeprazole is associated with an increased risk of communityacquired pneumonia and Clostridium difficile colitis. Omeprazole has also been shown to acutely
decrease the absorption of vitamin B 12 , and it decreases calcium absorption, leading to an increased
risk of hip fracture. The risk for Clostridium difficile colitis is also increased.
586.
B. Twice-daily use of ibuprofen for 2 weeks. Acute interstitial nephritis (AIN) is often druginduced. Discontinuation of medications that are likely to cause AIN is the most important
first step in management. If these medications are withdrawn early, most patients can be
expected to recover normal renal function. Of the medications listed, ibuprofen is the most
likely offending agent, because all NSAIDs are known to be associated with AIN.
Development of AIN usually becomes evident approximately 2 weeks after starting a
medication and is not dose-related. Other medications strongly associated with AIN include
various antibiotics (particularly cephalosporins, penicillins, sulfonamides, aminoglycosides,
and rifampin), diuretics, and miscellaneous medications such as allopurinol.
588.
590.
A 62-year-old white
male complains of
fatigue and proximal
extremity discomfort
without any localized
joint pain. Which one
of the following
conditions is
associated with a
consistently normal
creatine kinase
enzyme level at all
phases of disease?
(check one)
A. Polymyalgia
rheumatica
B. Polymyositis
C. Dermatomyositis
D. Drug-induced
myopathy
E. Hypothyroid
endocrinopathy
A. Polymyalgia rheumatica. Polymyalgia rheumatica is a disease of the middle-aged and elderly. Discomfort is
common in the neck, shoulders, and hip girdle areas. There is an absence of objective joint swelling, and
findings tend to be symmetric. Characteristically, the erythrocyte sedimentation rate and C-reactive protein
levels are significantly elevated; however, these tests are nonspecific. Occasionally there are mild elevations of
liver enzymes, but muscle enzymes, including creatine kinase, are not elevated in this disorder. Elevation of
muscle enzymes strongly suggests another diagnosis. Polymyositis and dermatomyositis are associated with
variable levels of muscle enzyme elevations during the active phases of the disease. Drug-induced
myopathies such as those seen with the cholesterol-lowering statin medications tend to produce some
elevation of muscle enzymes during the course of the disorder. Hypothyroidism is associated with creatine
kinase elevation. It should be strongly considered in the patient with unexplained, otherwise asymptomatic
creatine kinase elevation found on a routine chemistry profile. Hyperthyroidism may cause muscle disease
and loss of muscle, but it is not associated with creatine kinase elevation.
591.
592.
A. Pseudomonas
B. Streptococcus
C. Clostridium
D. Escherichia coli
E. Adenovirus
593.
D. now and a repeat dose once at age 68. Both the CDC and the
American Academy of Family Physicians recommend that all adults
over the age of 65 receive a single dose of pneumococcal
polysaccharide vaccine. Immunization before the age of 65 is
recommended for certain subgroups of adults, including
institutionalized individuals over the age of 50; those with chronic
cardiac or pulmonary disease, diabetes mellitus, anatomic asplenia,
chronic liver disease, or kidney failure; and health-care workers. It is
recommended that those receiving the vaccine before the age of 65
receive an additional dose at age 65 or 5 years after the first dose,
whichever is later.
594.
596.
597.
A. amoxicillin
B. amoxicillin/clavulanate
(Augmentin)
C. ciprofloxacin (Cipro)
D. doxycycline
E. azithromycin (Zithromax)
598.
E. No limitations on other intake. Patients with diverticulosis should increase dietary fiber
intake or take fiber supplements to reduce progression of the diverticular disease.
Avoidance of nuts, corn, popcorn, and small seeds has not been shown to prevent
complications of diverticular disease.
600.
602.
603.
604.
A. Foley catheterization
B. Hospitalization for intravenous antibiotics
C. Digital disimpaction of the rectum, and Fleet enemas
until clear
D. MRI of the lumbosacral spine
605.
C. Melanosis coli. This patient has typical findings of melanosis coli, the
term used to describe black or brown discoloration of the mucosa of the
colon. It results from the presence of dark pigment in large mononuclear
cells or macrophages in the lamina propria of the mucosa. The coloration
is usually most intense just inside the anal sphincter and is lighter higher
up in the sigmoid colon. The condition is thought to result from fecal
stasis and the use of anthracene cathartics such as cascara sagrada,
senna, and danthron. Ectopic endometrial tissue (endometriosis) most
commonly involves the serosal layer of those parts of the bowel adjacent
to the uterus and fallopian tubes, particularly the rectosigmoid colon.
Collagenous colitis does not cause mucosal pigmentary changes.
Melanoma rarely metastasizes multicentrically to the bowel wall. Multiple
arteriovenous malformations are more common in the proximal bowel,
and would not appear as described.
606.
607.
A. Multiple myeloma
B. Waldenstrm's macroglobulinemia
C. Sarcoidosis
D. Monoclonal gammopathy of undetermined
significance
E. Non-Hodgkin's lymphoma
608.
609.
611.
612.
A. Alzheimer's disease
B. Dementia with Lewy bodies
C. Fronto-temporal dementia
D. Multi-infarct dementia
E. Pseudodementia
613.
615.
A. Chlamydia
B. Mycoplasma
C. Legionella
D. Haemophilus influenzae
E. Pseudomonas
616.
617.
C. Ask the patient if he would like to talk again at another time. When giving bad news to
a patient, it is important to assess how much information the patient wants to know and
tailor the discussion accordingly (SOR C). If the patient states that he does not want to
know about the prognosis, the most appropriate response is to ask if he would like to
talk again at another time. The physician may be regarded as rude, cruel, or uncaring if
he persists in providing information that the patient is not ready to hear. In addition, the
patient is more at risk for feelings of hopelessness, depression, or anxiety if he is not
psychologically ready to hear a bad prognosis. Once the patient verbalizes a readiness
to discuss the prognosis, specific information can be provided, focusing on both the
positive and negative aspects of the situation. It is not appropriate to discuss the case
with the patient's wife, unless he specifically requests she be a proxy to receive the
information. Referrals to either a support group or an oncologist should be deferred
until the information has been discussed with the patient.
619.
A 67-year-old white female has a DXA scan with a resulting Tscore of -2.7. She has a strong family history of breast cancer.
Which one of the following would be the most appropriate
treatment for this patient? (check one)
A. A bisphosphonate
B. Raloxifene (Evista)
C. Calcitonin nasal spray (Miacalcin)
D. Teriparatide (Forteo)
E. Conjugated estrogens (Premarin)
620.
A. Glipizide (Glucotrol)
B. Metformin (Glucophage)
C. Glyburide (DiaBeta)
D. Acarbose (Precose)
621.
622.
C. Cortisol. It has been recognized that patients suffering from a critical illness with an
exaggerated inflammatory response often have a relative cortisol deficiency. Clinically,
this can cause hypotension that is resistant to intravenous fluid resuscitation, and
evidence is mounting that survival is increased if these patients are treated with
intravenous corticosteroids during acute management. Cortisol levels can be assessed
with a single serum reading, or by the change in the cortisol level after stimulation with
cosyntropin (referred to as cortisol). The other hormones listed are not important for
the acute management of a critically ill patient.
625.
626.
628.
629.
631.
B. Oral terbinafine (Lamisil) daily for 12 weeks. Continuous therapy with oral
terbinafine for 12 weeks has the highest cure rate and best long-term
resolution rate of the therapies listed. Other agents and pulsed dosing
regimens have lower cure rates. Topical creams are not appropriate for
onychomycosis because the infection resides in the cell of the toenail.
Antifungal nail lacquers have a lower cure rate than systemic therapy and
should be used only when oral agents would not be safe. Toenail removal is
reserved for patients with an isolated infected nail or in cases involving a
dermatophytoma.
632.
A 69-year-old male has a 4-day history of swelling in his left leg. He has no
history of trauma, recent surgery, prolonged immobilization, weight
loss, or malaise. His examination is unremarkable except for a diffusely
swollen left leg. A CBC, chemistry profile, prostate-specific antigen level,
chest radiograph, and EKG are all normal; however, compression
ultrasonography of the extremity reveals a clot in the proximal femoral
vein. He has no past history of venous thromboembolic disease. In
addition to initiating therapy with low molecular weight heparin, the
American College of Chest Physicians recommends that warfarin
(Coumadin) be instituted now and continued for at least (check one)
A. 1 month
B. 3 months
C. 6 months
D. 12 months
633.
634.
635.
A. viral gastroenteritis
B. Clostridium difficile colitis
C. ulcerative colitis
D. gluten-sensitive enteropathy (celiac sprue)
E. digoxin toxicity
636.
637.
638.
640.
E. Make no change to her regimen. Even though the patient's DEXA has improved and
she is technically osteopenic, she still has risk factors for osteoporosis, including recent
smoking, low BMI, and a prior fragility fracture. She should continue her current
regimen.
642.
A. Lumbar spine extension. Extension that increases lumbar lordosis decreases the
cross-sectional area of the spinal canal, thereby compressing the spinal cord further.
Walking downhill can cause this. Spinal flexion that decreases lordosis has the opposite
effect, and will usually improve the pain, as will sitting.
Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the
groin. Pain in the lateral hip is more typical of trochanteric bursitis. Increased pain
walking uphill is more typical of vascular claudication.
B. inhaled fluticasone (Flovent), 2 puffs twice daily. This patient is suffering from severe
COPD (stage III) and has a history of frequent exacerbations. The addition of a
corticosteroid inhaler for patients with severe disease has been found to significantly
decrease the number of exacerbations, but has no effect on overall mortality. Side
effects of oral candidiasis and easy bruising of the skin are increased. Continuous
oxygen has been shown to improve overall mortality and endurance in patients with
an oxygen saturation of 88% or less, but has not been shown to improve quality of life
in those with mild hypoxemia or if used only at night. Oral prednisone has been shown
to be effective when used to treat acute exacerbations, but when used on a chronic
basis it is no more effective than corticosteroid inhalers. Chronic oral prednisone is also
associated with significant side effects, and therefore is not generally recommended.
Oral theophylline has not been shown to be of benefit in either preventing
exacerbations or improving quality of life, and has significant side effects of
gastrointestinal toxicity, seizures, and arrhythmias. It should be reserved for carefully
selected patients only.
643.
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)
644.
D. hip fracture. Women older than 65 years of age who have low serum TSH levels,
indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral
fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels
are normal.
646.
647.
649.
C. 5.5 cm. Based on recent clinical trials, the most common recommendation for surgical
repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the
Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and
the United Kingdom Small Aneurysm Trial, failed to show any benefit from early
surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm
rupture were 1% or less in both studies, with 6-year cumulative survivals of 74% and
64%, respectively. Interestingly, the risk for aneurysm rupture was four times greater in
women, indicating that 5.5 cm may be too high, but a new evidence-based threshold
has not yet been defined.
650.
...
651.
C. One long-acting niacin tablet per day. Hepatotoxicity resulting from timed-release
formulations of niacin has been reported in elderly individuals. Patients may be taking
this supplement without their physician's knowledge, feeling it is safe because it is a
vitamin. Aspirin and vitamin C can result in gastrointestinal iron loss and anemia. The
other medications listed, if used in moderation, would not be expected to alter
laboratory findings.
652.
654.
656.
657.
A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
658.
E. Having a bedsitter or family member stay in the room to reassure and orient the
patient. Delirium is a frequent complication of hospital admission in older patients,
especially those with preexisting dementia. Orientation and reassurance in a quiet
environment will usually be effective in treating the confusion and agitation, once
serious causes of the delirium have been ruled out. Benzodiazepines and
meperidol have been reported to cause delirium. Physical restraints and
restrictive environments (e.g., intensive-care units) can predispose to delirium and
are best avoided if possible.
660.
661.
A 72-year-old male
presents to your clinic
in atrial fibrillation
with a rate of 132
beats/min. He has
hypertension, but no
history of congestive
heart failure or
structural heart
disease. He is otherwise
healthy and active. The
best INITIAL approach
to his atrial fibrillation
would be: (check one)
A. Rhythm control with
antiarrythmics and
warfarin (Coumadin)
only if he cannot be
consistently
maintained in sinus
rhythm
B. Rhythm control with
antiarrythmics and
warfarin regardless of
maintenance of sinus
rhythm
C. Ventricular rate
control with digoxin,
and warfarin for
anticoagulation
D. Ventricular rate
control with digoxin,
and aspirin for
anticoagulation
E. Ventricular rate
control with a calcium
channel blocker or
beta-blocker, and
warfarin for
anticoagulation
E. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation.
Five recent randomized, controlled trials have indicated that in most patients with atrial fibrillation, an initial
approach of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT
have a morbidity or mortality benefit and were more likely to suffer from adverse drug effects and
increased hospitalizations. The most efficacious drugs for rate control are calcium channel blockers and
beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for
those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left
ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for
stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. Of note, in
patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate
is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who
choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are
consistently in sinus rhythm.
662.
A 72-year-old
male presents to
your clinic in
atrial fibrillation
with a rate of 132
beats/min. He has
hypertension, but
no history of
heart failure or
structural heart
disease. He is
otherwise healthy
and active.
The best INITIAL
approach to his
atrial fibrillation
would be:
(check one)
A. rhythm control
with
antiarrythmics
and warfarin
(Coumadin) only
if he cannot be
consistently
maintained in
sinus rhythm
B. rhythm control
with
antiarrythmics
and warfarin
regardless of
maintenance of
sinus rhythm
C. ventricular rate
control with
digoxin, and
warfarin for
anticoagulation
D. ventricular
rate control with
digoxin, and
aspirin for
anticoagulation
E. ventricular rate
control with a
calcium channel
blocker or blocker, and
warfarin for
anticoagulation
E. ventricular rate control with a calcium channel blocker or -blocker, and warfarin for anticoagulation.
Randomized, controlled trials have indicated that in most patients with atrial fibrillation, rate control is the best
initial management. Patients who were stratified to the rhythm control arm of these trials did not have lower
morbidity or mortality and were more likely to suffer from adverse drug effects and increased hospitalizations.
The most efficacious drugs for rate control are calcium channel blockers and -blockers. Digoxin is less effective
for rate control and its role should be limited to a possible additional drug for those not controlled with a blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients
65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent
thromboembolic disease is warfarin. If rhythm control is successful and sinus rhythm is maintained, the
thromboembolic rate is equivalent to that seen with a rate control strategy. Thus, the data suggests that patients
managed with a rhythm control strategy should be maintained on anticoagulation regardless of whether they
are consistently in sinus rhythm.
663.
A. Order a CBC, chemistry panel, stool for occult blood, and TSH. There should be a rational
approach to evaluating weight loss in an elderly patient. The workup should be directed by
findings in the history and physical examination, with special emphasis given to neurologic and
psychosocial aspects. Unless the history or physical examination point in a specific direction,
standard tests should be performed first, including a CBC, chemistry panel, stool for occult blood,
and TSH level. Although the etiology of unintentional weight loss in the elderly is malignancy in 16%36% of such cases, specific tests are not indicated before CT. Medications, including SSRIs, NSAIDs,
bupropion, digoxin, and metformin can cause weight loss; however, tricyclics often lead to weight
gain. Mirtazapine has been shown to increase appetite and promote weight gain. Megestrol has
been used successfully to treat cachexia in patients with AIDS or cancer. When given in a dosage of
at least 320 mg/day, megestrol has produced weight gain, but side effects of edema, constipation,
and delirium may limit its usefulness. Lower dosages may be effective for stimulating weight gain in
frail elderly patients, although this approach needs to be tested in randomized, controlled trials. In
the patient described, a workup seeking the etiology of the weight loss should begin promptly.
E. Lisinopril (Prinivil, Zestril). ACE inhibitors such as lisinopril are indicated for all patients with heart
failure due to systolic dysfunction, regardless of severity. ACE inhibitors have been shown to
reduce both morbidity and mortality, in both asymptomatic and symptomatic patients, in
randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used in
all heart failure patients. No ACE inhibitor has been shown to be superior to another, and no study
has failed to show benefit from an ACE inhibitor (SOR A).
Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE
inhibitors have been shown to be superior in randomized, controlled trials (SOR B). -Blockers are
also recommended in heart failure patients with systolic dysfunction (SOR A), except those who
have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to
reduce mortality from heart failure.
A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients.
Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic
heart failure. In addition, they can be used in patients with a recent myocardial infarction who
develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin
currently is recommended for patients with heart failure and atrial fibrillation, and can be
considered in patients who continue to have symptoms despite maximal therapy with other agents.
665.
A. Atenolol (Tenormin)
B. Verapamil (Calan, Isoptin)
C. Digoxin
D. Transdermal nitroglycerin
E. Intravenous nitroglycerin
666.
A. N-acetylcysteine. Current methods for reducing the risk of renal failure induced by
contrast material include adequate hydration and the use of N-acetylcysteine. Neither
mannitol nor furosemide has been shown to prevent contrast-induced renal failure.
Corticosteroids and antihistamines are useful for the prevention of idiosyncratic
reactions to contrast, but are not helpful in reducing the risk of renal failure.
667.
D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause
fluid retention. If possible, NSAIDs should be avoided in patients with heart failure. They cause
sodium and water retention, as well as an increase in systemic vascular resistance which may lead to
cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of
hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular
function have not been associated with initial episodes of heart failure. NSAIDs, including high-dose
aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE
inhibition. They have been shown to have a negative impact on the long-term morbidity and
mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less
likely to cause these negative effects.
D. Systemic corticosteroids and antibiotics. Acute exacerbations of COPD are very common, with most
caused by superimposed infections. Supplemental oxygen, antibiotics, and bronchodilators are used
for management. Systemic corticosteroids, either oral or parenteral, have been shown to significantly
reduce treatment failures and improve lung function and dyspnea over the first 72 hours, although
there is an increased risk of adverse drug reactions.
669.
A. systolic dysfunction
B. diastolic dysfunction
C. hypertrophic cardiomyopathy
D. high-output failure
670.
672.
673.
674.
675.
A. Low-dose dopamine
B. Recombinant human activated protein C (Xigris)
C. Antithrombin
D. Bicarbonate
E. Erythropoietin
676.
A. CT of the brain
B. MRI of the brain
C. A positive response to levodopa
D. Confirming that the tremor occurs with movement
E. Confirming that the tremor had a symmetric onset
677.
678.
679.
680.
681.
682.
683.
684.
A. Clopidogrel (Plavix)
B. High-dose corticosteroids
C. NSAIDs
E. Dipyridamole/aspirin (Aggrenox)
685.
686.
687.
688.
689.
E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present
without symptoms. With dissecting aneurysms, however, the presenting symptom depends on
the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in
branch vessel compression or embolization of peripheral arteries from a thrombus within the
aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic
results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta
may present with acute heart failure brought about by aortic regurgitation from aortic root
dilatation and distortion of the annulus. Other presenting findings may include hoarseness,
myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea,
dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in
their sixties and seventies with the same risk factors as those for coronary artery disease,
particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of
the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful
when dissection is suspected. CT with intravenous contrast is very accurate for showing the size,
extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred
method for evaluation and is best for evaluation of branch vessel pathology. MR angiography
provides noninvasive multiplanar image reconstruction, but does have limited availability and
lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is
a surgical emergency, but dissections confined to the descending aorta are managed medically
unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal
space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg
or to the lowest level tolerated. The use of a -blocker such as propranolol or labetalol to get the
heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains
over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade,
vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous
system, causing increased ventricular contraction and increased shear stress on the aorta. For
descending dissections, surgery is indicated only for complications such as occlusion of a major
aortic branch, continued extension or expansion of the dissection, or rupture (which may be
manifested by persistent or recurrent pain).
A. Immediate surgical
intervention
B. Arteriography of the aorta
C. Intravenous nitroprusside
(Nipride)
D. A nitroglycerin drip
E. Intravenous labetalol
(Normodyne, Trandate)
690.
E. Aortic stenosis. Syncope with exercise is a manifestation of organic heart disease in which
cardiac output is fixed and does not rise (or even fall) with exertion. Syncope, commonly on
exertion, is reported in up to 42% of patients with severe aortic stenosis. Vasovagal syncope is
associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells,
sudden pain, sustained upright posture, heat, hunger, and acute blood loss. Transient ischemic
attacks are not related to exertion. Orthostatic hypotension is associated with changing from a
sitting or lying position to an upright position. Atrial myxoma is associated with syncope related to
changes in position, such as bending, lying down from a seated position, or turning over in bed.
691.
A 75-year-old patient
with underlying
chronic renal failure
requires cardiac
catheterization.
Which one of the
following
interventions is most
likely to help prevent
acute renal failure due
to contrast-induced
nephropathy? (check
one)
A. Hydration with
normal saline and
mannitol
B. Hydration with
sodium bicarbonatecontaining fluids
C. Hydration plus a
loop diuretic
D. Administering
fenoldopam
(Corlopam) prior to
the procedure
E. Infusion of
natriuretic peptides
prior to the procedure
B. Hydration with sodium bicarbonate-containing fluids. Several studies have demonstrated that hydration
with sodium bicarbonate-containing fluids reduces the risk of contrast-induced nephropathy in those
undergoing cardiac catheterization. Studies of interventions to prevent renal failure in patients at high risk
have shown that mannitol plus hydration does not reduce acute renal failure compared to hydration alone.
Randomized, controlled trials have shown that fenoldopam does not decrease the need for dialysis or
improve survival. One systematic review found that low-osmolality contrast media reduced nephrotoxicity in
persons with underlying renal failure requiring studies using contrast. One systematic review and one
subsequent randomized, controlled trial found that adding loop diuretics to fluids was not effective and may
actually increase the possibility of acute renal failure compared to fluids alone. A large randomized,
controlled trial found no significant difference between natriuretic peptides and placebo in preventing
acute renal failure induced by contrast media.
692.
D. Obtain a bone marrow examination. This patient has typical symptoms and laboratory
findings of multiple myeloma, which accounts for 1% of all malignant diseases and has a mean
age at diagnosis of 61 years. The diagnosis is confirmed by a bone marrow examination
showing >10% plasma cells in the marrow. The serum level of monoclonal immunoglobulin is
typically >3 g/dL. A bone scan is inferior to conventional radiography and should not be used.
Tamoxifen is indicated for the treatment of breast cancer, which is unlikely given the
physicaland laboratory findings in this case.
693.
C. Free water restriction. This patient probably has the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH). SIADH can be caused by CNS tumors, various infections such
as meningitis, and pneumonia. Several drugs can cause this condition, including amiodarone,
carbamazepine, SSRIs, and chlorpromazine. In this fairly asymptomatic patient, initial
management should be free water restriction. As she is hemodynamically stable, she does not
need normal saline. Moreover, administration of normal saline may exacerbate the
hyponatremia, as the sodium may be rapidly excreted while the water is retained. If she had a
rapid onset and neurologic symptoms such as seizures, hypertonic saline could be given.
Correction should be slow, with a goal of no more than a 1-2 mmol/L/hr increase in the sodium
level; a normal sodium level should not be reached within the first 48 hours of treatment.
Demeclocycline is appropriate for patients who cannot adhere to the requirement for fluid
restriction, or who have recalcitrant hyponatremia despite restriction. References: 1) Goh KP:
Management of hyponatremia. Am Fam Physician 2004;69(10):2387-2394. 2) Ellison DH, Berl T:
The syndrome of inappropriate antidiuresis. N Engl J Med 2007;356(20):2064-2072.
A. Administration of 3% normal
saline
B. Administration of normal saline
C. Free water restriction
D. Demeclocycline (Declomycin)
694.
A. rheumatoid arthritis
B. gout
C. systemic lupus erythematosus
D. scleroderma
E. osteoarthritis
695.
696.
698.
A 78-year-old Hispanic male comes to see you after attending a health fair.
He is concerned because he had a prostate-specific antigen (PSA) level of
5.0 ng/mL (N 0.0-4.0). He has never had his PSA checked before. His medical
history is significant for class IV heart failure treated with furosemide
(Lasix), enalapril (Vasotec), carvedilol (Coreg), digoxin, and spironolactone
(Aldactone). His review of systems is positive for longstanding nocturia and
gradually worsening weakness of the urinary stream. His physical
examination is noteworthy for bibasilar rales, an S3 gallop, and moderate
lower extremity edema. His prostate is diffusely large and smooth. His
urinalysis is unremarkable. Which one of the following is the most
appropriate management for his elevated PSA? (check one)
A. No intervention
B. Repeat testing after a course of antibiotics
C. Referral for a CT scan or MRI of the pelvis
D. Referral for prostate ultrasonography and biopsy
699.
A 78-year-old male comes to your office with a 3day history of pain in the right side of his chest.
The pain is described as burning and intense. Two
days ago he noted a rash at that site. Examination
reveals groups of vesicles on an erythematous
base in a T-5 dermatome distribution on the right.
Which one of the following would be the most
appropriate treatment to minimize the chance of
post-herpetic neuralgia? (check one)
A. Famciclovir (Famvir)
B. Prednisone
C. Capsaicin (Zostrix)
D. Carbamazepine (Tegretol)
700.
701.
A 78-year-old male presents for a routine followup visit for hypertension. He is a smoker, but has
no known coronary artery disease and is
otherwise healthy. On examination you note an
irregular pulse. An EKG reveals multiple
premature ventricular contractions (PVCs), but
no other abnormalities.
Current guidelines recommend which one of the
following? (check one)
Strong evidence from randomized, controlled trials suggests that PVCs should
not be suppressed with antiarrhythmic agents. The CAST I trial showed that
using encainide or flecainide to suppress PVCs increases mortality (SOR A).
A. Intravenous furosemide
B. Ascorbic acid
C. Calcium antagonists
D. Isotonic bicarbonate infusion
E. High osmolar contrast media
702.
703.
A. Watchful waiting
B. Reduction of systolic blood pressure (SBP) to 190 mm Hg
C. Reduction of SBP to 170 mm Hg
D. Reduction of SBP to 150 mm Hg
E. Reduction of SBP to 130 mm Hg
705.
706.
707.
A. Statin-induced myopathy
B. Polymyalgia rheumatica
C. Guillain-Barr syndrome
D. Diabetic ketoacidosis
708.
A. Moxifloxacin (Avelox)
B. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
C. Doxycycline
D. Ceftriaxone and metronidazole (Flagyl)
E. Ceftazidime (Fortaz), imipenem/cilastatin (Primaxin), and
vancomycin (Vancocin)
709.
710.
711.
714.
716.
717.
718.
E. A thiazide diuretic. Clinical trials support the treatment of systolic hypertension in the
older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension
is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure
of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics
and long-acting calcium channel blockers as first-line therapy. Alpha-blockers are not
recommended. ACE inhibitors, beta-blockers, and angiotensin receptor blockers are
used when certain compelling indications are present, e.g., in a patient with diabetes or
who has had a myocardial infarction.
A. An alpha-blocker
B. An ACE inhibitor
C. A beta-blocker
D. An angiotensin receptor blocker
E. A thiazide diuretic
719.
720.
721.
A. Alzheimer's disease
B. Dementia resulting from depression
C. Lewy body dementia
D. Multi-infarct dementia
E. Normal aging
722.
...
723.
D. Sustained-release bupropion (Wellbutrin SR) has been shown to reduce the relapse rate for up
to 12 months. Sustained-release bupropion has been shown to reduce the relapse rate for
smoking cessation and blunt weight gain for 12 months. Beneficial effects of smoking cessation are
seen even among older smokers. Evidence has now shown that smokers who switch to low-tar or
low-nicotine cigarettes do not significantly decrease their health risks. The approved Food and
Drug Administration medications for smoking cessation (sustained-release bupropion, nicotine
patch, nicotine gum, nicotine inhaler, and nicotine nasal spray) have been shown to be safe and
should be recommended for all patients without contraindications who are trying to quit smoking.
The nicotine patch in particular is safe, and has been shown not to cause adverse cardiovascular
effects.
D. Heart failure. The chest radiograph is consistent with heart failure. It shows cardiomegaly, with a
cardiothoracic ratio >6.50, as well as some enlargement of pulmonary veins due to pulmonary
venous hypertension. The radiograph does not show an infiltrate, as would be expected with
community-acquired pneumonia. Pleural plaques would be expected with asbestosis, and upperlobe involvement or cavitary lesions with tuberculosis. With emphysema, there is typically a small
vertical heart and evidence of hyperexpansion.
725.
727.
...
729.
C. hospitals ask patients about advance directives. The 1990 Patient SelfDetermination Act (PSDA) requires hospitals, nursing homes, and health care
programs to ask patients about advance directives and then incorporate the
information into medical records. The living will, a written advance directive, allows a
competent person to indicate his or her health care preferences while cognitively
and physically healthy. A living will may list medical interventions the patient wishes
to have withheld or withdrawn when he or she becomes unable to communicate.
Another type of advance directive, the durable power of attorney for health care,
allows persons to designate a proxy (or surrogate) to make decisions for them if they
become incapacitated.
Although PSDA mandates that patients be asked about their advance directive
status upon admission to the hospital, it does not require hospitals or individual
physicians to offer patients an opportunity to complete an advance directive. The
acceptance and precision of verbal preferences varies from state to state. Although
verbal discussions are binding in many states, five states require "clear and
convincing evidence of patient preferences." In California, Delaware, Michigan,
Missouri, and New York, advance directives must include such evidence regarding a
specific condition and/or treatment, even if a durable power of attorney states prior
general verbal preferences. Therefore, lack of an advance directive may result in
continued medical interventions to preserve life even if the patient may not want
such treatment.
730.
A. leishmaniasis. The indolent course of the sore described favors the diagnosis of
cutaneous leishmaniasis. Neither malaria nor schistosomiasis produces these sores.
The chancres of syphilis and trypanosomiasis are more fleeting in duration.
732.
E. 115 mm Hg. According to JNC 7, the risk of both ischemic heart disease and stroke
increases progressively when systolic blood pressure exceeds 115 mm Hg and
diastolic blood pressure exceeds 75 mm Hg.
A. 150 mm Hg
B. 140 mm Hg
C. 130 mm Hg
D. 125 mm Hg
E. 115 mm Hg
733.
A. Indomethacin. The Beers criteria, a list of drugs that should generally be avoided
by older patients, was developed by expert consensus, and was last updated in 2002.
Indomethacin is on the list due to its propensity to produce more central nervous
system adverse effects than other NSAIDs.
734.
735.
C. 130/80 mm Hg. Hypertension and diabetes mellitus are very common, both
separately and in combination. End-organ damage to the heart, brain, and kidneys is
more common in patients with both diabetes mellitus and hypertension, occurring at
lower blood pressure levels than in patients with only hypertension. JNC 7, an evidencebased consensus report, recommends that patients with diabetes and hypertension be
treated to reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg
for other adults.
A. 140/95 mm Hg
B. 135/90 mm Hg
C. 130/80 mm Hg
D. 120/75 mm Hg
It should be noted, however, that the recently published ACCORD blood pressure trial
found no significant cardiovascular benefit from targeting systolic blood pressure at
<120 mm Hg rather than <140 mm Hg in patients with type 2 diabetes. This finding may
affect the JNC 8 guidelines, which are currently being developed.
A. are not recommended for prevention of any disorder. The U.S. Preventive Services
Task Force makes no specific recommendations for vitamins or antioxidants to prevent
cancer or cardiovascular disease. Moreover, it makes no specific recommendations for
vitamin supplements for any condition.
B. An asymptomatic 67-year-old male smoker with no chronic illness. The U.S. Preventive
Services Task Force has released a statement summarizing recommendations for
screening for abdominal aortic aneurysm (AAA). The guideline recommends one-time
screening with ultrasonography for AAA in men 65-75 years of age who have ever
smoked. No recommendation was made for or against screening women. Men with a
strong family history of AAA should be counseled about the risks and benefits of
screening as they approach 65 years of age.
738.
C. Begin universal screening at age 65. No single study has evaluated the effectiveness of
osteoporosis screening. The U.S. Preventive Services Task Force (USPSTF) recommends universal
screening for women over the age of 65, as well as for women age 60-64 with risk factors for
osteoporosis. Multiple risk assessment scales have been studied to identify women over the age of
65 who are at increased risk for hip fracture. None of the scales, however, had good discriminatory
performance. Thus, the criteria for screening women less than 65 years of age are unclear.
C. squamous cell cancer. Actinic keratoses are scaly lesions that develop on sun-exposed skin, and
are believed to be carcinoma in situ. While most actinic keratoses spontaneously regress, others
progress to squamous cell cancers.
E. when the individual becomes unable to communicate health care wishes. The living will, a written
advance directive, allows a competent person to indicate his or her health care references while
cognitively and physically healthy. A living will may list medical interventions the patient would
prefer to have withheld or withdrawn when he or she becomes unable to communicate.
741.
743.
B. BNP. This patient has heart failure with a bronchospastic component. The
S3 gallop occurs with a dilated left ventricle and a right-sided pleural
effusion, which are common in heart failure. A BNP level is useful in
differentiating cardiac and pulmonary diseases, while a troponin I level is
helpful in assessing for cardiac ischemia. Arterial blood gasses are not useful
in confirming the diagnosis. A CT angiogram of the chest would be useful for
diagnosing pulmonary embolism. A d-dimer test is helpful to rule out
venous thromboembolic disease.
745.
A. atropine
B. diphenhydramine (Benadryl)
C. haloperidol
D. succinylcholine (Anectine)
E. carbamazepine (Tegretol)
746.
747.
748.
749.
751.
C. The most likely diagnosis is Gilbert syndrome. Gilbert syndrome is an autosomal dominant
disease characterized by indirect hyperbilirubinemia caused by impaired glucuronyl
transferase activity. The workup includes studies to exclude hemolysis (CBC, reticulocyte count,
and haptoglobin) and liver disease (AST, ALT, alkaline phosphatase, and prothrombin time).
Alcoholic liver disease is associated with a greater elevation of AST than of ALT. Dubin-Johhnson
syndrome is a benign liver disease distinguished by direct or conjugated hyperbilirubinemia.
Imaging studies are not required to confirm Gilbert syndrome; such studies are more useful for
conditions involving conjugated hyperbilirubinemia. Other causes of indirect
hyperbilirubinemia include hematoma, infection, cardiac disease, rhabdomyolysis, living at
high altitude, thyrotoxicosis, and some medications.
B. Abdominal ultrasonography. The U.S. Preventive Services Task Force (USPSTF) recommends
one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 6575 who have ever smoked (SOR B, USPSTF B Recommendation). The USPSTF found good
evidence that screening these patients for AAA and surgical repair of large AAAs (5.5 cm) leads
to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography,
performed in a setting with adequate quality assurance (i.e., in an accredited facility with
credentialed technologists), is an accurate screening test for AAA. There is also good evidence of
important harms from screening and early treatment, including an increased number of
operations, with associated clinically significant morbidity and mortality, and short-term
psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded
that the benefits of screening for AAA in men aged 65-75 who have ever smoked outweighs the
potential harm.
While they may be considered for making the diagnosis in patients who have symptoms, none
of the other tests listed have evidence to support a net benefit from their use as routine
screening tools in patients like the one described here.
753.
At a routine annual visit, a 31-year-old innercity elementary school teacher asks you
about a lesion on the nail of her ring finger,
shown in Figure 8.
On examination, you note that her other nails
all have a slight linear depression or groove.
Which one of the following is the most likely
cause of this problem? (check one)
A. Fast walking for 30 minutes on 5 or more days per week. This patient would
benefit from exercise to prevent or delay the onset of heart disease and
hypertension, and to manage her weight. Exercise stress testing is not specifically
indicated for this patient. Current recommendations are for healthy adults to
engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or
more days per week.
A. A previous history of angioneurotic edema. Angioneurotic edema can be lifethreatening, and ACE inhibitors should not be given to patients with a history of
this condition from any cause. Elevated creatinine levels are not an absolute
contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced
cardiac ejection fraction are indications for ACE inhibitor therapy. ACE inhibitors do
not affect asthma.
756.
A. Recommend intramuscular vaccine and tell her that evidence indicates some protection for
the baby up to 6 months of age. Women who will be pregnant during the influenza season
should receive the inactivated vaccine (SOR C). The live nasal vaccine is not approved for use in
pregnancy. The vaccine can be given in any trimester. Coexistent illness is not required for this
indication. There appears to be some protective effect for the infant up to the age of 6 months.
Immunization of family members is sometimes recommended for immunocompromised
patients. In the absence of other indications, however, it has not been recommended for family
members of pregnant patients.
A. Recommend intramuscular
vaccine and tell her that evidence
indicates some protection for the
baby up to 6 months of age
B. Recommend nasal vaccine
because the patient is under age 50
and needle-averse
C. Recommend vaccine only if the
patient has a coexistent chronic
illness
D. Recommend that vaccination
be delayed until the second
trimester to reduce fetal risk
E. Recommend immunization of
household contacts to reduce
maternal risk, but no
immunization of the patient
757.
758.
D. Delayed attainment of social skill milestones. Delayed attainment of social skill milestones is
the earliest and most specific sign of autism. Delayed or odd use of language is a common, but
less specific, early sign of autism. Compared with social and language impairments, restricted
interests and repetitive behaviors are less prominent and more variable in young children.
Self-injurious behaviors are associated with autism, but not specific for it. For example, newonset head banging may be the way an autistic child attempts to deal with pain from a dental
abscess, headache, sinusitis, otitis media, or other source of pain.
759.
A. Physicians should delay having a detailed discussion with the patient about the expected prognosis of cancer
until staging is completed. It is best to discuss prognosis after accurate cancer staging, when specific details about
survival rates will give a much clearer and more accurate picture. After assessing the patient's readiness to
receive prognostic information, the physician should focus on communicating an accurate prognosis without
giving a false sense of hope. Using simultaneous-care models, physicians can provide palliative and curative care
at the same time. Physicians should initiate a discussion about the availability of coordinated, symptomdirected
services such as palliative care early in the disease process; as the disease progresses, patients should transition
from curative to palliative therapy. How much information to share with the patient depends on the physician's
assessment of the patient's level of understanding about the disease and how much patients themselves want
to know.
760.
B. Metformin (Glucophage) reduces cardiovascular mortality rates. Metformin is the only hypoglycemic
agent shown to reduce mortality rates in patients with type 2 diabetes mellitus. A recent systematic review
concluded that cardiovascular events are neither increased nor decreased with the use of sulfonylureas.
The effect of incretin mimetics and incretin enhancers on cardiovascular events has not been determined.
The STOP-NIDDM study suggests that -glucosidase inhibitors reduce the risk of cardiovascular events in
patients with impaired glucose tolerance.
A. Sulfonylureas
increase
cardiovascular events
B. Metformin
(Glucophage) reduces
cardiovascular
mortality rates
C. Incretin mimetics
reduce the risk of
cardiovascular events
D. -Glucosidase
inhibitors have no
effect on
cardiovascular events
761.
762.
B. propranolol (Inderal). The primary treatment for symptomatic mitral valve prolapse is -blockers.
Quinidine and digoxin were used to treat this problem in the past, especially if sinus bradycardia or cardiac
arrest occurred with administration of propranolol. Procainamide and phenytoin have not been used to
treat this syndrome. Asymptomatic patients require only routine monitoring, while those with significant
mitral regurgitation may require surgery. Some patients with palpitations can be managed with lifestyle
changes such as elimination of caffeine and alcohol. Orthostatic hypotension can often be managed with
volume expansion, such as by increasing salt intake.
D. sending the patient home in a sling and swathe. Fractures of the medial third of the clavicle in pediatric
patients are common and are best treated by a figure-of-8 apparatus. Open surgical reduction with
intramedullary fixation will minimize angular deformity at the fracture site but leaves a scar and may result
in nonunion. With the rare exception of neurovascular injury accompanying the fracture, there are no
indications for open reduction of a clavicular fracture in a child.
763.
The best
management of
localized, welldifferentiated
prostate cancer in
men older than 65 is:
(check one)
C. watchful waiting. For men older than 65 years of age with small-volume, low-grade disease and a 10- to 15year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from
prostate cancer. Radiation, androgen deprivation therapy, and surgical approaches have not been shown to
improve disease-free survival (SOR A).
A. radiation
implants
B. external beam
radiation therapy
C. watchful waiting
D. primary androgen
deprivation therapy
E. robot-assisted
prostatectomy
764.
Brain natriuretic
peptide (BNP) is a
marker for which
one of the
following? (check
one)
D. Heart failure. Brain-type natriuretic peptide (BNP) is synthesized, stored, and released by the ventricular
myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This
hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high
specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes. In
addition, the availability of a bedside assay makes BNP useful for evaluating patients in the emergency
department.
A. Renal failure
B. Acute adrenal
insufficiency
C. Cerebrovascular
accident
D. Heart failure
E. Ureteral
obstruction
765.
The CAGE-AID
questionnaire is a
tool for screening
for: (check one)
C. substance abuse risk. The CAGE-AID (CAGE Adapted to Include Drugs) questionnaire is a tool for assessing
potential substance abuse risk. In one study it had a sensitivity of 70% and a specificity of 85% for drug abuse
when two or more affirmative responses were defined as a positive result. It consists of the following four
questions:
A. depression
B. bipolar illness
C. substance abuse
risk
D. psychosis
E. compatibility
Have you ever felt you ought to Cut down on your drinking or drug use?
Have people Annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or Guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning as an Eye opener to steady your nerves or
to get rid of a hangover?
766.
A case of meningococcal
meningitis has just been
confirmed at a day-care
center. The susceptibility of
the microorganism is not
yet known. At this point,
you should do which one of
the following for the daycare center contacts?
(check one)
E. Prescribe rifampin (Rifadin). Rifampin, in the absence of major contraindications, is the drug of
choice for preventing the spread of meningococcal disease when the susceptibility of the organism is
not known. In this situation, meningococcal vaccines are of no value because their protective effects
take a few days to develop, and because they do not protect against group B meningococci, the most
prevalent strain for meningococcal disease. Sulfadiazine is the drug of choice if the meningococcus is
known to be susceptible to it. Chloramphenicol and penicillin, which are effective in treating the
disease, are ineffective in eliminating nasopharyngeal carriers of meningococci, possibly because they
do not appear in high concentrations in saliva. Culturing contacts for meningococcal carriage in the
nasopharynx has no value for identifying those at risk for meningococcal disease.
A. Culture their
nasopharyngeal secretions
B. Administer
meningococcal vaccine
C. Prescribe sulfadiazine
D. Prescribe
chloramphenicol
(Chloromycetin)
E. Prescribe rifampin
(Rifadin)
767.
D. contact dermatitis related to his occupation. Because this dermatitis is recurrent and symmetric,
contact dermatitis should be suspected. Rhus dermatitis is a contact dermatitis, but it is more acute and
presents with bullae and vesicles that are more linear than those seen in this patient. MRSA usually
presents as a unilateral cellulitis, or more commonly as inflammatory nodules or pustules. This
dermatitis is not scaling and does not have a distinct border that would suggest tinea.
768.
E. Obtaining cultures from the rectum and vaginal introitus at 35-37 weeks' gestation. The gastrointestinal
tract is the most likely reservoir of group B Streptococcus with secondary spread to the genital tract.
Cultures from the vaginal introitus and the rectum are the most sensitive for detecting colonization. No
speculum examination is necessary. The closest time to delivery that cultures can be performed and
allow time for results to be available is 35-37 weeks' gestation. Culture-positive women are then treated
during labor. Other criteria for the use of chemoprophylaxis during delivery continue to apply.
E. HIV infection. The focus of screening for HIV has been shifted from testing only high-risk individuals to
routine testing of all individuals in health-care settings. There are an estimated 1.1 million people in the
United States with HIV, and 25% are undiagnosed. Only 36.6% of adults have had an HIV test. Screening
for hepatitis B and for tuberculosis is recommended only for certain at-risk populations. There is no
generally used test for human papillomavirus. The CDC has not made any recommendations regarding
screening for high cholesterol.
770.
771.
C. Pelvic inflammatory disease. The promise of a reduction in the incidence and prevalence of
sexually transmitted diseases through partner notification and treatment programs remains elusive,
as evidence supporting this effect is scarce and inconclusive. What is clear is that treating sexual
partners does reduce reinfection of the index patient. Programs such as contact notification,
counseling and scheduling of appointments for evaluation of the partner, and expedited partner
therapy (EPT), in which sexual contacts of infected patients are provided antibiotics delivered by the
index patient without evaluation or counseling, have demonstrated only limited effectiveness; in the
case of EPT this limited benefit has been shown only with trichomoniasis. Because currently available
evidence fails to demonstrate benefit from treating the male sexual contacts of women with vaginal
candidiasis, vaginal warts, or bacterial vaginosis, the Centers for Disease Control and Prevention
(CDC) states that treating the male partner is not indicated with these infections.
In the case of pelvic inflammatory disease (PID), evaluation and treatment of males with a history of
sexual contact with the patient during the 60 days preceding the onset of symptoms is imperative
because of the high risk of reinfection. Current CDC guidelines recommend empiric treatment of
these male contacts with antibiotic regimens effective against both chlamydial and gonococcal
infection, regardless of the presumed etiology of the PID.
D. partial rupture of the thoracic aorta. Deceleration-type blows to the chest can produce partial or
complete transection of the aorta. A chest radiograph shows an acutely widened mediastinum
and/or a pleural effusion when the condition is severe. The other conditions listed would produce
mediastinal emphysema (esophageal or bronchial rupture), a widened heart, or pulmonary edema
(acute heart failure, myocardial contusion).
A. myocardial contusion
B. spontaneous rupture of the
esophagus
C. rupture of a bronchus
D. partial rupture of the
thoracic aorta
E. acute heart failure
772.
A. No additional drug therapy. Behavioral symptoms such as agitation and wandering become
common as Alzheimer's disease progresses. Cholinesterase inhibitors may improve some of these
symptoms. If they persist, use of a psychotropic agent may be necessary. Atypical agents can help
control problematic delusions, hallucinations, severe psychomotor agitation, and combativeness.
Typical agents help control these same problems, but are used more as second-line therapy in those
who do not respond to atypical agents. Mood-stabilizing drugs can help control these symptoms as
well, and may also be useful alternatives to antipsychotic agents for controlling severe agitated,
repetitive, and combative behaviors. Benzodiazepines are used to manage insomnia, anxiety and
agitation. Some behaviors, such as wandering and pacing, are not amenable to drug therapy.
773.
B. Clostridium botulinum. The most common cause of infant botulism is ingestion of Clostridium
botulinum spores in honey.
A. Staphylococcus aureus
B. Clostridium botulinum
C. Clostridium difficile
D. Escherichia coli
E. Hepatitis A
774.
C. Osteoporosis. Even mild chronic excess thyroid hormone replacement over many years can
cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The
elevated calcium decreases parathyroid hormone. Goiter is an indicator, not a cause, for hormone
replacement. Osteoarthritis is not related to thyroid hormone replacement.
776.
Compared to
anesthesia using
only parenteral
opioids, the use of
epidural anesthesia
in labor and delivery
increases the rate of
which one of the
following? (check
one)
D. Prolonged second stage of labor. Multiple systematic reviews have been conducted to examine the effects of
epidural anesthesia on maternal and neonatal outcomes. There are many confounding variables in the
studies and, as a result, only a few effects of epidural anesthesia are consistently seen on a statistically
significant basis: an increased duration of the second stage of labor, an increased rate of instrument-assisted
vaginal deliveries, and an increased likelihood of maternal fever. Overall, there is no statistically significant
difference in the duration of the first stage of labor, the incidence of low Apgar scores, or the incidence of
maternal backache at 3 months or 12 months.
A. Cesarean section
B. Low Apgar scores
(<7)
C. Maternal low
backache 3 months
post delivery
D. Prolonged second
stage of labor
777.
Compared to
children with
attentiondeficit/hyperactivity
disorder (ADHD),
adults with ADHD:
(check one)
A. Tend to be more
hyperactive
B. Tend to be less
impulsive
C. Are less likely to
have corroboration
of symptoms by
family members
D. Are less likely to
complain of
inattention
difficulties
B. Tend to be less impulsive. Longitudinal studies of young people diagnosed with attentiondeficit/hyperactivity disorder (ADHD) show that symptoms of hyperactivity and impulsivity may decrease with
age, but inattention tends to persist. Studies of clinically referred adults with ADHD show that about half have
clinically important levels of hyperactivity and impulsivity and up to 90% have prominent attentional
symptoms. Like some youth with ADHD, adults with ADHD tend to have additional cognitive deficits,
specifically executive function deficits, which include problems encoding and manipulating information and
difficulties with organization and time management. Research shows that using retrospective self-reports of
adults is a valid method of diagnosing ADHD. Studies have shown that the consistent reporting of childhood
ADHD symptoms by both adults and their parents is highly correlated. Research has also found strong
agreement between the self-reports of adults and their partners regarding ADHD symptoms.
778.
The condition
shown in Figure 4
occurred in a 31year-old sexually
active male. Which
one of the
following is true
regarding this
problem?
E. HPV testing is indicated for this patient's sexual partners. Genital warts are typically caused by human
papillomavirus (HPV) types 5 and 11, which are rarely associated with invasive squamous cell carcinoma. In
general, chemical treatments are more effective on soft, moist, nonkeratinized genital lesions, while physical
ablative treatments are more effective for keratinized lesions. Diagnosis by biopsy and viral typing is no longer
recommended. Acetowhite staining has not been shown to favorably affect the course or treatment of HPVassociated genital warts. Topical 5% fluorouracil cream has been associated with severe local reactions and
teratogenicity, and is no longer recommended. Treatment of genital warts has not been shown to reduce the
incidence of cervical or genital
cancer.
(check one)
A. Diagnosis by
biopsy and viral
typing is
recommended
B. Acetowhite
staining is
indicated to
accurately map
margins prior to
treatment
C. Treatment with
5% fluorouracil
cream (Efudex) is
effective and safe
D. Treatment has a
favorable impact
on the incidence of
cervical and
genital cancer
E. HPV testing is
indicated for this
patient's sexual
partners
779.
Contraindications
to thrombolytic
therapy in acute
stroke include
which one of the
following? (check
one)
A. Age >80
B. Resolving
transient ischemic
attack
C. Blood glucose
>200 mg/dL
D. Deficit present
for >1 hour
B. Resolving transient ischemic attack. Thrombolysis is now an approved treatment for acute stroke. The critical
time frame is 3 hours after the onset of the deficit. Beyond that time span, the use of thrombolytic agents is
contraindicated. Advanced age per se is not a contraindication to thrombolytic therapy. Contraindications
include blood glucose levels <50 mg/dL or >400 mg/dL, resolving transient ischemic attack, and hemorrhage
visible on a CT scan.
780.
Contraindications to use of
the levonorgestrel
intrauterine system
(Mirena) include which one
of the following? (check
one)
A. Nulliparity
B. A previous history of
deep vein thrombosis
C. A previous history of
endometriosis
D. Current pelvic
inflammatory disease
E. Current breastfeeding
781.
782.
D. 12 months. Whole cow's milk does not supply infants with enough vitamin E, iron, and essential fatty
acids, and overburdens their system with too much protein, sodium, and potassium. Skim and low-fat
milk lead to the same problems as whole milk, and also fail to provide adequate calories for growth. For
these reasons cow's milk is not recommended for children under 12 months of age. Human breast milk
or iron-fortified formula, with introduction of solid foods after 4-6 months of age if desired, is
appropriate for the first year of life.
D. 140-180 mg/dL. The 2009 consensus guidelines on inpatient glycemic control issued by the American
Association of Clinical Endocrinologists and the American Diabetes Association recommend insulin
infusion with a target glucose level of 140-180 mg/dL in critically ill patients. This recommendation is
based on clinical trials in critically ill patients. In the groups studied, there was no reduction in mortality
from intensive treatment targeting near-euglycemic glucose levels compared to conventional
management with a target glucose level of <180 mg/dL. There also were reports of harm resulting from
intensive glycemic control, including higher rates of severe hypoglycemia and even increased
mortality.
783.
B. counseling or coordinating care accounts for more than 50% of the face-to-face time spent
with the patient. The times published for Current Procedural Terminology codes are typical
for each level of office visit, but there is no requirement associated with them unless
counseling or coordination of care accounts for more than 50% of the face-to-face time of the
encounter. In such cases physicians are able to code on the basis of time.
D. unknown. Colic is a frustrating condition for parents and doctors alike. The parents would
like an explanation and relief, and physicians would like to offer these things. At this time,
however, in spite of numerous studies and theories, the cause of colic remains unknown.
785.
B. Oral fluoride is not necessary if the primary water source contains adequate fluoride. The
U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians
prescribe oral fluoride supplementation at currently recommended dosages to preschool-aged
children older than 6 months of age whose primary water source is deficient in fluoride. The
USPSTF concluded that the benefits of caries prevention outweigh the potential harms of
dental fluorosis. The USPSTF also concluded that there is insufficient evidence to recommend
for or against routine risk assessment of preschool-aged children for dental disease prevention.
E. A 75-year-old female. The current Dietary Reference Intake (DRI - which has replaced RDA's)
recommendation for vitamin D is 200 IU/day for all women between the ages of 9 and 50 years;
pregnancy or lactation does not affect the recommendation. The DRI doubles to 400 IU daily for
women age 51-70 and triples to 600 IU daily for women over the age of 70. The maximum daily
oral intake of vitamin D thought to be safe is 2000 IU/day for all females over the age of 12
months.
A. A 15-year-old nonpregnant
female
B. A 25-year-old pregnant female
C. A 35-year-old lactating female
D. A 55-year-old female
E. A 75-year-old female
787.
A. is associated with diplopia. Diplopia, along with other neurologic symptoms such as weakness
or difficulty with speech, suggests a central cause of vertigo and requires a complete workup.
Dizziness on first arising, dizziness with rolling over in bed, and dizziness with nausea and
vomiting are consistent with peripheral causes of vertigo, such as benign positional vertigo.
Dizziness that occurs after a couple of minutes of hyperventilation suggests a psychogenic
cause.
788.
A. Observation, with repeat evaluation in 1 year. Watchful waiting with annual follow-up is
appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific
antigen (PSA) levels correlate with prostate volume, which may affect the treatment of
choice, if indicated (SOR C). PSA levels >2.0 ng/mL for men in their 60s correlate with a
prostatic volume >40 mL. This patient's PSA falls below this level. In men with a prostatic
volume >40 mL, 5 -reductase inhibitors should be considered for treatment (SOR A). Blockers provide symptomatic relief in men whose disease has progressed to the point
that they have moderate to severe BPH symptoms (SOR A). A recent high-quality,
randomized, controlled trial found no benefit from saw palmetto with regard to symptom
relief or urinary flow after 1 year of therapy. The American Urological Association does not
recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when
medical therapy fails or the patient develops refractory urinary retention, persistent
hematuria, or bladder stones.
790.
During a routine physical examination of a 35year-old Asian female, you note a right
adnexal fullness. She has had no symptoms of
pain or bloating and has been menstruating
normally. Her menses occur approximately
every 30 days and her next period is expected
to occur in 1 week. Pelvic ultrasonography
reveals a thin-walled simple cyst 5 cm in
diameter. No other abnormalities are seen in
the pelvic structures. Which one of the
following is the best course of management
for this condition? (check one)
A. Reassurance only
B. Checking for any increase in adnexal
fullness at her next annual physical
examination
C. Repeat ultrasonography in 2-3 months to
confirm resolution of the cyst
D. Referral for ultrasound-guided aspiration
of the cyst
E. Referral for laparoscopic removal of the
cyst
791.
C. Core stability exercise. Low back pain and pelvic pain are commonly
encountered in pregnancy, a time when medication or physical modality use may
prove undesirable or difficult. A properly prescribed exercise program is a
generally safe and effective method to treat this pain. The most appropriate
exercises for pregnancyrelated pelvic pain and low back pain target the low back,
trunk, and abdominal muscles to increase core stability. Examples of such exercises
include Pilates, back extension exercises, and abdominal crunches.Isometric and
isotonic exercises work muscle groups against either an external force or opposing
muscle groups, and are best suited for the development of muscle tone, strength,
and conditioning in the extremities. Likewise, concentric and closed kinetic chain
exercises involve working muscles against resistance, and are best suited for
rehabilitating and strengthening the extremities.
A. Isometric exercise
B. Concentric exercise
C. Core stability exercise
D. Closed kinetic chain exercise
E. Isotonic exercise
792.
793.
A. Erythema toxicum neonatorum. This infant has the typical "flea-bitten" rash of erythema
toxicum neonatorum (ETN). Transient neonatal pustular melanosis is most common in
African-American newborns, and the lesions lack the surrounding erythema typical of ETN.
Acne neonatorum is associated with closed comedones, mostly on the face. As the infant
described is not ill, infectious etiologies are unlikely.
D. Tunnel vision. About 3% of persons over age 55 have glaucoma, making it a leading cause
of vision impairment. Although it is usually asymptomatic, the most common presenting
symptom is tunnel vision, a gradual loss of peripheral vision.
D. decrease depressive symptoms. It has been shown that palliative care offered early in the
course of a terminal disease has many benefits. Palliative care leads to improvement in a
patient's quality of life and mood, and patients who receive palliative care often have fewer
symptoms of depression than those who do not receive palliative care. In addition, palliative
care reduces aggressive end-of-life care and thus reduces health care costs. Palliative care
does not reduce the need for hospice, but in fact enables patients to enter hospice care
earlier and perhaps for longer. Palliative care has been shown to extend survival times in
terminal patients (SOR B).
796.
B. Most of the drugs available from Canada come from the same manufacturers as in the U.S..
The FDA has approved more than 90% of the drugs available from Canada. Most of these drugs
come from the same manufacturers as drugs in the U.S. Health Canada takes longer, on
average, to approve a drug for release than does the FDA, and most drugs discontinued for
safety reasons by the FDA between 1992 and 2001 had not been approved for use in Canada.
Websites advertising Canadian drugs may be selling counterfeit drugs from unregulated
sources.
E. Ginkgo biloba. Herbal and dietary supplements can affect the absorption, metabolism, and
disposition of other drugs. Ginkgo biloba has been associated with serious intracerebral
bleeding. In most of these patients, concurrent anticoagulant drugs were being used. Ginkgo
has been shown in vitro to inhibit platelet aggregation and has been associated with case
reports of spontaneous bleeding. Caution is recommended when using this supplement with
aspirin or other anticoagulants. Kava is associated with gastrointestinal side effects and skin
rashes. Yohimbine is associated with hypertension. Saw palmetto and echinacea are not
associated with bleeding.
A. Kava
B. Yohimbine
C. Saw palmetto
D. Echinacea
E. Ginkgo biloba
798.
Electrosurgical destruction is
contraindicated for which one of
the following skin lesions? (check
one)
A. Cherry angiomata
B. Pyogenic granuloma
C. Basal cell carcinoma
D. Melanoma
E. Actinic keratosis
799.
B. the liver. Alkaline phosphatase is elevated in conditions affecting the bones, liver, small
intestine, and placenta. The addition of elevated 5'-nucleotidase suggests the liver as the focus of
the problem. Measuring 5'-nucleotidase to determine whether the alkaline phosphatase
elevation is due to a hepatic problem is well substantiated, practical, and cost effective (SOR C).
A. bone
B. the liver
C. the placenta
D. the small intestine
800.
An elevation of serum
methylmalonic acid is both
sensitive and specific for a
cellular deficiency of which
vitamin? (check one)
C. Vitamin B 12. An elevation in serum methylmalonic acid is both sensitive and specific for cellular
vitamin B 12 deficiency.
A. Vitamin A
B. Vitamin B 6
C. Vitamin B 12
D. Vitamin D
E. Folate
801.
802.
C. An otherwise healthy 36-year-old white male smoker. The 10-year risk of developing coronary heart
disease can be effectively predicted with the algorithmic calculator developed using multivariable data
collected over a period of more than half a century as part of the Framingham Heart Study. This iconic
study defined what are now commonly known as major risk factors: elevated blood pressure, cigarette
smoking, cholesterol levels, diabetes mellitus, and advancing age. Using measurements of each of these
risk factors and consideration of the gender of the individual,a reliable determination of risk can be
obtained in individuals 30-74 years of age who have no overt coronary heart disease. The largely white
study population presumptively makes the risk determination most accurate for white patients.
A. A 19-year-old female
with a strong family
history of cardiac disease
B. An obese 50-year-old
male with a history of a
previous myocardial
infarction
C. An otherwise healthy
36-year-old white male
smoker
D. A postmenopausal 54year-old female with
angina
E. A 78-year-old male with
a history of hypertension
803.
False-positive urine
screens for drug abuse
can occur as a result of
(check one)
A. passive inhalation of
crack cocaine
B. passive inhalation of
marijuana smoke
C. eating poppy seed
muffins
D. consuming products
containing hemp
E. use of black cohosh
804.
C. eating poppy seed muffins. Eating as little as one poppy seed muffin can produce amounts of
morphine and codeine detectable by immunoassay, as well as by gas chromatography and mass
spectrometry. Passively inhaled crack cocaine or marijuana (unless an extreme amount is inhaled), and
ingested products containing hemp or other common herbal preparations do not produce positive urine
drug screens. In addition to poppy seeds, substances reported to cause false-positive urine drug screens
include selegiline, Vicks inhalers, NSAIDs, oxaprozin, fluoroquinolones, rifampin, venlafaxine, and
dextromethorphan. Reference: Vincent EC, Zebelman A, Goodwin C: What common substances can
cause false positives on urine screens for drugs of abuse? J Fam Pract 2006;55(10):893-894, 897.
D. heart failure. The black box warning for thiazolidinediones specifically addresses heart failure. These
agents are also contraindicated in patients with type 1 diabetes mellitus or hepatic disease, and in
premenopausal anovulatory women.
805.
806.
807.
808.
809.
810.
A. Phototherapy
B. Exchange transfusion
C. Blood cultures and
antibiotic therapy
D. Dextrose and water
supplementation
E. A recommendation to
increase feedings to 10 times a
day
811.
D. Kava. The use of herbal and nutritional supplements has become commonplace in the United
States. Unfortunately, there is insufficient research for most herbal remedies, in terms of both
efficacy and safety. However, there is a significant body of evidence from randomized, controlled
trials and various meta-analyses showing benefit from the use of kava in the short-term treatment
of anxiety disorders (up to 24 weeks), including generalized anxiety disorder (SOR A). The other
remedies listed have only single studies or anecdotal evidence attesting to benefit for patients with
anxiety. At best, information about them is limited, and there are often conflicting results. Safety
concerns about kava have been addressed by recent randomized, controlled trials demonstrating
that kava has a safety profile similar to those of FDA-approved treatments for anxiety disorders.
Care should be taken with any concurrent use of kava and medications metabolized by the liver,
and patients should be discouraged from using alcohol while taking kava. Physicians should be
aware of all remedies their patients are taking, even if they are not prescribed. In addition, it is
important to be aware of remedies that have evidence supporting their use.
812.
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.
A. Risk of falling
B. Effects of
peripheral
neuropathy
C. Kinetic tremor
D.
Neurocardiogenic
syncope
E. Central causes
of vertigo
813.
Hantavirus
pulmonary
syndrome results
from exposure to
the excreta of:
(check one)
D. mice. Hantavirus pulmonary syndrome results from exposure to rodent droppings, mainly the deer mouse in
the southwestern U.S. About 10% of deer mice are estimated to be infected with hantavirus. In other parts of the
country the virus is carried by the white-footed mouse. While other rodents are carriers of the virus, they are less
likely to live near dwellings, and populations are less dense.
A. migratory fowl
B. bats
C. parrots
D. mice
E. turtles
814.
Having all
patients over age
50 take low-dose
(81 mg) aspirin
daily would result
in (check one)
A. a decrease in
cardiovascular
mortality in men
and women
B. a decrease in
hemorrhagic
stroke in women
C. a decrease in
myocardial
infarction in men
D. a decrease in
strokes in men
E. no increase in
major bleeding
episodes
C. a decrease in myocardial infarction in men. A meta-analysis of six well controlled clinical trials of aspirin
prophylaxis showed a 32% decrease in myocardial infarctions in men taking aspirin. There was no decrease in
cardiovascular mortality or all-cause mortality in either sex, and there was a trend toward increased risk of stroke,
primarily hemorrhagic stroke. There was a 24% decrease in ischemic stroke in women, however. The risk of major
bleeding disorders was around 76% higher in aspirin users. The analysis suggests that aspirin may do more
harm than good in healthy persons without cardiovascular risk factors. Reference: Aspirin for primary
prevention of cardiovascular disease (revisited). Med Lett Drugs Ther 2006;48:53.
815.
D. Long-standing, latent infection. A positive result on the second, but the not the first, step of a twostep Mantoux tuberculin skin test indicates long-standing, latent infection.
A. Previous vaccination
with BCG
B. A false-positive skin test
C. Recent conversion
D. Long-standing, latent
infection
E. Probable
immunodeficiency
816.
A health-care worker
repeatedly develops a rash
on her hands after using
latex gloves. The rash is
papular and pruritic, with
vesicles. Latex allergy is
confirmed by skin patch
testing.
A. Avocados. Latex allergy management includes preventing exposure and treating reactions. Patients
with latex allergy can reduce their risk of exposure by avoiding direct contact with common latex
products. Additionally, they should be aware of foods with crossreactive proteins. Foods that have the
highest association with latex allergy include avocados, bananas, chestnuts, and kiwi. Walnuts, shellfish,
strawberries, and wheat have low or undetermined associations.
A. sets a federal minimum on the protection of privacy. HIPAA regulations set a minimum standard for
privacy protection. Privacy notices must be provided at the first delivery of health services, and written
acknowledgement is encouraged but not required.Exceptions to patient inspections include
psychotherapy notes and instances where disclosure is likely to cause substantial harm to the patient
or another individual in the judgment of a licensed health professional. Although it is not necessary to
provide patients with a privacy notice before rendering emergency care, it is required that patients be
provided with a privacy notice after the emergency has ended.
818.
A. Treat with analgesics and supportive care. The Centers for Disease Control and
Prevention (CDC) assembled a panel of national health experts to develop evidence-based
guidelines for evaluating and treating adults with acute respiratory disease. According to
these guidelines, the most reliable clinical predictors of streptococcal pharyngitis are the
Centor criteria. These include tonsillar exudates, tender anterior cervical
lymphadenopathy, absence of cough, and history of fever. The presence of three or four
of these criteria has a positive predictive value of 40%-60%, and the absence of three or
four of these criteria has a negative predictive value of 80%. Patients with four positive
criteria should be treated with antibiotics, those with three positive criteria should be
tested and treated if positive, and those with 0-1 positive criteria should be treated with
analgesics and supportive care only. This patient has only one of the Centor criteria, and
according to the panel should not be tested or treated with antibiotics.
A. A repeat PPD in 2 weeks. In 2000, the American Thoracic Society and the Centers for
Disease Control and Prevention (CDC) advocated a shift in focus from screening the
general population to testing only patients at increased risk for developing tuberculosis. In
some persons PPD reactivity wanes with time but can be recalled by a second skin test
administered 1 week or more after the first (i.e., two-step testing). For persons undergoing
PPD skin testing, such as health-care workers, initial two-step testing may preclude
misclassification of persons with boosted reactions as PPD converters. In those at low risk,
such as this patient, a tuberculin skin test is now considered positive only if induration is at
least 15 mm. Thus, this hospital volunteer would pose little risk to the hospital population
since her 10-mm reaction falls within the guidelines of a negative test. She does not require
diagnostic evaluation at this time, and isoniazid therapy is not indicated.
821.
823.
824.
...
825.
A. Hepatic function
B. Trough serum levels
C. Peak serum levels
D. Audiograms
826.
A. Depression
B. Dementia
C. A brain tumor
D. Hypoglycemia
E. Myocardial infarction
827.
A. External anogenital warts. Since its FDA approval, imiquimod has been used offlabel to treat all of the conditions listed, but is approved only for treatment of
external genital and perianal warts in patients 12 years of age and over.
A. Easy bruising. Easy bruising, moon facies, buffalo hump, abdominal striae,
hypertension, and proximal myopathy suggest Cushing's syndrome. Because this
syndrome is very rare compared to polycystic ovarian syndrome, routine screening
is not indicated in women with hypoandrogenic anovulation. Acne, hirsutism,
androgenic alopecia, and acanthosis nigricans are all consistent with polycystic
ovarian syndrome.
A. Easy bruising
B. Acne
C. Hirsutism
D. Androgenic alopecia
E. Acanthosis nigricans
829.
A. A blood pressure of 150/100 mm Hg. The criteria for severe preeclampsia specify a
blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other
criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count
<100,000/mm3, liver enzyme abnormalities, epigastric or right upper quadrant pain,
and alteration of mental status.
830.
In a child,
which one of
the
following is
most likely
to improve
adherence
to a chronic
medication
regimen?
(check one)
A. Adding a
favorite
flavor to
bitter liquid
medications
B. More
frequent
dosing of
daily
medication
C. Having
only one
person from
the healthcare team
discuss the
medication
regimen
with the
patient and
his parents
D. Advising
the parents
to avoid
giving
rewards for
following
the regimen
E. Putting
the parents
in complete
control of
the dosing
schedule
A. Adding a favorite flavor to bitter liquid medications. A number of useful strategies for promoting adherence to a
chronic medical regimen can be employed in children. Adding flavors to unpleasant tasting medicines is helpful (SOR
B). Chocolate flavoring is especially useful for masking the taste of bitter medications. Using medications that are given
only once or twice a day is associated with compliance rates of greater than 70% (SOR B). Consistent advice given by
multiple members of the health-care team reinforces the importance of following a medication regimen. Parental use of
rewards for children who take their medicine properly helps improve adherence. Involving children in decisions
concerning their care gives them a sense of control and improves adherence. Other strategies for improving
adherence include patient handouts, keeping financial costs in mind when prescribing, advising patients to
incorporate dosing into daily routines such as meals, keeping tally sheets, and using visual reminders such as notes on
the refrigerator.
831.
A. bisphosphonate therapy
B. calcitonin
C. estrogen replacement therapy
D. recombinant human parathyroid
hormone
E. raloxifene (Evista)
832.
B. left heart failure. Although myocarditis, pulmonic stenosis, and ventricular septal defects
can be causes of right heart failure, left heart failure is the most common cause of right
heart failure in adults.
833.
In an 11-year-old
male with dark
brown urine and
hand and foot
edema, which one
of the following
would be most
suggestive of
glomerulonephritis?
(check one)
B. RBC casts in the urine. Acute glomerulonephritis (AGN) in children manifests as brown or cola-colored urine,
which may be painless or associated with mild flank or abdominal pain. There are many etiologies of AGN but
the most common in children are IgA nephropathy (which may directly follow an acute upper respiratory tract
infection) and acute poststreptococcal glomerulonephritis following a streptococcal throat or skin infection
(usually 7-21 days later). In cases with more severe renal involvement, patients may develop hypertension,
edema, and oliguria. RBC casts are the classic finding on urinalysis in a patient with AGN. WBC casts are seen in
acute pyelonephritis, often manifested by high fever, and costovertebral angle or flank pain and tenderness.
Patients may also appear septic. Positive serum antinuclear antibodies are associated with lupus nephritis.
Urine eosinophils are seen in drug-induced tubulointerstitial nephritis. Serum complement levels are
reduced, not elevated, in various forms of acute glomerulopathies, including poststreptococcal AGN.
In a patient who
presents with
symptoms of acute
myocardial
infarction, which
one of the following
would be an
indication for
thrombolytic
therapy? (check
one)
A. New-onset STsegment depression
B. New-onset left
bundle branch
block
C. New-onset first
degree
atrioventricular
block
D. New-onset
Wenckebach second
degree heart block
E. Frequent unifocal
ventricular ectopic
beats
B. New-onset left bundle branch block. In patients with ischemic chest pain, the EKG is important for
determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation 1 mm in two
or more limb leads and 2 mm in two or more contiguous precordial leads. In a patient with an MI, new left
bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of
the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not
infarction - they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant
antiarrhythmic therapy, but not thrombolytic therapy.
835.
In a patient with a
severe anaphylactic
reaction to peanuts,
the most appropriate
route for epinephrine
is: (check one)
A. intramuscular. Intramuscular epinephrine is the recommended drug for anaphylactic reactions (SOR A).
Epinephrine is absorbed more rapidly intramuscularly than subcutaneously.
A. intramuscular
B. intravenous
C. oral
D. subcutaneous
E. sublingual
836.
In a patient with a
sudden onset of
dyspnea, which one of
the following makes a
pulmonary embolus
more likely? (check
one)
B. Chest pain. Chest pain is common in patients with pulmonary embolism (PE). When evaluating a patient
for possible PE, the presence of orthopnea suggests heart failure, fever suggests an infectious process,
wheezing suggests asthma or COPD, and rhonchi suggest heart failure, interstitial lung disease, or infection.
These generalizations are supported by a 2008 study designed to improve the diagnosis of PE based on the
history, physical examination, EKG, and chest radiograph.
A. Fever >38.0C
(100.4F)
B. Chest pain
C. Orthopnea
D. Wheezes
E. Rhonchi
837.
In a patient with
chronic hepatitis B,
which one of the
following findings
suggests that the
infection is in the
active phase? (check
one)
A. A normal liver
biopsy
B. Detectable levels of
HBeAb
C. Detectable levels of
HBsAb
D. Elevated levels of
ALT
E. Undetectable levels
of HBV DNA
D. Elevated levels of ALT. Chronic hepatitis B develops in a small percentage of adults who fail to recover
from an acute infection, in almost all infants infected at birth, and in up to 50% of children infected between
the ages of 1 and 5 years. Chronic hepatitis B has three major phases: immune-tolerant, immune-active, and
inactive-carrier.There usually is a linear transition from one phase to the next, but reactivation from
immune-carrier phase to immune-active phase also can be seen.
Active viral replication occurs during the immune-tolerant phase when there is little or no evidence of
disease activity, and this can last for many years before progressing to the immune-active phase (evidenced
by elevated liver enzymes, indicating liver inflammation, and the presence of HBeAg, indicating high levels
of HBV DNA). Most patients with chronic hepatitis B eventually transition to the inactive-carrier phase, which
is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by
normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.
838.
In a patient with
hypertriglyceridemia, the National
Cholesterol Education Program
recommends that a reasonable
goal for non-HDL cholesterol is no
more than (check one)
A. 30 mg/dL above the LDL-cholesterol level. The National Cholesterol Education Program's
Adult Treatment Panel III recommends a goal non-HDLcholesterol level of no more than 30
mg/dL greater than the LDL-cholesterol level. This is based on a "normal" very low density
lipoprotein cholesterol level being defined as that present when triglycerides are <150 mg/dL.
This value typically is 30 mg/dL. Conversely, when triglyceride levels are >150 mg/dL, very low
density lipoprotein is usually >30 mg/dL.
B. Milk. Reducing consumption of red meat, seafood, and alcohol may help reduce the risk of a
gout attack. Dairy products, in contrast to other foods high in protein, decrease the risk of
another attack. Nuts and beans are high in purines and will worsen gout.
A. Red meat
B. Milk
C. Seafood
D. Nuts
E. Beans
840.
C. Ferritin low, TIBC high, serum iron low. Ferritin and serum iron levels fall with iron deficiency.
Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the
plasma protein that binds to iron for transport throughout the body) when iron levels are low.
841.
In a patient with
symptoms of
thyrotoxicosis and
elevated free thyroxine (T4
), the presence of thyroid
TSH receptor site
antibodies would indicate
which one of the following
as the cause of thyroid
gland enlargement? (check
one)
E. Graves' disease. When there is a question about the etiology of goiter and thyrotoxicosis, the
presence of thyroid TSH receptor immunoglobulins would indicate the presence of Graves' disease,
which is considered an autoimmune disease. The prevalence of specific forms of TSH receptor site
antibodies can distinguish Graves' disease from Hashimoto's disease. Both are autoimmune diseases,
but in Graves' disease there is a predominance of TSH receptor antibodies. In Hashimoto's disease TSH
receptor-blocking antibodies are more predominant. These immunoglobulins tend to disappear during
therapy.
A. Toxic multinodular
goiter
B. Toxic adenoma
C. Hashimoto's
(lymphadenoid)
thyroiditis
D. Subacute (giant cell)
thyroiditis
E. Graves' disease
842.
B. 14 days. A helpful guideline for assessing normal growth in the very young infant is that birth weight
should be regained within 14 days.
A. 5 days
B. 14 days
C. 21 days
D. 28 days
843.
In a study to evaluate a
test as a screen for the
presence of a disease, 235
of the 250 people with the
disease had a positive test
and 600 of the 680 people
without the disease had a
negative test. Based on
this data, the specificity of
the test for the disease is
(check one)
A. 235/250 = 94%
B. 15/250 = 6%
C. 600/680 = 88%
D. 80/680 = 12%
E. 15/80 = 19%
C. 600/680 = 88%. The specificity of a test for a disease is the proportion or percentage of those without
the disease who have a negative test. In this case, option A is the sensitivity, i.e., the proportion of those
with the disease who have a positive test. Option B is the false-negative rate and option D is the falsepositive rate. Option E is the ratio of false-negative tests to false-positive tests, a meaningless ratio. The
predictive values of positive and negative tests are extremely important characteristics of a screening
test. Determination of these values requires knowledge of the prevalence of the disease in the
population screened, as well as the sensitivity, specificity, and false-positive and false-negative rates.
Since the prevalence of most diseases is low, the percentage of those with a positive test (the predictive
value of a positive test) is relatively low, even when sensitivity and specificity are high. When prevalence
is low, however, the predictive value of a negative test is very high and may approach 100%.
844.
845.
846.
C. Phenytoin (Dilantin). All of the drugs listed are inhibitors of the cytochrome P450
enzyme except phenytoin, which is a potent inducer. Grapefruit juice is also a
cytochrome P450 enzyme inhibitor.
847.
A. Group B Streptococcus
B. Mycoplasma pneumoniae
C. Bordetella pertussis
D. Parainfluenza virus 3
E. Respiratory syncytial virus
848.
849.
850.
In healthy adults, performance on the Folstein MiniMental State Examination is affected by which one of
the following? (check one)
A. Educational attainment
B. Socioeconomic status
C. Gender
D. Race
851.
In order to be
eligible for
Medicare
hospice
benefits, a
patient must be
entitled to
Medicare Part A
and: (check
one)
B. have a life expectancy of 6 months or less. The Medicare Hospice Benefit reimburses hospice providers for the
care of terminally ill patients. In order to be eligible for this benefit, patients must be entitled to Medicare Part A and
be certified by both the personal physician and the hospice medical director as having a life expectancy of 6
months or less. Services covered include physician services; nursing services; social services; counseling services;
physical, occupational, and speech therapy; diagnostic testing; home health aides; homemaker services; and
medical supplies. These services may be provided in the patient's home or in the hospital setting. Malignancy,
ambulatory status, caregiver availability, and do-not-resuscitate orders are not specifically related to eligibility
requirements for this benefit.
A. be essentially
bedridden
B. have a life
expectancy of 6
months or less
C. have a
hematologic or
a solid tumor
malignancy
D. have a
caregiver in the
home who is
present at least
50% of the time
E. have
documentation
of a do-notresuscitate
(DNR) order
852.
In patients with
breast cancer,
the most
reliable
predictor of
survival is
(check one)
A. estrogen
receptor status
B. cancer stage
at the time of
diagnosis
C. tumor grade
D. histologic
type
E. lymphatic or
blood vessel
involvement
B. cancer stage at the time of diagnosis. The most reliable predictor of survival in breast cancer is the stage at the
time of diagnosis. Tumor size and lymph node involvement are the main factors to take into account. Other
prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been
proposed as important variables, but most microscopic findings other than lymph node involvement correlate
poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to
be less aggressive than ER-negative tumors.
853.
854.
855.
C. <130/80 mm Hg. Treatment of hypertension reduces the risk of stroke, myocardial infarction, and heart
failure. For most patients, JNC-7 recommends a goal blood pressure of <140/90 mm Hg. However, the goal
for patients with chronic kidney disease (CKD) or diabetes mellitus is <130/80 mm Hg. Both conditions are
independent risk factors for cardiovascular disease. The National Kidney Foundation and the American
Society of Nephrology recommend treating most patients with CKD with an ACE inhibitor or angiotensin
receptor blocker (ARB), plus a diuretic, with a goal blood pressure of <130/80 mm Hg. Most patients with
CKD will require two drugs to reach this goal.
C. over the medial proximal tibia. The pes anserine bursa is associated with the tendinous insertion of the
sartorius, gracilis, and semitendinosus muscles into the medial aspect of the proximal tibia. Commonly
associated with early osteoarthritis in the medial knee compartment, pes anserine bursitis can also result
from overuse of the involved muscles or from direct trauma to the area. A patient with pes anserine
bursitis will generally complain of pain in the area of insertion when flexing and extending the knee and
tenderness of the area will be noted on examination. Slight swelling may be present but no effusion is
generally evident. Treatment may include oral anti-inflammatory agents, physical therapy, and
corticosteroid injection.
856.
In prescribing an
exercise program for
elderly, communitydwelling patients, it is
important to note
that: (check one)
A. Graded exercise
stress testing should
be done before
beginning the
program
B. Target heart rates
should be 80% of the
predicted maximum
C. The initial routines
can be as short as 6
minutes repeated
throughout the day
and still be beneficial
D. Treadmill walking
is especially beneficial
to patients with
peripheral
neuropathy
C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial. Initial
exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of
exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level
exercise is planned. A target heart rate of 60%-75% of the predicted maximum should be set as a ceiling.
Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the
risk of damage to their feet.
857.
858.
859.
D. are homebound. Factors associated with a higher risk of heat-related death 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 death 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.
A. ACE inhibitors
B. Hormone therapy
C. Calcium channel blockers
D. Vitamin E
E. Oral glycoprotein IIb/IIIa
receptor inhibitors
Oral glycoprotein IIb/IIIa receptor inhibitors appear to increase the risk of mortality when
compared with aspirin. Calcium channel blockers, class I anti-arrhythmic agents, and sotalol all
appear to increase mortality compared with placebo in patients who have had a myocardial
infarction. Contrary to decades of large observational studies, multiple randomized, controlled
trials show no cardiac benefit from hormone therapy in postmenopausal women.
860.
D. child neglect. Neglect is the most common form of child abuse (60% of cases) and is the most common
cause of death in abused children. It is defined by the Office on Child Abuse and Neglect as failure to
provide for a childs basic physical, emotional, educational/cognitive, or medical needs.
A. physical abuse
B. emotional abuse
C. sexual abuse
D. child neglect
861.
D. Pertussis. In the United States, deaths from pertussis increased from 4 deaths in 1996 to 17 deaths in
2001, and a total of 56 deaths from 2001 to 2003. Immunity has decreased in previously vaccinated
adolescents and adults, and now they are a reservoir for infection. Tdap vaccine is recommended as a
single booster for patients age 19-65, and those between the ages of 11 and 18 years should receive Tdap
rather than a Td booster. The Tdap vaccine protects against pertussis, in addition to tetanus and
diphtheria. Tetanus and rubella deaths are not increasing. There are no vaccines for hepatitis C or West
Nile virus.
A. Tetanus
B. Hepatitis C
C. Rubella
D. Pertussis
E. West Nile virus
862.
A. Iron. Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest
in children and in women of childbearing age (especially pregnant women).
863.
A. A 5-year-old female who is otherwise healthy. The live, attenuated influenza vaccine is an option for
vaccinating healthy, nonpregnant individuals age 5-49 years. The vaccine is administered intranasally. It is
not indicated in patients with underlying medical conditions, such as chronic pulmonary or cardiovascular
disease, or in patients with a history of Guillain-Barr syndrome, pregnant patients, or children and
adolescents who receive long-term aspirin or salicylate therapy. Patients with a history of hypersensitivity to
eggs should not receive this vaccine.
A. A 5-year-old female
who is otherwise
healthy
B. A 12-year-old male
who has a history of
severe persistent
asthma
C. A 21-year-old
female who has a
history of GuillainBarr syndrome
D. A 24-year-old
female who is 24
weeks pregnant
E. A 55-year-old
healthy male who
requests influenza
vaccine
864.
Intravenous
magnesium is used to
correct which one of
the following
arrhythmias? (check
one)
A. Wenckebach
second-degree heart
block
B. Complete heart
block
C. Idioventricular
rhythm
D. Reentrant
supraventricular
tachycardia
E. Ventricular
tachycardia of
torsades de pointes
865.
In which one of
the following
patients can a
diagnosis of
osteoporosis be
made? (check one)
A. A 58-year-old
female who
fractured her
wrist when she
slipped and fell on
her outstretched
hand onto a
carpeted floor
B. A 62-year-old
female who
sustained a pelvic
fracture in a
motor vehicle
accident
C. A 52-year-old
female with a Tscore of +2.5 on
bone mineral
density (BMD)
testing of her hip
D. A 67-year-old
female with a Tscore of -1.7 on
BMD testing of her
spine
E. A 72-year-old
female with a Tscore of -2.0 on
BMD testing of her
spine
A. A 58-year-old female who fractured her wrist when she slipped and fell on her outstretched hand onto a
carpeted floor. Osteoporosis is defined as a fragility or low-impact fracture, or as a spine or hip bone mineral
density (BMD) 2.5 standard deviations below the mean for young, healthy women. A fracture of the radius
caused by a fall from a standing position would be considered a low-impact fracture. A fracture resulting from a
motor vehicle accident would be considered a high-impact fracture, which is not diagnostic for 11 osteoporosis. A
T-score of -2.5 or less is considered osteoporosis, a T-score between -1.0 and -2.5 is considered osteopenia, and a
T-score of -1.0 or higher is considered normal.
866.
In which one of
the following
scenarios is a
physician most
likely to be
protected by a
Good Samaritan
statute? (check
one)
A. Assisting
flight attendants
with the care of
a fellow
passenger who
develops
respiratory
distress while in
flight over the
United States
B. Attending to
an unconscious
player while
acting as an
unpaid
volunteer
physician at a
high-school
football game
C. Attending to a
bicyclist with
heat exhaustion
while
volunteering at
a first-aid
station during a
fund-raising ride
D. Attending to
the family
member of a
patient who
slips and falls in
the waiting
room at the
physician's
office
E. Attending to a
nurse's aide who
collapses while
the physician is
staffing the
hospital
emergency
department
A. Assisting flight attendants with the care of a fellow passenger who develops respiratory distress while in flight
over the United States. Generally, Good Samaritan laws apply to situations in which the physician does not have a
preexisting duty to provide care to the patient. A physician who volunteers as a standby health care provider at
an event assumes a duty to care for illness or injury in the participants. Likewise, physicians have a duty to provide
emergency care to a person in need within a facility where they are working, such as a medical office or an
emergency department. On an airplane, there is no preexisting duty for a physician to attend to a fellow
passenger who becomes ill. In addition, a specific federal law, the Aviation Medical Assistance Act, ensures that
physicians have Good Samaritan protection if they provide medical assistance while in flight over the United
States.
867.
E. A 16-year-old female who has driven herself to her clinic appointment reports a 2-day history of ear pain;
she says her mother made this appointment for her. Informed consent to treat is considered an important
ethical and legal part of caring for children and adolescents. Some situations can become confusing when
trying to balance the need for treatment, a child's assent, and a parent or guardian's permission. In most
states, 18 is the age when legal decisions can be made; however, in some states it is 21.
Children under the age of majority must have proof of permission to treat from a parent or guardian for
non-emergent care. This does not apply to emergency situations in which a delay in care could result in
serious harm. Another exception to parental consent is when a child is considered emancipated under state
law. This can happen with a court order, or (in some states) if the child is married, is a parent, is in the
military, or is living independently. Either biologic parent can consent to treatment unless one of them is
explicitly denied guardianship. If a child presents with a non-emergent condition and does not have
evidence of permission from a parent or guardian, permission should be sought before the physician
interaction takes place.
868.
869.
870.
872.
E. no screening for asymptomatic individuals. The U.S. Preventive Services Task Force
states that there is insufficient evidence to recommend either for or against screening for
cancer of the lung. To date, screening has not been shown to decrease the number of
deaths from lung cancer. Case control studies done in Japan suggest improved mortality
with annual chest radiographs, and a large randomized, controlled trial is now under way.
While screening CT in high-risk groups would identify a high percentage of stage 1 lung
cancers, there is no data available at this time from randomized studies to show that this is
worthwhile. Studies of this issue are also currently under way, however.
874.
875.
E. Percentage of body fat. The physiologic changes that accompany aging result in altered
pharmacokinetics. Drug distribution is one important factor. In older persons, there is a
relative increase in body fat and a relative decrease in lean body mass, which causes
increased distribution of fat-soluble drugs such as diazepam. This also increases the
elimination half-life of such medications. The volume of distribution of water-soluble
compounds such as digoxin is decreased in older patients, which means a smaller dose is
required to reach a given target plasma concentration. There is a predictable reduction in
glomerular filtration rate and tubular secretion with aging, which causes decreased
clearance of medications in the geriatric population. The absorption of drugs changes little
with advancing age. All of these changes are important factors in choosing dosages of
medications in the elderly population.
D. Screening mammography. Medicare pays for some preventive measures, including
pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou test
every 3 years. Medicare does not pay for custodial care, nursing-home care (except
limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids,
routine physical checkups and related tests, or prescription drugs.
876.
877.
C. Polycystic ovary syndrome. Recent data suggest that insulin resistance and
hyperinsulinemia are important in the pathogenesis of polycystic ovary syndrome (POS).
Treatment with drugs that reduce insulin levels, such as metformin, has been shown to correct
many of the metabolic abnormalities associated with POS. Such correction results in
resumption of ovulation, decreased insulin resistance, and improved beta-cell function; it also
produces improvement in cardiovascular risk factors such as dyslipidemia and impaired
fibrinolysis.
C. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4
weeks. Chronic paronychia is a common condition in workers whose hands are exposed to
chemical irritants or are wet for long periods of time. This patient is an otherwise healthy
hairdresser, with frequent exposure to irritants. The patient should be advised to avoid
exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids
over several weeks can greatly reduce the inflammation, allowing the nail folds to return to
normal and helping the cuticles recover their natural barrier to infection. Soaking in iodine
solution would kill bacteria, but would also perpetuate the chronic irritation. Because the
condition is related to chemical and water irritation, a prolonged course of antibiotics should
not be the first treatment step, and could have serious side effects. There is no need to explore
less likely autoimmune causes for nail changes at this time.
D. Cognitive function. The MMSE is most commonly used in clinical settings. It is considered
valuable because it assesses a broad range of cognitive abilities (i.e., memory, language, spatial
ability, set shifting) in a simple and straightforward manner. In addition, the wide use of the
MMSE in epidemiologic studies has yielded cutoff scores that facilitate the identification of
patients with cognitive dysfunction.
879.
A. An SSRI. An SSRI is the treatment of choice for patients who have never had
pharmacotherapy for panic disorder.
A. An SSRI
B. A tricyclic antidepressant
C. Valproic acid (Depakene)
D. Lithium
881.
B. 5% permethrin cream (Elimite). In adults and children over 5 years of age, 5% permethrin
cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and
minimally toxic.
E. Bacterial vaginosis. Bacterial vaginosis (BV) is the most common cause of acute vaginitis,
accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal
vaginal flora. BV is considerably more common as a cause of vaginal discharge than C. albicans
and T. vaginalis.
883.
884.
A. Cardiac dysrhythmia
B. Medications
C. Orthostatic hypotension
D. Psychiatric disorders
E. Vasovagal syncope
885.
D. Orthostatic proteinuria. Orthostatic proteinuria accounts for up to 60% of all cases of asymptomatic
proteinuria reported in children, with an even higher incidence in adolescents.
A. Acute postinfectious
glomerulonephritis
B. Lupus glomerulonephritis
C. Hydronephrosis
D. Orthostatic proteinuria
E. Reflux nephropathy
886.
D. methicillin-resistant Staphylococcus aureus (MRSA). Recent clinical experience has shown that
methicillin-resistant Staphylococcus aureus (MRSA) is the most
common identifiable cause of skin and soft-tissue infections among patients presenting to emergency
departments in 11 U.S. cities. The other responses should be considered in evaluating these
infections,
but they are not as common as MRSA infections.
A. Staphylococcus
epidermidis
B. Streptococcus
pneumoniae
C. Pseudomonas aeruginosa
D. methicillin-resistant
Staphylococcus aureus
(MRSA)
E. Bacillus cereus
887.
888.
A. Fetal distress. Fetal distress with prolonged, variable, or late decelerations and bradycardia is the most
common, and often only, sign of uterine rupture. The other signs listed are unreliable and often absent.
A. Fetal distress
B. Sudden, tearing
uterine pain
C. Vaginal
hemorrhage
D. Cessation of
uterine contractions
E. Regression of the
fetus
889.
D. 800 IU vitamin D and 1200 mg calcium. The most effective daily dose of vitamin D for hip fracture
prevention in postmenopausal women is 800 IU, and the recommended daily dose of calcium is 1200 mg.
A. 800 IU vitamin D
and 500 mg calcium
B. 400 IU vitamin D
and 500 mg calcium
C. 400 IU vitamin D
and 1000 mg calcium
D. 800 IU vitamin D
and 1200 mg calcium
890.
A. Longstanding pruritus. The most common symptom of vulvar cancer is longstanding pruritis. The other
symptoms mentioned occur less frequently.
A. Longstanding
pruritus
B. Bleeding
C. Pain
D. Discharge
E. Dysuria
891.
D. central retinal artery occlusion. The retinal findings shown are consistent with central retinal artery
occlusion. The painless, unilateral, sudden loss of vision over a period of seconds may be caused by
thrombosis, embolism, or vasculitis. Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of
vision often associated with a red eye, which will lead to blindness if not treated. In persons with optic
neuritis, funduscopy reveals a blurred disc and no cherry-red spot. Occlusion of the central retinal vein
causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages.
892.
893.
A. human parvovirus. All of these viruses can cause an erythematous exanthem; however, this
description is classic for fifth disease, or erythema infectiosum. It was the fifth exanthem to be
identified after measles, scarlet fever, rubella, and Filatov-Dukes disease (atypical scarlet fever).
Roseola infantum is known as sixth disease.
Erythema infectiosum is caused by parvovirus B19. It presents with the typical viral prodrome,
along with mild upper respiratory symptoms. The hallmark rash has three stages. The first is a
facial flushing, described as a "slapped cheek" appearance. In the next stage, the exanthem can
spread concurrently to the trunk and proximal extremities as a diffuse macular erythematous
rash. Finally, central clearing of this rash creates a lacy, reticulated appearance, as seen in Figure
1. This rash tends to be on the extensor surfaces and spares the palms and soles. It resolves in 13 weeks but can recur with heat, stress, and exposure to sunlight.
C. Avascular necrosis. Avascular necrosis is the most serious complication of a slipped capital
femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and
total hip replacement early in adulthood.
A. Osteomyelitis
B. Pathologic fracture
C. Avascular necrosis
D. Chondrolysis
894.
895.
897.
A mother brings in her 2-week-old infant for a well child check. She
reports that she is primarily breastfeeding him, with occasional
formula supplementation.
Which one of the following should you advise her regarding vitamin D
intake for her baby? (check one)
A. Breastfed infants do not need supplemental vitamin D
B. As long as the baby is taking at least 16 oz of formula per day, he
does not need supplemental vitamin D
C. The baby should be given 400 IU of supplemental vitamin D daily
D. Intake of vitamin D in excess of 200 IU/day is potentially toxic
E. Vitamin D supplementation should not be started until he is at
least 6 months old
898.
899.
901.
903.
904.
905.
906.
A nursing-home resident is
hospitalized, and shortly before she
is to be discharged she develops a
skin ulcer, which proves to be
infected with methicillin-resistant
Staphylococcus aureus (MRSA).
Which one of the following is most
important in terms of infection
control when she returns to the
nursing home? (check one)
A. Surveillance cultures of nursinghome residents living near the
patient
B. Aggressive housekeeping in the
patient's room
C. Masks, gowns, and gloves for all
those entering the patient's room
D. Strict handwashing practices by
all staff, visitors, and residents
E. Isolation of the patient in a room
by herself
B. Test the nurse for hepatitis B antibody. Postexposure prophylaxis after hepatitis B
exposure via the percutaneous route depends upon the source of the exposure and the
vaccination status of the exposed person. In the case described, a vaccinated person has
been exposed to a known positive individual. The exposed person should be tested for
hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay,
negative by enzyme immunoassay) HBIG should be administered immediately, as well as a
hepatitis B vaccine booster dose. An unvaccinated individual in this same setting should
receive HBIG immediately (preferably within 24 hours after exposure) followed by the
hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month
and a third dose in 6 months).
D. Strict handwashing practices by all staff, visitors, and residents. All staff, visitors, and
nursing-home residents should observe strict handwashing practices in this situation. Barrier
precautions for wounds and medical devices should also be initiated. Surveillance cultures
are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the
spread of MRSA. Isolating the patient is not practical or cost-effective.
907.
D. I and AVL. Circumflex occlusion causes changes in I, AVL, and possibly V5 and V6 as well.
Left anterior descending coronary artery occlusion causes changes in V1 to V6. Right
coronary occlusion causes changes in II, III, and AVF.
A. V1 and V2
B. V3 and V4
C. II, III, and AVF
D. I and AVL
909.
B. Tibial apophysitis. The three most common knee conditions in children and adolescents
are patellar subluxation, tibial apophysitis, and patellar tendinitis. Gout, osteoarthritis, and
popliteal cysts present in older adults. Inflammatory arthritis is more common in adults
than in children.
A. Gout
B. Tibial apophysitis
C. A popliteal cyst
D. Inflammatory arthropathy
E. Pes anserine bursitis
910.
A. Citalopram (Celexa). Like all drugs, SSRIs have significant side effects, including
inhibition of the cytochrome P-450 system. However, citalopram is least likely to inhibit this
system, making it a preferred SSRI for patients taking multiple medications for other
illnesses.
911.
B. Increased intake of omega-3 fats. Omega-3 fats contribute to the production of eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet
aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart
Association guidelines state that omega-3 supplements may be recommended to patients with
preexisting disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like
or are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily resulted
in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with particular decreases in
the rate of sudden death.
A. Increased intake of
plant protein
B. Increased intake of
omega-3 fats
C. Increased intake of
dietary fiber and whole
grains
D. Increased intake of
monounsaturated oils
E. Moderate alcohol
consumption (1 or 2
standard drinks per day)
912.
D. familial adenomatous polyposis. People with familial adenomatous polyposis typically develop
hundreds or thousands of polyps in their colon and rectum, usually in their teens or early adulthood.
Cancer usually develops in one or more of these polyps as early as age 20. By age 40, almost all people
with this disorder will have developed cancer if preventive colectomy is not performed.
The approximate lifetime risk of colon cancer in the general population of the United States is 6%. Most
case-control studies of cigarette exposure and adenomas have found an elevated risk for smokers.
Tobacco use raises the risk of colon cancer by approximately 50%.
Patients with ulcerative colitis are at increased risk for colon cancer. The anatomic extent and duration of
the disease correlate with the degree of risk. In one meta-analysis, investigators found that the risk of
colon cancer was 2% in the first 10 years after ulcerative colitis develops, 8% during the first 20 years, and
18% during the first 30 years.
The evidence is still evolving regarding the level of future risk of colon cancer associated with having had
an adenomatous polyp removed in the past, but it may approach a doubling of the baseline risk of colon
cancer. Studies suggest a clear association with a history of multiple polyps or a single large (>1 cm) polyp.
The data is less clear for single small adenomas. Of the three types of adenomas (tubular, tubulovillous,
and villous), villous adenomas are most likely to develop into adenocarcinomas.
Having a family history of a first degree relative with colon cancer raises the risk approximately two-to
threefold. If that relative was younger than age 50 at the time of diagnosis the risk is three-to fourfold
higher.
913.
A. Labetalol (Trandate, Normodyne) intravenously. In pregnant women with severe hypertension, the
primary objective of treatment is to prevent cerebral complications such as encephalopathy and
hemorrhage. Intravenous hydralazine, intravenous labetalol, or oral nifedipine may be used. Sublingual
nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short
intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions
lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy.
A. Labetalol
(Trandate,
Normodyne)
intravenously
B. Reserpine
(Serpasil)
intramuscularly
C. Nifedipine
(Procardia, Adalat)
sublingually
D. Enalapril (Vasotec)
intravenously
914.
Of the following,
which is the most
frequent cause of
seizures in the
elderly? (check one)
B. Stroke. The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in
the elderly, including primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric
population, cerebrovascular disease is the most common cause of seizures, with about 10% of stroke victims
developing epileptic seizures. Seizures are more common following hemorrhagic strokes compared to
nonhemorrhagic strokes.
A. Alcohol
withdrawal
B. Stroke
C. Head trauma
D. Hypoglycemia
E. Dementia
915.
Of the following,
which one causes the
most deaths in the
United States? (check
one)
A. Colorectal cancer
B. Breast cancer
C. Prostate cancer
D. Lung cancer
D. Lung cancer. Lung cancer is the leading cause of cancer-related deaths in the United States. In 2006, lung
cancer caused more deaths than colorectal, breast, and prostate cancers combined.
916.
Of the following,
which one is most
consistent with
this patient's
history and
examination?
(check one)
A. Guttate
psoriasis
B. Tinea
versicolor
C. Radiation
dermatitis
D. Cutaneous Tcell lymphoma
E. Pityriasis rosea
917.
Of the following,
which one is the
most common
adverse event to
complicate the
hospital course of
patients age 65
and over? (check
one)
A. Falls
B. Wound
infections
C. Drug-related
events
D. Procedurerelated events
E. Anesthesiarelated events
E. Pityriasis rosea. This presentation is typical of pityriasis rosea. There was a mild prodrome, thought to be jet lag
by this patient, followed by the development of an ovoid salmon-colored, slightly raised herald patch, most
commonly seen on the trunk. This was followed by an outbreak of multiple smaller, similar lesions that trend
along Langer's lines. In this case, clear evidence of the herald patch remains visible in the left interscapular
region, which is helpful in confirming the diagnosis.
Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a
triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however,
the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from
pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous,
scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of
radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols
and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a
nonspecific dermatitis, most commonly in men over the age of 50.
An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some
evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no
residual signs other than postinflammatory hyperpigmentation.
C. Drug-related events. It has been observed that drug-related problems are the most common type of adverse
event, and for hospitalized patients the rate of these events increases with the patient's age. One study showed
that in patients who are >65 years of age, the number of events per 1000 discharges was 11.46 for drug-related
events, 6.15 for wound infection, 3.85 for procedure-related events, 3.19 for falls, and 0.09 for anesthesia-related
events.
918.
A. Fluoxetine (Prozac)
B. Buspirone (BuSpar)
C. Prochlorperazine
(Compazine)
D. Omeprazole (Prilosec)
E. Metoclopramide (Reglan)
919.
B. Rifampin, 600 mg every 12 hours for 2 days. Health-care workers exposed to a patient with
meningococcal meningitis are at increased risk of developing systemic disease and should receive
chemoprophylaxis, especially if the contact is intimate. Secondary cases usually occur within 4 days of
the initial case. Therefore, prophylactic treatment should begin as soon as possible. Rifampin has
been shown to be 90% effective in eliminating meningococcus from the nasopharynx. Other
appropriate chemoprophylactic agents include minocycline and ciprofloxacin. Even high doses of
penicillin may not eradicate nasopharyngeal meningococci. Prednisone has no place in
chemoprophylaxis. Meningococcal vaccine appears to have clinical efficacy, but it usually takes more
than 5 days to become effective.
A. Penicillin G benzathine
(Bicillin LA), 1.2 million units
intramuscularly
B. Rifampin, 600 mg every 12
hours for 2 days
C. Oral prednisone, 40 mg
daily for 5 days
D. Quadrivalent
meningococcal vaccine
E. No prophylaxis
920.
921.
C. hookworm. When third-stage hookworm larvae, most commonly of the species infecting
dogs and cats, penetrate the skin and migrate through the dermis, they create the
serpiginous, erythematous tracks characteristic of cutaneous larva migrans. Although this
dermatosis can occur in northern areas when conditions are ideal, it is most often
encountered in tropical and semitropical regions such as the Caribbean, Africa, Asia, and
South America.
Travelers to beach environments where pet feces have been previously deposited are most
at risk because of the direct contact of bare skin with the sand. As in this case, a stinging or
itching sensation may be noted upon penetration; this is followed by the development of the
creeping eruption, which usually appears 1-5 days later, although the onset may be delayed
for up to a month. The larvae will not develop in the human host, so the infection is selflimited, usually resolving within weeks to months. Treatment with antihelminthic drugs can
greatly reduce the clinical course. Preventive measures include treatment of infected dogs
and cats and limiting exposure to contaminated soil by wearing shoes and protective clothing.
E. 1500 mg/day. For treating acute otitis media in this patient, the current recommended
dosage of amoxicillin is 80-90 mg/kg/day.
A. 375 mg/day
B. 500 mg/day
C. 750 mg/day
D. 1000 mg/day
E. 1500 mg/day
923.
D. 5 years. Overuse of colonoscopy has significant costs. In response to these concerns, the
American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer
collaborated on a consensus guideline on the use of surveillance colonoscopy. According to
these guidelines, patients with one or two small (<1 cm) tubular adenomas, including those
with only low-grade dysplasia, should have their next colonoscopy in 5-10 years (SOR B).
924.
925.
E. fluoxetine (Prozac). Fluoxetine is the only SSRI approved by the FDA for the
treatment of depression in children 8-17 years of age, although all of the
antidepressants may be used off-label . The FDA has warned against the use
of paroxetine in this age range because of a possible increased risk of suicidal
thinking and suicide attempts associated with the drug. Tricyclic
antidepressants have more side effects and can be lethal in overdose. In
children and adolescents, there is limited or no evidence evaluating the use of
lithium, monoamine oxidase inhibitors, St. Johns wort, or venlafaxine.
A. Alcohol consumption
B. Caffeine consumption
C. Cigarette smoking
D. Cocaine use
E. A high-fat diet
926.
927.
B. Herpes zoster dermatitis. Herpes zoster can occur from either a wild strain
or a vaccine strain of varicella-zoster virus in vaccinated children, but the
incidence is low. All cases are mild and uncomplicated.
929.
A. Amoxicillin
B. Erythromycin
C. Ketoconazole
D. Nystatin (Mycostatin)
E. Triamcinolone (Kenalog)
930.
D. Testing for viral hepatitis. Nonalcoholic fatty liver disease is the most likely
diagnosis in this patient, but hepatitis B and C should be ruled out. The
patient's alcohol consumption of less than two drinks per week makes alcoholic
fatty liver disease unlikely. A liver biopsy would not be appropriate at this time.
Liver ultrasonography should be considered after hepatitis B and C are ruled
out. The patient is younger than the recommended screening age for
colonoscopy.
A. A liver biopsy
B. Ultrasonography of the liver
C. Colonoscopy
D. Testing for viral hepatitis
E. Repeat AST and ALT levels in 3 months
931.
932.
B. Pseudomonas. Pseudomonas organisms have been associated with outbreaks of otitis externa,
dermatitis, and folliculitis in persons using swimming pools and hot tubs.
A. Listeria
B. Pseudomonas
C. Streptococcus
D. Shigella
E. Staphylococcus
933.
Outbreaks of diarrheogenic
Escherichia coli 0157:H7 have
been associated with which
one of the following? (check
one)
C. Ground beef. Recent outbreaks of E. coli 0157:H7-related illnesses have been associated with
contaminated ground beef bought either uncooked in supermarkets or as cooked hamburgers at
fast-food restaurants.
A. Pet turtles
B. Ice cream
C. Ground beef
D. Canned sardines
E. Home-preserved vegetables
934.
D. Crohn's disease. The most common age of onset for inflammatory bowel disease is during
adolescence and young adulthood, with a second peak at 50-80 years of age. The manifestations of
Crohn's disease are somewhat dependent on the site of involvement, but systemic signs and
symptoms are more common than with ulcerative colitis. Perianal disease is also common in Crohn's
disease. Irritable colon and other functional bowel disorders may mimic symptoms of Crohn's
disease, but objective findings of weight loss and anal lesions are extremely uncommon. This is also
true for viral hepatitis and giardiasis. In addition, the historical and epidemiologic findings in this
case are not consistent with either of these infections. Celiac disease and giardiasis can produce
Crohn's-like symptoms of diarrhea and weight loss, but are not associated with anal fissures.
935.
C. Laboratory testing. Testing for androgen excess is indicated in the young woman with
an acute onset of hirsutism or when it is associated with menstrual irregularity, infertility,
central obesity, acanthosis nigricans, or clitoromegaly. It should be kept in mind that
excess hair has a male pattern in women with hirsutism, whereas hypertrichosis is
characterized by excessive hair growth all over the body.
Elevated early morning total testosterone is most often associated with polycystic ovary
syndrome, but other causes of hyperandrogenism and other endocrinopathies should
be eliminated. These studies should include pregnancy testing if the patient has
amenorrhea, as well as a serum prolactin level to exclude hyperprolactinemia. DHEA-S
and early morning 17-hydroxyprogesterone can detect adrenal hyperandrogenism and
congenital adrenal hyperplasia. Assessment for Cushing syndrome, thyroid disease, or
acromegaly is appropriate if associated signs or symptoms are present. Pelvic
ultrasonography can be performed to evaluate for ovarian neoplasm or polycystic
ovaries, although PCOS is a clinical diagnosis and ultrasonography has a low sensitivity.
937.
A. Metformin (Glucophage). Metformin and insulin are the only agents approved
for treatment of type 2 diabetes mellitus in children.
A. Metformin (Glucophage)
B. Glyburide (DiaBeta)
C. Sitagliptin (Januvia)
D. Pioglitazone (Actos)
E. Acarbose (Precose)
938.
B. BMI percentile for age and gender. In children, overweight and obesity is
determined by the BMI percentile for age and gender. In adults, BMI, body fat
percentage, and abdominal girth are used to determine a patient's classification
(SOR B).
A. Body weight
B. BMI percentile for age and gender
C. Individual BMI
D. Abdominal girth
E. Percentage of body fat
939.
940.
D. Excision of the lateral nail plate combined with lateral matricectomy. Excision of
the lateral nail plate with lateral matricectomy yields the best results in the
treatment of painful ingrown toenails that display granulation tissue and lateral
nail fold hypertrophy. Antibiotic therapy and cotton-wick elevation are
acceptable for very mildly inflamed ingrown toenails. Partial nail avulsion often
leaves a spicule of nail that will grow and become an ingrown nail. Phenol
produces irregular tissue destruction and significant inflammation and discharge
after the matricectomy procedure.
941.
D. oppositional defiant disorder. This child meets the DSM-IV criteria for
oppositional defiant disorder, defined as a pattern of negativistic, hostile, and
defiant behavior lasting at least 6 months. The child will often lose his or her
temper, argue with adults, actively defy or refuse to comply with adults' requests
or rules, deliberately annoy people, blame others for his or her mistakes or
misbehavior, be easily annoyed by others, appear angry and resentful, or be
spiteful or vindictive. At least four of these behaviors must be present to meet the
criteria for diagnosis. The disturbance in behavior must also cause clinically
significant impairment in social, academic, or occupational functioning, and the
behaviors must not occur exclusively during the course of a psychotic or mood
disorder. Meeting the criteria for conduct disorder excludes the diagnosis of
oppositional defiant disorder. If the individual is 18 years of age or older and
meets the criteria for antisocial personality disorder, then oppositional defiant
disorder is excluded.
A. attention-deficit/hyperactivity disorder
B. bipolar disorder
C. conduct disorder
D. oppositional defiant disorder
E. normal childhood individualization
942.
B. Home care and reevaluation in 24 hours. Most children will be evaluated for a
febrile illness before 36 months of age, with the majority having a self-limited viral
illness. Nontoxic-appearing febrile infants 29-90 days of age who have a negative
screening laboratory workup, including a CBC with differential and a normal
urinalysis, can be sent home and followed up in 24 hours (SOR B). A second
option is to obtain blood cultures and stool studies, or a chest film if indicated by
the history or examination, and spinal fluid studies if empiric antibiotics are to be
given. This infant's clinical status did not indicate that any of these additional
studies should be performed, and empiric antibiotic treatment is not planned.
Observation with no follow-up is an appropriate strategy in nontoxic children,
but only if the child is 3-36 months of age and the temperature is under 39C
(SOR B). Nontoxic children 3-36 months of age should be reevaluated in 24-48
hours if the temperature is over 39C. Although a positive response to
antipyretics has been considered an indication of a lower risk of serious bacterial
infection, there is no correlation between fever reduction and the likelihood of
such an infection. Any infant younger than 29 days, and any infant or child with a
toxic appearance regardless of age, should undergo a complete sepsis workup
and be admitted for observation until culture results are obtained or the source
of the fever is found and treated (SOR A).
943.
Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently
recommended fluoride intake, and has no other functional or physiologic
consequences. Fluoridated toothpaste can cause fluorosis in children younger than 2
years of age, and is therefore not recommended in this age group. Fluoridated
toothpaste by itself does not reliably prevent tooth decay.
Fluoride varnish, applied by a dental or medical professional, is another treatment
option to prevent caries. It provides longer-lasting protection than fluoride rinses, but
since it is less concentrated, it may carry a lower risk of fluorosis than other forms of
supplementation.
Oral fluoride supplementation for children over the age of 6 months is based not only
on age but on the concentration of fluoride in the primary source of drinking water,
whether it be tap water or bottled water. Most municipal water supplies in the United
States are adequately fluoridated, but concentrations vary. Fluoride concentrations in
bottled water vary widely. If the concentration is >0.6 ppm no supplementation is
needed, and may result in fluorosis if given. Lower concentrations of fluoride may
indicate the need for partial or full-dose supplementation.
944.
The parents of
three children ask
your advice about
the need for
fluoride
supplementation
in order to
prevent tooth
decay. Which one
of the following is
true regarding
current U.S.
Preventive
Services Task
Force guidelines
for fluoride
supplementation?
(check one)
A. It is not
recommended
due to potential
fluoride toxicity
B. Dental fluoride
varnish is too
toxic for routine
use
C. Oral fluoride
supplementation
is recommended
if the primary
drinking water
source is low in
fluoride
D. Fluoridated
toothpaste
provides
adequate
protection if used
as soon as the
child has teeth
E. The need for
fluoride
supplementation
is determined by
serum fluoride
levels
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride. The
current (2004) recommendation of the U.S. Preventive Services Task Force is that children over the age of 6
months receive oral fluoride supplementation if the primary drinking water source is deficient in fluoride. They
cite fair evidence (B recommendation) that such supplementation reduces the incidence of dental caries and
conclude that the overall benefit outweighs the potential harm from dental fluorosis. Dental fluorosis is chiefly a
cosmetic staining of the teeth, is uncommon with currently recommended doses, and has no other functional or
physiologic consequences. Fluoridated toothpaste can cause fluorosis in children younger than 2 years of age,
and is therefore not recommended in this age group. By itself it does not reliably prevent tooth decay. Fluoride
varnish, applied by a dental or medical professional, is another treatment option to prevent caries. It provides
longer lasting protection than fluoride rinses, but since it is less concentrated, it may carry a lower risk of fluorosis
than other forms of supplementation. Oral fluoride supplementation for children over the age of 6 months is
based not only on age but on the concentration of fluoride in the primary source of drinking water, whether it be
tap water or bottled water. Most municipal water supplies in the U.S. are adequately fluoridated, but
concentrations vary. Fluoride concentrations in bottled water vary widely. If the concentration is greater than 0.6
ppm no supplementation is needed, and if given, may result in fluorosis. Lower concentrations of fluoride may
indicate the need for partial or full-dose supplementation.
945.
A. Cesarean section
B. Induction of labor with oxytocin
(Pitocin)
C. Cervical ripening with prostaglandins
D. Scheduling a routine prenatal visit in 1
week
946.
947.
B. A physician-led team of care providers taking responsibility for the quality and
safety of an individual's health. The patient-centered medical home (PCMH) is a
development in primary care that stresses a personal physician leading a
multidisciplinary team that takes responsibility for integrating and coordinating an
individual's care. Quality and safety are hallmarks of the PCMH, which stresses
outcome-based and evidence-supported practices. This concept was originated by
organizations in the field of pediatrics and was further developed by a collaboration of
the major academies of primary care. There are institutions that accredit individual and
group practices as fulfilling the role of a PCMH, which are now being compensated at a
higher level by third-party payers, including Medicare.
948.
B. Double effect. The concept of "double effect" dates back to the Middle Ages. It is used to justify
medical treatment designed to relieve suffering when death is an unintended but foreseeable
consequence. It is based on two basic presuppositions: first, that the doctor's motivation is to
alleviate suffering, and second, that the treatment is appropriate to the illness. Distributive justice
relates to the allocations of resources. Death with dignity is a recently introduced concept and is not
a factor in the scenario described here. Futility refers to using a treatment for which there is no
rational justification. Autonomy refers to the patient's ability to direct his or her own care,which is n
ot an issue in this case.
A. Distributive justice
B. Double effect
C. Death with dignity
D. Futility
E. Autonomy
949.
950.
C. Pain in the maleolar zone and bone tenderness of the posterior medial malleolus. The Ottawa
ankle and foot rules are prospectively validated decision rules that help clinicians decrease the use
of radiographs for foot and ankle injuries without increasing the rate of missed fracture. The rules
apply in the case of blunt trauma, including twisting injuries, falls, and direct blows.
According to these guidelines, an ankle radiograph series is required only if there is pain in the
malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of
either the lateral malleolus or the medial malleolus. Inability to bear weight for four steps, both
immediately after the injury and in the emergency department, is also an indication for ankle
radiographs. Foot radiographs are required only if there is pain in the midfoot zone and bone
tenderness at the base of the 5th metatarsal or the navicular, or if the patient is unable to bear
weight both immediately after the injury and in the emergency department.
A positive Thompson sign, seen with Achilles tendon rupture, is the absence of passive plantar foot
flexion when the calf is squeezed.
B. supplemental oxygen. Patients with carbon monoxide poisoning should be treated immediately
with normobaric oxygen, which speeds up the excretion of carbon monoxide.
951.
B. Upper respiratory symptoms. Echinacea is a genus of native North American plants commonly known as
purple coneflower. It has been recommended as a prophylactic treatment for upper respiratory infection,
and is widely used for this indication, although it appears to be relatively ineffective. The research is difficult to
evaluate because of the heterogeneity of the products used in various studies.
A. Memory loss
B. Upper respiratory
symptoms
C. Gastrointestinal
illnesses
D. Depression
E. Fatigue
952.
Patients treated
with which one of
the following
require regular
hematologic
monitoring for the
development of
granulocytopenia?
(check one)
C. Clozapine (Clozaril). Clozapine is one of the so-called second-generation antipsychotics, which are believed
to be less likely to cause extrapyramidal side effects than the first-generation drugs such as haloperidol or the
phenothiazines (e.g., fluphenazine). A 2003 meta-analysis concluded that clozapine was the most efficacious
second-generation antipsychotic, followed by risperidone and olanzapine. However, clozapine use is
associated with an approximately 1% incidence of granulocytopenia or agranulocytosis. Early detection by
monitoring blood counts every 1-2 weeks has led to a reduction in agranulocytosis-related death, but
clozapine is generally considered second-line therapy, to be used in cases unresponsive to other drugs.
A. Olanzapine
(Zyprexa)
B. Haloperidol
(Haldol)
C. Clozapine
(Clozaril)
D. Fluphenazine
(Prolixin)
E. Risperidone
(Risperdal)
953.
Patients with
obstructive sleep
apnea have an
increased risk for
(check one)
A. chronic renal
failure
B. hypertension
C. hypokalemia
D. hypothyroidism
E. sepsis
B. hypertension. Obstructive sleep apnea-hypopnea syndrome is defined as the presence of at least five
obstructive events per hour with associated daytime sleepiness. It is present in 2%-4% of the population. The
prevalence in men is almost three times that seen in premenopausal women and twice that of
postmenopausal women. Other factors associated with an increased prevalence are obesity, older age, and
systemic hypertension.
954.
955.
C. Infliximab (Remicade). Tumor necrosis factor inhibitors have been associated with an
increased risk of infections, including tuberculosis. This class of agents includes
monoclonal antibodies such as infliximab, adalimumab, certolizumab pegol, and
golimumab. Patients should be screened for tuberculosis and hepatitis B and C before
starting these drugs.
The other drugs listed can have adverse effects, but do not increase the risk for
tuberculosis.
A. An ACE inhibitor. It has been shown that congestive heart failure (CHF) patients
treated with ACE inhibitors survive longer, and all such patients should take these
agents if tolerated. Warfarin and/or antiarrhythmic drugs should be given only to
selected CHF patients. Verapamil may adversely affect cardiac function and should be
avoided in patients with CHF. Hydralazine can be used, but because of its side effect
profile would be a second-line agent.
A. An ACE inhibitor
B. Hydralazine (Apresoline)
C. Warfarin (Coumadin)
D. Amiodarone (Cordarone)
E. Verapamil (Calan, Isoptin)
956.
957.
958.
E. Dermatomyositis. In one study, 32% of patients with dermatomyositis had cancer. The
risk of cancer was highest at the time of diagnosis, but remained high into the third year
after diagnosis. The cancer types most commonly found were ovarian, pulmonary,
pancreatic, gastric, and colorectal, as well as non-Hodgkin's lymphoma.Among patients
with polymyositis, 15% developed cancer. Cancer rates in patients with rheumatoid
arthritis, systemic lupus erythematosus, and scleroderma were above those of the general
population, but much lower than for patients with dermatomyositis. In Sjgren's
syndrome, the risk of non-Hodgkin's lymphoma is 44 times higher than in the general
population, with an individual lifetime risk of 6%-10%.
D. Radiofrequency catheter ablation of bypass tracts. Radiofrequency catheter ablation of
bypass tracts is possible in over 90% of patients and is safer and more cost effective than
surgery, with a similar success rate. Intravenous and oral digoxin can shorten the
refractory period of the accessory pathway, and increase the ventricular rate, causing
ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial
fibrillation when conduction proceeds over the bypass tract.
D. Liver enzymes. Red yeast rice (Monascus purpureus) is a widely available dietary
supplement that has been used as an herbal medication in China for centuries. In recent
years it has been used for alternative management of hyperlipidemia in the U.S. Extracts
of red yeast rice contain several active ingredients, including monacolin K and other
monacolins, that have HMG-CoA reductase inhibitory activity and are considered to be
naturally occurring forms of lovastatin. Red yeast rice extract lowers total cholesterol, LDLcholesterol, and triglycerides. It may be useful for patients unable to tolerate statins due to
myalgias, but requires periodic monitoring of liver enzymes because its metabolic effects
and potential for consequences are similar to those of statins.
960.
962.
B. 10-12 g/dL. The Cardiovascular risk Reduction by Early Anemia Treatment with
Epoetin Beta (CREATE) trial, the Correction of Hemoglobin and Outcomes in Renal
insufficiency (CHOIR) trial, and the Trial to Reduce Cardiovascular Events with Aranesp
Therapy (TREAT) have shown that patients who had hemoglobin levels targeted to
normal ranges did worse than patients who had hemoglobin levels of 10-12 g/dL. The
incidence of stroke, heart failure, and death increased in patients targeted to normal
hemoglobin levels, and there was no demonstrable decrease in cardiovascular events
(SOR A).
963.
Pay-forperformance (P4P)
programs provide
financial incentives
for meeting
predetermined
quality targets.
Contracts with
major payors often
include these
programs.
When considering
P4P programs in
such contracts,
physicians should
negotiate for which
one of the
following? (check
one)
A. Guidelines
developed by
academic medicine
researchers
B. Guidelines based
on consensus
opinions
C. Mandatory
physician
participation
D. Reporting of
negative
performance results
to licensure boards
E. Taking patient
compliance into
account when
performing the
evaluation
E. Taking patient compliance into account when performing the evaluation. Pay-for-performance programs are
becoming a critical part of the health care reform debate, and when the discussion began in 2005, over 100
such programs were in existence. The objective is to reward physicians for achieving goals that should lead to
improved patient outcomes. In addition to evaluating clinical performance, many programs now also evaluate
efficiency and information technology. However, many programs are not based on outcomes data, and have
less desirable aspects such as inadequate incentive levels, withholding of payment, limited clinical focus, or
unequal or unfair distribution of incentives. Plans that exclude patient compliance as a factor can lead to
withholding of physician incentives because of patient nonadherence, or to physicians selectively removing
such patients from their panels.
As the exact process is still being defined, all family physicians should be actively engaged in learning more
about these programs, and in negotiating for appropriate measures to be included. The AAFP has seven main
principles in its support for pay-for-performance programs: (1) the focus should be on improved quality of
care; (2) physician-patient relationships should be supported; (3) evidence-based clinical guidelines should be
utilized; (4) practicing physicians should be involved with the program design; (5) reliable, accurate, and
scientifically valid data should be used; (6) physicians should be provided with positive incentives; and (7)
physician participation should be voluntary. Ensuring that patient adherence is included helps prevent
conflicts between patients and their physicians.
A pay-for-performance program should not result in a reduction of fees paid to the physician as a result of
implementing a program. Negative results should not penalize the physician with regard to health plan
credentialing, verification, or licensure.
964.
The physician
counseling a 4-year-old
child about the death of
a loved one should keep
in mind that children in
this age group: (check
one)
A. often feel no sense of
loss
B. often believe they are
somehow responsible
for the death
C. should not attend a
funeral
D. should usually be
told the loved one is
having a long sleep
E. usually accept the
finality of death with
little question
B. often believe they are somehow responsible for the death. Children from the ages of 2 to 6 often believe
they are somehow responsible for the death of a loved one. The emotional pain may be so intense that the
child may react by denying the death, or may somehow feel that the death is reversible. If children wish to
attend a funeral, or if their parents want them to, they should be accompanied by an adult who can
provide comfort and support. Telling a child the loved one is asleep or that he or she "went away" usually
creates false hopes for return, or it may foster a sleep phobia.
965.
The
pneumococcal
polyvalent
vaccine
(Pneumovax 23)
would be
recommended
for which one
of the following
patients?
(check one)
C. A 35-year-old patient recently diagnosed with HIV infection. The Advisory Committee on Immunization Practices
(ACIP) recommends routine pneumococcal vaccination for healthy patients starting at age 65 years. One-time
revaccination after 5 years is recommended only for persons with chronic renal failure or nephrotic syndrome;
functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising
conditions. For persons aged >65 years, one-time revaccination is recommended if they were vaccinated >5 years
previously and were aged <65 years at the time of primary vaccination. Patients over 2 years of age with various
chronic diseases and patients who are immunocompromised also should be vaccinated (SOR A). Children less than
2 years of age should receive the 13-valent conjugate vaccine as a part of their routine well child vaccinations at 2, 4,
6, and 12 to 15 months of age.
A. A 1-year-old
patient as a
routine
immunization
B. An 18month-old
patient
diagnosed with
cystic fibrosis
C. A 35-year-old
patient
recently
diagnosed with
HIV infection
D. A healthy 49year-old
patient
E. A healthy 75year-old
patient who
received a dose
8 years ago
966.
A positive
flexion
abduction
external
rotation
(FABER) test
that elicits
posterior pain
indicates
involvement of
which joint?
(check one)
A. Sacroiliac
B. Shoulder
C. Ankle
D. Wrist
E. Knee
A. Sacroiliac. When the flexion abduction external rotation (FABER) test elicits pain posteriorly, it indicates sacroiliac
involvement. Anterior pain indicates hip involvement.
967.
968.
E. Neuroblastoma. Tumor markers are useful in determining the diagnosis and sometimes the
prognosis of certain tumors. They can aid in assessing response to therapy and detecting tumor
recurrence. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for
homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or
pheochromocytoma is suspected; both should be collected before surgical intervention.
Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors
and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver
and germ cell tumors.
A.
trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. cephalexin (Keflex)
C. azithromycin (Zithromax)
D. penicillin V
E. ciprofloxacin (Cipro)
969.
970.
B. the cricothyroid membrane. Fortunately, emergency tracheotomy is not often necessary, but
should one be necessary the best site for the incision is directly above the cricoid cartilage,
through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is
actually above the trachea. However, it is below the vocal cords and bypasses any laryngeal
obstruction. The thyrohyoid membrane lies well above the vocal cords, making this an impractical
site. The area directly below the cricoid cartilagewhich includes the second, third, and fourth
tracheal rings, as well as the thyroid isthmusis the preferred tracheotomy site under controlled
circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede
the procedure in an emergency.
A. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth. Infants born to hepatitis
B-positive mothers should receive both immune globulin and hepatitis B vaccine. They should
receive the entire series of the vaccine, with testing for seroconversion only after completion of
the vaccination series; the recommended age for testing is 9-12 months of age.
971.
The presence of
nonthrombocytopenic
palpable purpura, colicky
abdominal pain, and
arthritis is most consistent
with which one of the
following? (check one)
A. Kawasaki disease
B. Takayasu arteritis
C. Wegener granulomatosis
D. Polyarteritis nodosa
E. Henoch-Schonlein
purpura
972.
973.
D. Meckels diverticulum. Meckels diverticulum is the most common congenital abnormality of the
small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal
pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may
mimic appendicitis. Children with appendicitis have right lower quadrant pain, abdominal
tenderness, guarding, and vomiting, but not rectal bleeding. With acute viral gastroenteritis, vomiting
usually precedes diarrhea (usually without blood) by several hours, and abdominal pain is typically
mild and nonfocal with no localized tenderness. The incidence of midgut volvulus peaks during the
first month of life, but it can present anytime in childhood. Volvulus may present in one of three ways:
as a sudden onset of bilious vomiting and abdominal pain in the neonate; as a history of feeding
problems with bilious vomiting that now appears to be due to bowel obstruction; or, less commonly,
as a failure to thrive with severe feeding intolerance. Necrotizing enterocolitis is typically seen in the
neonatal intensive-care unit, occurring in premature infants in their first few weeks of life. The infants
are ill, and signs and symptoms include lethargy, irritability, decreased oral intake, abdominal
distention, and bloody stools. A plain abdominal film showing pneumatosis intestinalis, caused by gas
in the intestinal wall, is diagnostic of this disease.
974.
E. a single treatment with aerosolized albuterol, continued only if there is a positive response. For
patients with bronchiolitis, evidence supports a trial of an inhaled bronchodilator, albuterol, or
epinephrine, with treatment continued only if the initial dose proves beneficial. There is no
evidence to support the use of antibiotics unless another associated infection is present (e.g., otitis
media). Neither corticosteroids nor postural drainage has been found to be helpful.
A. azithromycin (Zithromax)
B. a short course of
corticosteroids
C. aerosolized racemic
epinephrine every 4 hours
D. postural drainage
E. a single treatment with
aerosolized albuterol,
continued only if there is a
positive response
975.
A. Dexamethasone, 0.6 mg/kg orally or intramuscularly as a single dose. Croup is a syndrome most
often caused by viruses, but can occasionally be of bacterial origin as in laryngotracheitis,
laryngotracheobronchitis (LTB), laryngotracheobroncheopneumonia (LTBP), or laryngeal
diphtheria. Mild croup is manifested by an occasional barking cough with no stridor at rest, and
mild or absent intercostal retractions. Moderate croup presents with a more frequent barking
cough, stridor with suprasternal and sternal retractions at rest, but no agitation. Severe croup
includes more prominent inspiratory and expiratory stridor with agitation and distress. There is
good evidence that corticosteroids produce significant improvement. The regimens studied most
frequently have consisted of single-dose dexamethasone (0.6 mg/kg orally or intramuscularly), with
some studies including up to four more doses over a 2-day period. Longer courses of corticosteroids
have not proven to be more effective and may be harmful, leading to secondary infections. Racemic
epinephrine by nebulization is indicated in severe croup. Antitussives and decongestants have not
been studied and are not recommended. Antibiotics are indicated in LTB and LTBP, which can be
diagnosed on the basis of crackles and wheezing on examination, or by an abnormal chest
radiograph. Laryngotracheitis can sometimes be associated with a bacterial infection, but should be
suspected only after a patient does not improve with corticosteroids and epinephrine.
976.
A. Preeclampsia
B. Unmasked chronic hypertension
C. Essential hypertension
D. Gestational hypertension
E. Hemolysis, elevated liver enzymes,
low platelets (HELLP) syndrome
977.
978.
979.
A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. Referral for aortic valve replacement
E. Watchful waiting
980.
981.
982.
A. Visual impairment. Gait and balance disorders are one of the most
common causes of falls in older adults. Correctly identifying gait and
balance disorders helps guide management and may prevent
consequences such as injury, disability, loss of independence, or
decreased quality of life. The "Timed Up and Go" test is a reliable
diagnostic tool for gait and balance disorders and is quick to
administer. A time of <10 seconds is considered normal, a time of >14
seconds is associated with an increased risk of falls, and a time of >20
seconds usually suggests severe gait impairment.
This patient has the cautious gait associated with visual impairment.
It is characterized by abducted arms and legs; slow, careful, "walking
on ice" movements; a wide-based stance; and "en bloc" turns.
Patients with cerebellar degeneration have an ataxic gait that is
wide-based and staggering. Frontal lobe degeneration is associated
with gait apraxia that is described as "magnetic," with start and turn
hesitation and freezing. Parkinson's disease patients have a typical
gait that is short-stepped and shuffling, with hips, knees, and spine
flexed, and may also exhibit festination and "en bloc" turns. Motor
neuropathy causes a "steppage" gait resulting from foot drop with
excessive flexion of the hips and knees when walking, short strides, a
slapping quality, and frequent tripping.
E. Candida infection. In breastfeeding women, bilateral nipple pain
with and between feedings after initial soreness has resolved is
usually due to Candida. Pain from engorgement typically resolves
after feeding. Mastitis is usually unilateral and is associated with
systemic symptoms and wedge-shaped erythema of the breast
tissue. Improper latch-on is painful only during feedings. Eczema
isolated to the nipple, while a reasonable part of the differential,
would be much more unusual.
983.
984.
C. Awaiting spontaneous labor. This estimated fetal weight is at the 90th percentile for a
term fetus. Unfortunately, the accuracy of fetal weight estimates declines as pregnancy
proceeds, and the actual size may be as much as 15% different from the estimate.
Delivery of a large infant results in shoulder dystocia more often than delivery of a
smaller infant, but most large infants are delivered without complications. Intuitively, it
would seem logical to induce labor when the fetus seems to be getting large, but this
intervention has been studied in controlled trials and the only difference in outcome
was an increase in the cesarean rate for women who underwent elective induction for
this indication.
Recently, there has been an increase in requests from patients to have an elective
cesarean section near term to avoid the risks of labor, including pain, shoulder dystocia,
and pelvic relaxation. The American Congress of Obstetricians and Gynecologists
(ACOG) recommends consideration of cesarean delivery without a trial of labor if the
estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the
absence of diabetes. Even at that size, there is not adequate data to show that cesarean
section is preferable to a trial of labor. Frequent ultrasonography is often performed to
reduce anxiety for both patient and physician, but the problem of accuracy of weight
estimates remains an issue even with repeated scans at term.
B. 1 day before ovulation. There is a 30% probability of pregnancy resulting from
unprotected intercourse 1 or 2 days before ovulation, 15% 3 days before, 12% the day of
ovulation, and essentially 0% 1-2 days after ovulation. Knowing the time of ovulation
therefore has implications not only for "natural" family planning, but also for decisions
regarding postcoital contraception.
C. bedbug bites. Bedbug bites are difficult to diagnose due to the variability in bite
response between people and the changes in a given individual's skin reaction over
time. It is best to collect and identify bedbugs to confirm bites. Cimex lectularius injects
saliva into the bloodstream of the host to prevent coagulation. It is this saliva that causes
the intense itching and welts.
987.
The
recommended
time to screen
for gestational
diabetes in
asymptomatic
women with no
risk factors for
this condition is:
(check one)
C. at 24-28 weeks gestation. The recommended time to screen for gestational diabetes is 24-28 weeks gestation.
The patient may be given a 50-g oral glucose load followed by a glucose determination 1 hour later.
A. in the first
trimester
B. at 16-20 weeks
gestation
C. at 24-28 weeks
gestation
D. at 35-37 weeks
gestation
988.
Regular breast
selfexaminations to
screen for breast
cancer: (check
one)
A. are performed
by most
American
women
B. reduce
mortality due to
breast cancer
C. reduce allcause mortality
in women
D. are
recommended
by the U.S.
Preventive
Services Task
Force
E. increase the
number of breast
biopsies
performed
E. increase the number of breast biopsies performed. Most women do not regularly perform breast selfexaminations (BSE). Evidence from large, well- designed, randomized trials of adequate duration has shown that
the performance of regular BSE by trained women does not reduce breast cancer-specific mortality or all-cause
mortality. The 2009 update to the U.S. Preventive Services Task Force breast cancer screening recommendations
recommended against teaching BSE (D recommendation). The rationale for this recommendation is that there is
moderate certainty that the harms outweigh the benefits. The two available trials indicated that more additional
imaging procedures and biopsies were done for women who performed BSE than for control participants, with no
gains in breast cancer detection or reduction in breast-cancer related mortality.
989.
990.
E. increase the number of breast biopsies performed. Most women do not regularly perform breast selfexaminations, even though it allows motivated women to be in control of this aspect of their health care.
Evidence from large, well-designed, randomized trials of adequate duration has shown that the
performance of regular breast self-examinations by trained women does not reduce breast cancerspecific mortality or all-cause mortality. The U.S. Preventive Services Task Force found insufficient evidence
(an I rating) to recommend breast self-examinations. A Cochrane review concluded that breast selfexaminations have no beneficial effect and increase the number of biopsies performed.
A. There is a 5% likelihood of the results having occurred by chance alone. The p-value is a level of statistical
significance, and characterizes the likelihood of achieving the observed results of a study by chance alone,
and in this case that likelihood is 5%. (In this case, 5% or less of the results can be achieved by chance alone
and still be significant.) The confidence interval is a measure of variance and is derived from the test data.
The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the
likelihood of the observed results occurring by chance is 5%. The a or type I error is akin to the error of
false-positive assignment; the B or type II error is analogous to the false-negative rate, or 1 - specificity, and
cannot be calculated from the information given.
991.
A. There is a 5% likelihood of the results having occurred by chance alone. The p-value is a level of
statistical significance, and characterizes the likelihood of achieving the observed results of a study by
chance alone; in this study that likelihood is 5%, although 5% or less of the results of the study can be
achieved by chance alone and still be significant. The confidence interval is a measure of variance and
is derived from the test data. The p-value in and of itself says nothing about the truth or falsity of the
null hypothesis, only that the likelihood of the observed results occurring by chance is 5%. The or
type I error is akin to the error of false-positive assignment; the or type II error is analogous to the
false-negative rate, or 1 - specificity, and cannot be calculated from the information given.
A. There is a 5% likelihood
of the results having
occurred by chance alone
B. If the study were
replicated 100 times, 95
studies would repeat this
finding and 5 would not
C. The confidence interval is
0%-10%
D. The null hypothesis has a
5% chance of being true
E. The (type II) error is <5%
992.
993.
E. Spinal cord injury. There are many risk factors for thromboembolism, including polycythemia vera,
oral contraceptive use, obesity, advanced age, and spinal cord injury. Spinal cord injury induces
immobility, as do obesity and advanced age. Oral contraceptives make blood more coagulable,
particularly in patients with clotting factor abnormalities such as factor V Leiden. Polycythemia vera
increases sludging of blood cells and increases the risk of forming clots. Clot risk is not increased by oral
hypoglycemic agents, low BMI, youth, or anemia.
B. Kidney stones. Indications for parathyroid surgery include kidney stones, age less than 50, a serum
calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density.
Hyperthyroidism is not a factor in deciding to perform parathyroid surgery.
994.
D. Smoking cessation programs. The U.S. Preventive Services Task Force recommends a routine
physical examination every 3-5 years for young adults until the age of 40. Mammograms are
not recommended until age 40. Lead screening is recommended for at-risk individuals
between 6 months and 6 years of age. Colorectal cancer screening for average-risk individuals
is recommended at age 50. Counseling on tobacco use and other substance abuse is
recommended as part of all routine preventive care.
B. Personal contact. The scabies mite is predominantly transmitted by direct personal contact.
Infestation from indirect contact with clothing or bedding is believed to be infrequent. Hats are
frequent transmitters of head lice, but not scabies.
A. Bedclothes
B. Personal contact
C. Hats
D. Pets
996.
B. A 40-year-old female whose mother was diagnosed with colon cancer at age 54. A history of a
first degree relative diagnosed with colon cancer before age 60 predicts a higher lifetime
incidence of colorectal cancer (CRC) and a higher yield on colonoscopic screening. The overall
colon cancer risk for these persons is three to four times that of the general population.
Screening should consist of colonoscopy, beginning either at age 40 or 10 years before the age
at diagnosis of the youngest affected relative, whichever comes first.
The 2008 update of the guidelines on screening for CRC published by the American College of
Gastroenterology no longer recommends earlier screening for patients who have a single first
degree relative with CRC diagnosed at 60 years of age or after. Another change in this
guideline is that an increased level of screening is no longer recommended for a simple family
history of adenomas in a first degree relative.
997.
Screening for
osteoporosis
should be done in
which one of the
following groups?
(check one)
A.
Postmenopausal
women
B. Women over age
50 with a BMI 30
kg/m2
C. Men over age 50
with type 2
diabetes mellitus
D. Men over age 70
998.
Secondary causes
of osteoporosis in
males include
which one of the
following? (check
one)
A. Weekly
consumption of 36 alcoholic drinks
B. Male hormone
supplementation
C. Vitamin D
excess
D. Obesity
E. Corticosteroid
use
D. Men over age 70. All women 65 (SOR A) and all men 70 (SOR C) should be screened for osteoporosis. For
men and women age 50-69, the presence of factors associated with low bone density would merit screening. Risk
factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls,
physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain
medical conditions.
Chronic systemic diseases that increase risk include COPD, HIV, severe liver disease, renal failure, systemic lupus
erythematosus, and rheumatoid arthritis. Endocrine disorders that increase risk include type 1 diabetes
mellitus, hyperparathyroidism, hyperthyroidism, Cushing's syndrome, and others. Medications that increase
risk include anticonvulsants, corticosteroids, and immunosuppressants. Nutritional risks include celiac disease,
vitamin D deficiency, anorexia nervosa, gastric bypass, and increased alcohol or caffeine intake.
E. Corticosteroid use. Corticosteroids are among the common secondary causes of osteoporosis in men. Other
causes include excessive alcohol use, hypogonadism, vitamin D deficiency, and decreased body mass index.
999.
1000.
D. the percentage of patients with the disease who have a positive test
result. Sensitivity is the percentage of patients with a disease who have a
positive test result. Specificity is the percentage of patients without the
disease who have a negative test result. Pretest probability is the
probability of disease before a test is performed. Posttest probability is
the probability of disease after a test is performed. Positive predictive
value is the percentage of patients with a positive test result who are
confirmed to have the disease.
A. Cognitive-behavioral therapy
B. Psychoanalysis
C. Electroconvulsive therapy
D. Goal-directed psychotherapy
E. Limbic stimulation
1001.
1002.
1003.
D. Reducing the risk of falls. There is strong evidence that physical activity will
prevent falls in the elderly. The evidence for maintaining weight, improving sleep,
and increasing bone density is not as strong.
1005.
A. A. When possible, it is important for the family physician to base clinical decisions
on the best evidence. Strength-of-Recommendation Taxonomy (SORT) grades in
medical literature are intended to help physicians practice evidence-based
medicine. SORT grades are only A, B, and C. These should not be confused with
the U.S. Food and Drug Administration labeling categories for the potential
teratogenic effects of medications on a fetus: pregnancy categories A, B, C, D, and
X.
Strength of Recommendation (SOR) A is a recommendation that is based on
consistent, good-quality, patient-oriented evidence. SOR B is a recommendation
that is based on limited-quality patient-oriented evidence. SOR C is a
recommendation that is based on consensus, disease-oriented evidence, usual
practice, expert opinion, or case series for studies of diagnosis, treatment,
prevention, or screening.
A. When being treated for a potentially fatal illness. Patients often welcome spiritual
discussion, depending on the situation. The percentage that welcome this
discussion increases with the severity of illness, and is greatest among those who
are very seriously ill with a potentially fatal disease. Spiritual inquiry during
medical care should focus on understanding, compassion, and hope, and should
be directed toward individuals who suffer from serious illness.
1006.
C. 75% of patients who test positive actually have breast cancer. Positive predictive value refers to the
percentage of patients with a positive test for a disease who actually have the disease. The negative
predictive value of a test is the proportion of patients with negative test results who do not have the
disorder. The percentage of patients with a disorder who have a positive test for that disorder is a test's
sensitivity. The percentage of patients without a disorder who have a negative test for that disorder is a
test's specificity.
Surgical management
for an acute midshaft
clavicle fracture would
be appropriate in which
one of the following?
(check one)
A. An 11-year-old male
with a comminuted
fracture
B. A 15-year-old female
with a -cm displaced
fracture
C. A 30-year-old male
with a -cm displaced
fracture
D. A 40-year-old male
with a nondisplaced
fracture
E. A 50-year-old female
with a comminuted
fracture
E. A 50-year-old female with a comminuted fracture. Midshaft clavicle fractures are usually treated
nonoperatively, but have a higher risk of nonunion. Risk
factors for nonunion include female gender, fracture comminution or displacement, clavicle shortening,
advanced age, and greater extent of initial trauma. These fractures in children heal extremely well, even
if displaced or comminuted, because of periosteal regenerative potential.
1008.
The test of
choice for
immediate
evaluation of an
acutely swollen
scrotum is:
(check one)
C. color Doppler ultrasonography. Any patient with a new scrotal mass should be evaluated immediately because
of the risk of potential emergencies, such as testicular torsion, or of life-threatening diseases such as testicular
carcinoma. Color Doppler ultrasonography is the test of choice for immediate evaluation of scrotal masses (SOR B)
because it can be done quickly and has a high sensitivity (86%-88%) and specificity (90%-100%) for detecting
testicular torsion, which is a surgical emergency. Radionuclide imaging is also accurate in diagnosing testicular
torsion, but involves too much of a time delay to be useful. CT and MRI should be used only if ultrasonography is
inconclusive or carcinoma is suspected, and are particularly useful for staging testicular tumors. Pelvic
radiographs are not recommended for evaluation of scrotal masses.
A. a pelvic
radiograph
B. radionuclide
imaging
C. color Doppler
ultrasonography
D. CT
E. MRI
1009.
This rhythm is
best described
as: (check one)
A. ventricular
flutter
B. ventricular
fibrillation
C. ventricular
tachycardia
D. torsades de
pointes
1010.
To be eligible for
Medicare
hospice
benefits, a
patient must:
(check one)
A. be enrolled in
Medicare Part D
B. be referred to
hospice by a
physician
C. be debilitated
and moribund
D. have a
malignancy
E. have an
estimated life
expectancy of
less than 6
months
D. torsades de pointes. The EKG shown represents torsades de pointes. This special form of ventricular
tachyarrhythmia is often regarded as an intermediary between ventricular tachycardia and ventricular
fibrillation. Morphologically it is characterized by wide QRS complexes with apices that are sometimes positive and
sometimes negative. It is generally restricted to polymorphous tachycardias associated with QT prolongation.
Anything that produces or is associated with a prolonged QT interval can cause torsades de pointes, including
drugs (quinidine, procainamide, disopyramide, phenothiazines), electrolyte disturbances, insecticide poisoning,
subarachnoid hemorrhage, and congenital QT prolongation. Its great clinical importance lies in the fact that the
usual anti-arrhythmic drugs are not only useless but contraindicated, because they can make matters worse.
Ventricular flutter is the term used by some authorities to describe a rapid ventricular tachycardia producing a
regular zigzag on EKG, without clearly formed QRS complexes. Ventricular tachycardia consists of at least three
consecutive ectopic QRS complexes recurring at a rapid rate. They are usually regular. Ventricular fibrillation is
characterized by the complete absence of properly formed ventricular complexes; the baseline wavers unevenly,
with no clear-cut QRS deflections.
E. have an estimated life expectancy of less than 6 months. To be eligible for Medicare hospice benefits, a patient
must be eligible for Medicare Part A (hospital
insurance). Although most hospice referrals come from physicians, nurses, and social workers, a patient's
family members can also make a hospice referral. The patient must sign a statement choosing hospice,
and both the patient's physician and the hospice medical director must certify that the patient has a terminal
illness with an estimated life expectancy of less than 6 months. There is no requirement that the patient be
debilitated or moribund.
1011.
Total parenteral
nutrition is most
appropriate for
patients: (check
one)
A. With poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding. Total parenteral nutrition
(TPN) is indicated for patients with poorly functioning gastrointestinal tracts who cannot tolerate other means of
nutritional support and for those with high caloric requirements that cannot otherwise be met. Patients who
cannot swallow because of an esophageal motility problem and those who are resistant to feeding can be
managed with tube feedings. Peripheral alimentation, which provides fewer calories than TPN or liquid tube
feedings, would be more appropriate over the short term in patients recovering from surgery.
A. With poorly
functioning
gastrointestinal
tracts who
cannot tolerate
enteral feeding
B. Who cannot
swallow because
of an esophageal
motility problem
C. Who refuse to
eat
D. In whom
maintenance
nutrition is
desired for a short
period following
recovery from
surgery
1012.
Treatment for
Helicobacter
pylori infection
will reduce or
improve which
one of the
following? (check
one)
A. The risk of
peptic ulcer
bleeding from
chronic NSAID
therapy
B. The risk of
developing
gastric cancer in
asymptomatic
patients
C. Symptoms of
nonulcer
dyspepsia
D. Symptoms of
gastroesophageal
reflux disease
A. The risk of peptic ulcer bleeding from chronic NSAID therapy. Eradication of Helicobacter pylori significantly
reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of
peptic ulcer development in patients on chronic NSAID therapy. Eradication has minimal or no effect on the
symptoms of nonulcer dyspepsia and gastroesophageal reflux disease. Although H. pylori infection is associated
with gastric cancer, no trials have shown that eradication of H. pylori purely to prevent gastric cancer is
beneficial.
1013.
The treatment of
choice for a 4month-old infant
with suspected
pertussis is: (check
one)
A. Supportive care
(respiratory, fluids)
only
B. Ceftriaxone
(Rocephin)
C. Ampicillin
D. Gentamicin
(Garamycin)
E. Erythromycin
1014.
Treatment with
donepezil (Aricept)
is associated with
an increased risk
for : (check one)
A. pulmonary
embolism
B. liver failure
C. bradycardia
requiring
pacemaker
implantation
D. cataract
development
requiring surgery
E. confusion
requiring
institutionalization
C. bradycardia requiring pacemaker implantation. A large population study has established a significant
increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy.
Elevation of liver enzymes with the potential for hepatic dysfunction has been seen with tacrine, but it has not
been noted with the other approved cholinesterase inhibitors. Cataract formation and thrombosis with
pulmonary embolism do not increase with this therapy. Although improvement in mental function is often
marginal with cholinesterase inhibitor therapy, the therapy has not been shown to increase the need for
institutionalization.
1015.
Typically, a high-grade
squamous
intraepithelial lesion
(HSIL) of the cervix is
treated with ablation
or excision. In which
one of the following
can treatment be
deferred? (check one)
A. Adolescents
B. Patients attempting
to conceive
C. Patients with a
history of three
previous normal
Papanicolaou smears
D. Patients with a
negative DNA test for
HPV
E. Patients over the age
of 70
1016.
Ultrasonography
shows a complete
placenta previa in a 23year-old primigravida
at 20 weeks gestation.
She has not
experienced any
vaginal bleeding.
Which one of the
following would be
the most appropriate
management for this
patient? (check one)
A. Schedule a cesarean
section at 38 weeks
gestation
B. Perform a digital
examination to assess
for cervical dilation
C. Administer
corticosteroids to
promote fetal lung
maturity
D. Order MRI to rule
out placenta accreta
E. Repeat the
ultrasonography at 28
weeks gestation
A. Adolescents. Patients attempting to conceive are not candidates for conservative management of cervical
dysplasia, because treatment of progressive disease during pregnancy may be harmful. When possible,
the problem should be resolved before conception. Patients who have had three normal Papanicolaou
(Pap) smears in succession are candidates for lengthened screening intervals according to some
recommendations. However, once a problem is found, they should be managed the same as other cases. A
negative test for HPV can be used to assess the risk of patients with atypical squamous cells of
undetermined significance (ASC-US) or a low-grade squamous intraepithelial lesion (LSIL); it does not
change the management of patients with a high-grade intraepithelial lesion (HSIL). HPV infection is
common and transient in most young women in their first few years of sexual activity. With careful followup, they can be observed rather than treated for HSIL. Patients over 70 years of age no longer require
screening if they have a long history of normal Pap smears, but when an abnormality is found it should be
treated.
E. Repeat the ultrasonography at 28 weeks gestation. Placenta previa is a relatively common incidental
finding on second trimester ultrasonography. Approximately 4% of ultrasound studies at 20-24 weeks
gestation show a placenta previa, but it occurs in only 0.4% of pregnancies at term, because of migration of
the placenta away from the lower uterine segment. Therefore, in the absence of bleeding, the most
appropriate management is to repeat the ultrasonography in the third trimester (SOR A).
Because many placenta previas resolve close to term, a decision regarding mode of delivery should not be
made until after ultrasonography is performed at 36 weeks gestation. Digital cervical examinations should
not be performed in patients with known placenta previa because of the risk of precipitating bleeding.
Corticosteroids are indicated at 24-34 weeks gestation if the patient has bleeding, given the higher risk of
premature birth. In patients with a history of previous cesarean delivery who have a placenta previa at the
site of the previous incision, a color-flow Doppler study should be performed to evaluate for a potential
placenta accreta. In such cases, MRI may be helpful to confirm the diagnosis.
1017.
Under current
guidelines, hospice
programs are most
likely to serve
patients dying from:
(check one)
E. cancer. The general requirement for enrolling an individual in hospice is that they have a terminal illness
and an estimated life expectancy of 6 months or less. Given these criteria, it is not surprising that over 40% of
hospice patients have a cancer diagnosis. Cancer usually has a short period of obvious decline at the end
and is predictable to a degree. Diseases such as COPD, end-stage liver disease, and heart failure result in
long-term disability with periodic exacerbations, any one of which could result in death, but far less
predictably. Those with severe dementia or frailty often experience a dwindling course that is also difficult to
predict.
A. heart failure
B. COPD
C. severe dementia
D. multiple strokes
E. cancer
1018.
U.S. Department of
Transportation
standards for
commercial drivers
would disqualify
which one of the
following? (check
one)
A. A 38-year-old male
type 1 diabetic, wellcontrolled on
insulin, whose last
HbA1c was 6.0% (N
3.8-6.4)
B. A 50-year-old
female with
uncorrected 20/40
vision in both eyes
C. A 57-year-old male
who had an inferior
myocardial
infarction 3 years
ago and had a recent
negative treadmill
test
D. A 64-year-old male
who fails a
whispered-voice test
in one ear
A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8-6.4).
Insulin-dependent diabetes, even if well controlled, disqualifies a driver for commercial interstate driving.
Vision of 20/40 is the minimum allowed under Department of Transportation regulations. Adequate hearing
in one ear and well-compensated controlled heart disease are both allowed. Blood pressure of 160/90 mm Hg
or less merits an unrestricted 2-year certification. Drivers with a blood pressure of 160/90-181/105 mm Hg can
receive a 3-month temporary certification during which treatment for hypertension should be undertaken.
1019.
The use of a
corticosteroid
inhaler in
patients with
stable chronic
obstructive lung
disease has been
shown to:
(check one)
A. increase the
risk for
osteoporotic
fracture
B. increase the
risk for
pneumonia
C. produce no
change in
patients'
perceptions of
quality of life
D. reduce
overall
mortality
B. increase the risk for pneumonia. COPD is the fourth leading cause of death in the United States. Stopping
smoking and the use of continuous oxygen, when necessary, are the main interventions that have been shown to
lessen overall mortality in this illness. The use of corticosteroid inhalers for COPD has received mixed reviews.
Studies show an increase in the incidence of pneumonia, which is directly related to the dosage. There are also
concerns about the potential for an increase in fractures; however, a meta-analysis of multiple studies has not
shown this to be the case. There has been no improvement in overall mortality with the use of the corticosteroid
inhalers; nevertheless, on questionnaires patients indicate an improvement in quality of life and fewer bronchitis
exacerbations.
1020.
1021.
1022.
C. Has been shown to contribute to significant gains in full neurologic and functional
recovery. The use of automated external defibrillators (AEDs) by lay persons, trained
and otherwise, has been quite successful, with up to 40% of those treated recovering
full neurologic and functional capacity. At present, 45 states have passed Good
Samaritan laws covering the use of AEDs by well-intentioned lay persons. There are
initiatives for widespread placement of AEDs, to include commercial airlines and other
public facilities. Implantable cardioverter defibrillators (ICDs) are useful in known atrisk patients, but the use of AEDs is for the population at large.
E. No routine screening for COPD with spirometry. The U.S. Preventive Services Task
Force recommends against screening adults for COPD with spirometry. Spirometry is
indicated for patients who have symptoms suggestive of COPD, but not for healthy
adults. While tobacco use is a risk factor for COPD, routine spirometry, chest
radiographs, or arterial blood gas analysis is not recommended to screen for COPD in
patients with a history of tobacco use. Peak flow measurement is not recommended for
screening for COPD.
E. Females 55-79 years of age. The U.S. Preventive Services Task Force (USPSTF)
recommends daily aspirin use for males 45-79 years of age when the potential benefit
of a reduction in myocardial infarction outweighs the potential harm of an increase in
gastrointestinal hemorrhage, and for females 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 (SOR A, USPSTF A Recomendation).
The USPSTF has concluded that the current evidence is insufficient to assess the
balance of benefits and harms of aspirin for cardiovascular disease prevention in men
and women 80 years of age or older (USPSTF I Recommendation). It recommends
against the use of aspirin for stroke prevention in women younger than 55, and for
myocardial infarction prevention in men younger than 45 (USPSTF D
Recommendation).
1023.
B. Fetal bradycardia. Uterine rupture occurs in 0.2%-1.0% of women in labor after one
previous low transverse cesarean section. Obviously, this can have devastating consequences
for the mother and baby, so vigilance during labor is paramount. Uterine pain, cessation of
contractions, vaginal bleeding, failure of labor to progress, or fetal regression may occur, but
none of these are as consistent as fetal bradycardia in cases of uterine rupture during labor
for VBAC patients.
A. Cessation of uterine
contractions during active labor
B. Fetal bradycardia
C. Vaginal bleeding
D. Sudden lower abdominal pain
E. Maternal hypotension
1024.
A. Aortic stenosis
B. Rheumatic mitral insufficiency
C. Valvular pulmonic stenosis
D. Hypertrophic obstructive
cardiomyopathy
1025.
B. Herpes simplex virus. Erythema multiforme usually occurs in adults 20-40 years of age,
although it can occur in patients of all ages. Herpes simplex virus (HSV) is the most commonly
identified cause of this hypersensitivity reaction, accounting for more than 50% of cases.
1026.
What is the
most likely
diagnosis?
(check one)
A. Patellar
tendon
rupture
B. Quadriceps
tendon
rupture
C. Tibial
plateau
fracture
D. Patellar
subluxation
E. Lumbar
radiculopathy
1027.
What is the
recommended
compressionto-breath
ratio for basic
life support
with a single
rescuer for a 2year-old child?
(check one)
A. 10:2
B. 15:2
C. 20:2
D. 25:2
E. 30:2
B. Quadriceps tendon rupture. Quadriceps tendon rupture can be partial or complete. When complete, as in this
case, the patient has no ability to straighten the leg actively. A similar pattern is seen with patellar tendon rupture,
but in this situation the patella is retracted superiorly by the quadriceps. Quadriceps rupture often produces a
sulcus sign, a painful indentation just above the patella. If the patient is not seen until some time has passed since
the injury, the gap in the quadriceps can fill with blood, so that it is no longer palpable. The clinical examination is
usually diagnostic for this condition, but this patient's radiograph shows some interesting findings, especially on the
lateral view. A small shard of the patella has been pulled off and has migrated superiorly with the quadriceps. The
hematoma filling the gap in the quadriceps is the same density as the muscle, but wrinkling of the fascia over the
distal quadriceps provides a clue that it is no longer attached to the superior margin of the patella.
Tibial plateau fractures are intra-articular, so they produce a large hemarthrosis. They are evident on a radiograph
in almost all cases. Pain inhibits movement of the knee, but the extreme weakness evident in this case would not be
seen. Patellar subluxation is obvious acutely, when the patella is displaced laterally. More often, the patient comes in
after the patella has relocated. Findings then include tenderness along the medial retinaculum, sometimes a joint
effusion, and a positive apprehension sign when the patella is pushed gently laterally. Lumbar radiculopathy can
cause weakness of the quadriceps if it involves the third lumbar root, but complete paralysis would not occur. Other
findings would include lumbar pain radiating to the leg, possibly with paresthesias and fasciculations if there were
significant neurologic impairment.
E. 30:2. For a single rescuer performing CPR on a 2-year-old, the ratio is 30 compressions to 2 ventilations. The
compression rate should be approximately 100 beats/min, and the chest should be compressed one-third
to one-half its depth with each compression. Compressions can be accomplished with one hand, the heel
of one or both hands, or the heel of one hand with the second hand on top.
1028.
When an
interpreter is
needed for a
patient with
limited English
proficiency,
which one of the
following should
be AVOIDED when
possible? (check
one)
E. Using an educated adult family member who is bilingual. Using trained, qualified interpreters for patients
with limited English proficiency leads to fewer hospitalizations, less reliance on testing, a higher likelihood of
making the correct diagnosis and providing appropriate treatment, and better patient understanding of
conditions and therapies. Although the patient may request that a family member interpret, there are many
pitfalls in using untrained interpreters: a lack of understanding of medical terminology, concerns about
confidentiality, and unconscious editing by the interpreter of what the patient has said. Additionally, the patient
may be reluctant to divulge sensitive or potentially embarrassing information to a friend or family member. The
other principles listed are important practices when working with interpreters. Pictures and diagrams can help
strengthen the patient's understanding of his or her health care.
A. Using mostly
short sentences,
with frequent
pauses
B. Using diagrams
and pictures
C. Addressing the
patient in the
second person
(i.e., "you")
D. Maintaining
eye contact with
the patient when
speaking
E. Using an
educated adult
family member
who is bilingual
1029.
When a screening
test identifies a
cancer earlier,
thereby
increasing the
time between
diagnosis and
death without
prolonging life,
this is called:
(check one)
A. length-time
bias
B. lead-time bias
C. a false-positive
screening test
D. increasing the
positive
predictive value
of the screening
test
E. attributable
risk
B. lead-time bias. Lead-time bias is when a screening test identifies a cancer earlier, thereby increasing the time
between diagnosis and death without actually prolonging life. Length-time bias is when a screening test finds a
disproportionate number of cases of slowly progressive disease and misses the aggressive cases, thereby
leading to an overestimate of the effectiveness of the screening. A false-positive test is one that suggests cancer
when no cancer exists. The positive predictive value is the proportion of positive test results that are true
positives. Attributable risk is the amount of difference in risk for a disease that can be accounted for by a specific
risk factor.
1030.
A. Human papillomavirus. There has been an increase in vulvar cancer in women 35-65 years of age over
the last decade. This increase is associated with human papillomavirus infection, particularly involving
subtypes 16 and 18. Lichen sclerosus is associated with vulvar cancer in older women. Hypertension,
diabetes mellitus, and obesity may coexist, but are not felt to be independent risk factors. Syphilis and other
granulomatous diseases have been associated with vulvar cancer in the past; they are not currently
considered to be significant risk factors, but are considered markers for sexual behavior associated with
increased risk.
A. Human
papillomavirus
B. Lichen sclerosus
C. Diabetes mellitus
D. Syphilis
E. Lymphogranuloma
venereum
1031.
When considering a
diagnosis of
pancreatitis, amylase
levels (check one)
A. can help
determine the
severity of the
disease
B. are less likely to be
elevated in
alcoholics
C. are more sensitive
and specific than
serum lipase levels
D. are less likely to be
affected by
nonpancreatic
conditions such as
renal insufficiency
B. are less likely to be elevated in alcoholics. Amylase and lipase levels are used to help make the diagnosis of
acute pancreatitis. The serum lipase level is more specific and more sensitive than the amylase level. Amylase
elevations can be seen with other abdominal illnesses, such as inflammation of the small bowel. Alcoholics
with recurrent pancreatitis may have normal serum amylase levels; in such cases, serum lipase would be a
better test. There are several scoring systems for the severity of pancreatitis, including the CT severity index,
the APACHE II score, the Imrie Scoring System, and Ransons Criteria, but none of these use serum amylase
in their calculation. The elevation of serum amylase does not correspond well with the severity of the
pancreatitis.
1032.
A. The absence of mental illness. Patients with mental illness may have decision-making
capacity if they are able to understand and communicate a rational decision. The key
factors to consider in determining decision-making capacity include whether the patient
can express a choice, understand relevant information, appreciate the significance of the
information and its consequences, and engage in reasoning as it relates to medical
treatment.
A. using a valved holding chamber. Pharyngeal and laryngeal side effects of inhaled
corticosteroids include sore throat, coughing on inhalation of the medication, a weak or
hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the
medication and using a valved holding chamber when it is delivered with a metereddose inhaler can minimize the risk of oral candidiasis.
1036.
A. Magnesium sulfate. Magnesium sulfate infusions must be carefully monitored because respiratory
depression is a potential lethal side effect. Reflexes are usually lost first. Terbutaline and ritodrine have the
potential to cause respiratory distress in the form of pulmonary edema. They do not cause respiratory
depression. Indomethacin and nifedipine are rarely used tocolytics that do not depress respiration.
A. Magnesium sulfate
B. Ritodrine
(Yutopar)
C. Terbutaline
(Brethine, Bricanyl)
D. Indomethacin
(Indocin)
E. Nifedipine (Adalat,
Procardia)
1037.
C. Valproic acid (Depakene). Anticonvulsant medications are used in the treatment of various psychiatric
disorders. Valproic acid is FDA-approved for the treatment of manic episodes associated with bipolar
disorder. It has been shown in controlled studies to be significantly more effective than placebo. The initial
dosage is 750 mg daily given in divided doses, and most individuals require between 1000 and 2500 mg daily.
Carbamazepine has also been used to treat mania and is an alternative for individuals who cannot tolerate
lithium or valproic acid. Clonazepam is used in the treatment of panic attacks, and gabapentin is used to treat
anxiety. Both phenytoin and gabapentin are also used to treat peripheral neuropathy. The primary use of
phenobarbital is as an anticonvulsant.
A. Phenytoin
(Dilantin)
B. Phenobarbital
C. Valproic acid
(Depakene)
D. Gabapentin
(Neurontin)
E. Clonazepam
(Klonopin)
1038.
A. Bupropion (Wellbutrin). Sexual dysfunction, including decreased libido, ejaculatory disturbance, and
anorgasmia, is common with the SSRIs (e.g., sertraline and fluoxetine). Tricyclic antidepressants such as
imipramine also cause sexual dysfunction. Trazodone can cause priapism. Only bupropion is relatively free of
sexual side effects.
1039.
B. Amlodopine (Norvasc). The most common side effects of calcium channel blockers, such as amlodipine, are
due to vasodilation. One result of this may be peripheral edema, but it can also cause dizziness, nausea,
hypotension, cough, and pulmonary edema. These problems may decrease with time, with reductions in
dosage, or with the addition of a diuretic or second calcium antagonist. Other classes of drugs are not
associated with these problems.
A.
Hydrochlorothiazide
B. Amlodopine
(Norvasc)
C. Lisinopril
(Prinivil, Zestril)
D. Losartan (Cozar)
E. Atenolol
(Tenormin)
1040.
A. Clozapine (Clozaril). Clozapine was the first atypical antipsychotic drug, so designated because it has
antipsychotic effects without the adverse effects on movement seen with first-generation agents, in addition
to having enhanced therapeutic efficacy compared with first-generation drugs. Because of these
advantages, it was introduced into clinical practice in the United States despite a serious known adverse
effect: an increased incidence of agranulocytosis. Although only clozapine causes agranulocytosis in a
substantial proportion of patients, many second-generation drugs produce clinically significant weight gain.
A. Clozapine
(Clozaril)
B. Aripiprazole
(Abilify)
C. Risperidone
(Risperdal)
D. Olanzapine
(Zyprexa)
1041.
B. Alprazolam (Xanax). Alprazolam (Xanax) has a half-life of about 12 hours, versus 25 hours for clonazepam
and 50 hours for flurazepam, clorazepate, and diazepam.
1042.
B. The test's accuracy in correctly identifying patients with the disease. Sensitivity is the ability of a test to
identify patients who actually have the disease, or the true-positive rate. Independent of the sensitivity is the
tests specificity, which is the ability to correctly identify patients who do not have the disease, or the truenegative rate. The greater the tests specificity, the lower the false-positive rate; the greater the tests
sensitivity, the lower the false-negative rate.
D. Slipped capital femoral epiphysis. The radiograph shows a typical slipped capital femoral epiphysis, with
the epiphysis displaced posteriorly and medially. The problem usually occurs in late childhood or
adolescence. Osgood-Schlatter disease involves the anterior tibial tubercle. Legg-Calv-Perthes disease is
avascular necrosis of the femoral head. Blount's disease involves the medial portion of the proximal tibia. All
of these conditions cause leg pain in children.
(check one)
A. Osgood-Schlatter
disease
B. Legg-Calv-Perthes
disease
C. Blount's disease
D. Slipped capital
femoral epiphysis
E. A normal hip
1044.
A. Triquetral fracture. Triquetral fractures typically occur with hyperextension of the wrist. Dorsal avulsion
fractures are more common than fractures of the body of the bone. Tenderness is characteristically noted on
the dorsal wrist on the ulnar side distal to the ulnar styloid. The typical radiologic finding is a small bony
avulsion visible on a lateral view of the wrist. Most studies indicate that this carpal bone has the second or
third highest fracture rate after the navicular. Avulsion fractures respond well to 4 weeks of splinting and
protection.
Clinical and radiologic signs do not match those expected in navicular or scaphoid fractures. Navicular
fractures may initially have normal radiologic findings. Immobilization and follow-up radiographs are
required. Tenderness in the snuffbox area is expected, but dorsal tenderness and swelling are not
characteristic. The radiographs do not show a lunate fracture or dislocation. A wrist sprain is a diagnosis of
exclusion and should not be considered too early.
1045.
D. Hydrochlorothiazide. While thiazide diuretics do not cause hypercalcemia by themselves, they can
exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides decrease the
renal clearance of calcium by increasing distal tubular calcium reabsorption. Furosemide tends to lower
serum calcium levels and is used in the treatment of hypercalcemia. None of the other medications
would be expected to significantly affect the serum calcium level in this patient.
A. Furosemide (Lasix)
B. Verapamil (Calan,
Isoptin)
C. Enalapril (Vasotec)
D. Hydrochlorothiazide
E. Allopurinol (Zyloprim)
1046.
C. -Thalassemia trait. Red cell distribution width (RDW) is a measure of the variability of size of the red
cells. It is particularly useful in distinguishing anemic disorders, especially iron deficiency anemia (high
RDW, normal to low mean corpuscular volume) and uncomplicated heterozygous thalassemia (normal
RDW, low mean corpuscular volume).
B. Intranasal decongestants. Intranasal decongestants such as phenylephrine should not be used for
more than 3 days, as they cause rebound congestion on drug withdrawal. When used for several
months or more, these agents can cause a form of rhinitis, rhinitis medicamentosa, that can be extremely
difficult to treat.
1048.
D. Sulfonylureas, such as glipizide (Glucotrol). Biguanides and thiazolidinediones are insulin sensitizers that
decrease hepatic glucose production and increase insulin sensitivity. Sulfonylureas and meglitinides stimulate
pancreatic insulin secretion, while DPP-4 inhibitors prevent GLP-1 breakdown and slow the breakdown of
some sugars. GLP-1 mimetics stimulate insulin secretion, suppress glucagon secretion, and promote -cell
production. Amylin analogs act with insulin to delay gastric emptying and they also inhibit glucagon release.
A. Biguanides, such
as metformin
(Glucophage)
B.
Thiazolidinediones,
such as
pioglitazone
(Actos)
C. DPP-4 inhibitors,
such as sitagliptin
(Januvia)
D. Sulfonylureas,
such as glipizide
(Glucotrol)
E. Amylin analogs,
such as pramlintide
(Symlin)
1049.
B. Blood pressure screening at a local church. Prevention traditionally has been divided into three categories:
primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a
medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs,
water fluoridation, antismoking programs, and education about safe sex). Secondary prevention targets
individuals who have developed an asymptomatic disease and institutes treatment to prevent complications
(e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia). Tertiary prevention
targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g.,
screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial
infarction prophylaxis with -blockers and aspirin).
1050.
B. A blood pressure screening at a local church. Prevention traditionally has been divided into three categories:
primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a
medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs,
water fluoridation, antismoking programs, and education about safe sex). Secondary prevention targets
individuals who have developed an asymptomatic disease and institutes treatment to prevent complications
(e.g., routine Papanicolaou smears, and screening for hypertension, diabetes, or hyperlipidemia). Tertiary
prevention targets individuals with a known disease, with the goal of limiting or preventing future complications
(e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial
infarction prophylaxis with -blockers and aspirin).
A. A smoking
education
program at a local
middle school
B. A blood
pressure screening
at a local church
C. A condom
distribution
program
D. Screening
diabetic patients
for
microalbuminuria
1051.
D. Iron and vitamin B12 deficiency. Iron and vitamin B12 deficiencies develop in more than 30% of patients after
Roux-en-Y gastric bypass. The incidence of pulmonary embolus is 1%-2%. The incidence of dumping syndrome
is very low.
1052.
Which one
of the
following
confirmed
findings in a
3-year-old
female is
diagnostic
of sexual
abuse?
(check one)
C. Gonorrhea. The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child
should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical
inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired
Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of
Chlamydia to result in infection that can go unnoticed for as long as 2-3 years. Although a diagnosis of genital herpes,
genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported
to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from
autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial
vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which
reporting is neither required nor strongly recommended.
A. Bacterial
vaginosis
B. Genital
herpes
C.
Gonorrhea
D.
Anogenital
warts
E. Hepatitis
1053.
Which one
of the
following
decreases
pain from
infiltration
of local
anesthetics?
(check one)
A. Cooling
the
anesthetic
solution
B. Using a
22-gauge
needle
rather than
a 30-gauge
needle
C.
Infiltrating
quickly
D.
Infiltrating
through
surrounding
intact skin
E. Adding
sodium
bicarbonate
to the
mixture
E. Adding sodium bicarbonate to the mixture. The pain from infiltration of local anesthetics can be decreased by using
a warm solution, using small needles, and performing the infiltration slowly.It is also helpful to add sodium bicarbonate
to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life. An exception to this tip is
bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. It also helps to inject
the agent through the edges of the wound (assuming the wound is not contaminated) and to pretreat the wound
with topical anesthetics.
1054.
D. Proton pump inhibitors. Long-term histamine H2 -blocker or proton pump inhibitor use is associated
with decreased absorption of calcium carbonate. Patients taking these medications who require calcium
supplementation should use calcium citrate to improve absorption. Calcium carbonate preparations
should be given with a meal to improve absorption. Vitamin D is important in calcium absorption.
A. Taking calcium
carbonate with meals
B. Taking calcium
citrate with meals
C. Vitamin D
supplementation
D. Proton pump
inhibitors
1055.
1056.
C. Maximal flexion and abduction of the maternal hips. When the just-delivered fetal head retracts firmly
against the perineum, shoulder dystocia is apparent. This is an obstetric emergency that requires
appropriate assistance and a calm but timely approach to ensure a safe delivery. While all of the
maneuvers described are steps in managing shoulder dystocia, the McRoberts maneuver by itself
(maximal flexion and abduction of the maternal hips) relieves the impaction of the anterior shoulder
against the maternal symphysis in a large percentage of cases, especially when combined with
suprapubic pressure.
B. Glucosamine sulfate. Glucosamine sulfate may be used to reduce symptoms and possibly slow disease
progression in patients with osteoarthritis of the knee (SOR B). Methylsulfonylmethane, devil's claw,
turmeric, and ginger are not recommended because of insufficient evidence of their effectiveness.
1057.
D. ACE inhibitors. ACE inhibitors have proven beneficial in patients who have either early or
established diabetic renal disease. They are the preferred therapy in patients with diabetes and
hypertension, according to guidelines from the American Diabetes Association, the National Kidney
Foundation, the World Health Organization, and the JNC VII report.
A. Centrally-acting
sympatholytics
B. Alpha-blocking agents
C. Beta-blocking agents
D. ACE inhibitors
E. Calcium channel blockers
1058.
A. Aspirin
B. Ibuprofen
C. Indomethacin (Indocin)
D. Capsaicin (Zostrix)
E. Hydroxychloroquine
(Plaquenil)
1059.
E. Levofloxacin (Levaquin). The major concern with regard to pneumonia in the nursing-home
setting is the increased frequency of oropharyngeal colonization by gram-negative organisms. In the
absence of collectible or diagnostic sputum Gram's stains or cultures, empiric therapy must cover
Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and gram-negative
bacteria. Levofloxacin is the best single agent for providing coverage against this spectrum of
organisms.
A. Cefazolin
B. Erythromycin
C. Ampicillin
D. Tobramycin (Nebcin)
E. Levofloxacin (Levaquin)
1060.
D. Crown-rump length. Because the growth pattern of the fetus varies throughout pregnancy, the
accuracy of measurements and their usefulness in determining gestational age and growth vary
with each trimester. Crown-rump length is the distance from the top of the head to the bottom of the
fetal spine. It is most accurate as a measure of gestational age at 7-14 weeks. After that, other
measurements are more reliable. In the second trimester, biparietal diameter and femur length are
used. During the third trimester, biparietal diameter, abdominal circumference, and femur length
are best for estimating gestational age.
1061.
A. Ciprofloxacin
(Cipro)
B. Gatifloxacin
(Tequin)
C. Levofloxacin
(Levaquin)
D. Moxifloxacin
(Avelox)
E. Norfloxacin
(Noroxin)
1062.
A. Horse chestnut seed extract. Horse chestnut seed extract has been shown to have some effect when used
orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins. It may also be useful for
relieving pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances,
including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability. Milk
thistle may be effective for hepatic cirrhosis. Ephedra is considered unsafe, as it can cause severe lifethreatening or disabling adverse effects in some people. St. John's wort may be effective for treating mild to
moderate depression. Vitamin B12 is used to treat pernicious anemia.
A. Horse chestnut
seed extract
B. Vitamin B12
C. Ephedra
D. Milk thistle
E. St. John's wort
1063.
A. Behavioral interventions. Behavioral interventions, especially those including telephone counseling and/or a
dental examination, have been shown to be helpful for promoting smokeless tobacco cessation (SOR B). Studies
examining mint snuff as a tobacco substitute, bupropion, and nicotine replacement in patch or gum form did
not show any significant benefit.
1064.
E. Women who are pregnant. Clinical guidelines published by the U.S. Preventive Services
Task Force in 2008 reaffirmed the 2004 recommendations regarding screening for
asymptomatic bacteriuria in adults. The only group in which screening is recommended is
asymptomatic pregnant women at 12-16 weeks gestation, or at the first prenatal visit if it
occurs later (SOR A).
B. Beta-blockers. Beta-blockers and ACE inhibitors have been found to decrease mortality late
after myocardial infarction. Aspirin has been shown to decrease nonfatal myocardial
infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and
calcium channel antagonists have not been found to reduce mortality after myocardial
infarction.
A. Nitrates
B. Beta-blockers
C. Digoxin
D. Thiazide diuretics
E. Calcium channel antagonists
1066.
A. Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose. Croup is a viral illness and is
not treated with antibiotics. Racemic epinephrine may be used acutely, but rebound can
occur. Albuterol has not been shown to be helpful. Oral or intramuscular dexamethasone, 0.6
mg/kg as a single dose, and nebulized budesonide have been shown to reduce croup scores
and shorten hospital stays.
1068.
1069.
D. Fluoxetine (Prozac). The use of psychiatric medications during pregnancy should always involve
consideration of the potential risks to the fetus in comparison to the well-being of the mother. Lithium is
known to be teratogenic. Benzodiazepines such as alprazolam are controversial due to a possible link to
cleft lip/palate. Studies have shown no significant risk of congenital anomalies from SSRI use in pregnancy,
except for paroxetine. Paroxetine is a category D medication and should be avoided in pregnant women
(SOR B). There is concern about an increased risk of congenital cardiac malformations from first-trimester
exposure. Bupropion has not been studied extensively for use in pregnancy, and in one published study
of 136 patients it was linked to an increased risk of spontaneous abortion.
A. Diaphoresis with feeding. Symptoms of congestive heart failure in infants are often related to feedings.
Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with
feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar
to adults, but the infant's greatest exertion is related to feeding. Fever and nasal congestion are more
suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive
heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process,
including pertussis.
A. Diaphoresis with
feeding
B. Fever
C. Nasal congestion
D. Noisy respiration or
wheezing
E. Staccato cough
1070.
A. Conductive hearing loss. Presbycusis, the hearing loss associated with aging, is gradual in onset, bilateral,
symmetric, and sensorineural.
1071.
1072.
1073.
D. Complete dilation of the uterine cervix. For many women, labor will be preceded by several hours, or
even days, by "bloody show." So-called "false labor," or Braxton Hicks contractions, consists of weak,
irregular, regional contractions that usually occur for weeks before the onset of actual labor and abate
with time, analgesia, and sedation. Spontaneous chorioamnionic membrane rupture precedes the onset
of labor in about 10% of pregnancies, and amniotic fluid leaks through the cervix and out the vagina.
The second stage of labor is defined as the period from complete cervical dilation to complete delivery of
the baby. When the cervix is completely dilated, the patient usually experiences the urge to push with
contractions. The third stage of labor begins with the delivery of the baby and ends with the delivery of
the placenta.
B. Abdomen. The use of a nonexercised injection site for insulin administration, such as the abdomen,
may reduce the risk of exercise-induced hypoglycemia. If the leg is used as an injection site, exercise may
accelerate insulin absorption, resulting in increased levels of plasma insulin. However, leg exercise has
no effect on insulin disappearance from the arm and may actually reduce the rate of insulin
disappearance from abdominal injection sites. Compared with leg injection, arm or abdominal injection
reduces the hypoglycemic effect of exercise by approximately 60% and 90%, respectively.
1074.
1075.
D. One hundred percent of this sample reached menopause by age 60. The most efficient method of gathering
epidemiologic data is to study a representative sample rather than the entire population subject to the event.
The measurements obtained are still affected by sampling variation, however, due to the effect of chance. In
the figure shown, only one of the listed conclusions can be inferred: 100% of the sample selected reached
menopause by age 60. This does not imply that all women reach menopause by age 60. No conclusions
regarding the plausible causes of menopause, surgical or hormonal, are valid on the basis of this graph.
Although 18 years is the earliest age of menopause represented on this particular graph, a comparative
conclusion cannot be drawn in the absence of corresponding comparative data.
This graph illustrates a skewed, or asymmetric, distribution. Therefore, the mean (arithmetic average) age of
menopause is different from the median age or middle value in the sequence from highest to lowest. Whereas
the median age of menopause is approximately 50, the mean age is closer to 45, due to the skewing effect of the
younger age groups represented.
D. The patient is pregnant. The failure to provide immunizations because of perceived contraindications is one
of the most common reasons for an inadequately protected population. A PPD may be falsely negative if
administered 2-30 days after MMR administration, not the reverse. If the patient is immunodeficient or
pregnant, rather than a household contact, then MMR is contraindicated. Breastfeeding is not a
contraindication.
1076.
D. Clearance by a mental health professional. The National Institutes of Health Consensus Development
Conference issued recommendations for gastric bypass surgery in 1991, and these are still considered to be
basic criteria (SOR C). Indications for laparoscopic bariatric surgery for morbid obesity include a BMI >40
kg/m2 or a BMI of 35-40 kg/m2 withsignificant obesity-related comorbidities. Weight loss by nonoperative
means should be attempted before surgery, and patients should be evaluated by a multidisciplinary team
that includes a dietician and a mental health professional before surgery.
A. A Framingham
risk score >25%
B. Severe insulin
resistance
C. Failed
pharmacotherapy
D. Clearance by a
mental health
professional
E. A BMI >30 kg/m2
with comorbidities
1077.
A. Avocadoes. The majority of patients who are latex-allergic are believed to develop IgE antibodies that crossreact with some proteins in plant-derived foods. These food antigens do not survive the digestive process, and
thus lack the capacity to sensitize after oral ingestion in the traditional food-allergy pathway. Antigenic
similarity with proteins present in latex, to which an individual has already been sensitized, results in an
indirect allergic response limited to the exposure that occurs prior to alteration by digestion, localized primarily
in and around the oral cavity. The frequent association with certain fruits has been labeled the "latex-fruit
syndrome." Although many fruits and vegetables have been implicated, fruits most commonly linked to this
problem are bananas, avocadoes, and kiwi.
1078.
A. Less tardive dyskinesia. A recent expert consensus panel endorsed the use of second-generation
antipsychotics rather than first-generation drugs. Tardive dyskinesia is much less common with the use of
second-generation antipsychotics. Several of the second-generation drugs require monitoring for major side
effects, however. For example, clozapine, shown by studies to be the most efficacious of the new class, causes
granulocytopenia or agranulocytosis, requiring weekly and later biweekly monitoring of blood counts. Both
classes have depot formulations for intramuscular administration every 2-4 weeks. Oral dosing of drugs from
both classes varies from 1 to 3 times daily. First-generation antipsychotics cost less than second-generation
drugs.
A. Less tardive
dyskinesia
B. Less monitoring
for major side effects
C. The availability of
depot
(intramuscular)
formulations
D. Lower cost
E. Simpler dosing
schedules
1079.
1080.
1081.
D. No currently available method. Two large European trials studied the use of CA-125 and CA-125 with
transvaginal ultrasonography (TVU) as screening methods for ovarian cancer. TVU has been reviewed
separately. None of these methods is effective as a screening test. No major organization recommends
screening women at average risk. The American Cancer Society does not recommend routine screening; the
American College of Obstetricians and Gynecologists recommends against population-based screening; an NIH
consensus conference recommended obtaining a family history and performing annual pelvic examinations.
The U.S. Preventive Services Task Force graded routine screening for ovarian cancer as a "D," meaning that
there is fair evidence to recommend excluding ovarian cancer screening as a part of the periodic health
examination. This recommendation reflects both a lack of benefit from screening and the fact that a significant
number of women have to undergo exploratory surgery to find a single case.
E. Slower gastrointestinal transit times in women. There are key physiologic differences between women and
men that can have important implications for drug activity. Gastrointestinal transit times are slower in women
than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and
verapamil. In addition, women should wait longer after eating before taking medications that should be
administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.
Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in
absorption of medications that require an acidic environment, such as ketoconazole. Women usually have lower
BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse
reactions. Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and
neuromuscular blockers have a longer duration of action. Women also have lower glomerular filtration rates
than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and
methotrexate.
1082.
1083.
B. Maternal fever. This tracing shows fetal tachycardia, defined as a baseline fetal heart rate >160
beats/min for at least 15 minutes. This is considered a nonreassuring pattern. Causes of fetal
tachycardia include maternal fever, fetal hypoxia, hyperthyroidism, maternal or fetal anemia,
medication effects of parasympatholytic or sympathomimetic drugs, chorioamnionitis, fetal
tachyarrhythmia, and prematurity. Fetal tachycardia is not a sign of normal progression of labor.
Epidural anesthesia, post-dates pregnancy, and umbilical cord prolapse would all be causes of fetal
bradycardia.
C. Ceftriaxone (Rocephin), 125 mg intramuscularly once. Not only has the incidence of gonorrhea
increased since 2002, but the rate of quinolone-resistant infection has also increased. Ceftriaxone is
therefore the currently recommended treatment, and amoxicillin, ciprofloxacin, and erythromycin
are no longer recommended because of resistance to these drugs. Doxycycline can be used but
should be continued for 7 days.
1085.
B. Screening for depression. Screening for postpartum depression is recommended as part of the
routine postpartum visit. The use of a screening tool for depression is recommended, such as the
Edinburgh Postnatal Depression Scale. This scale has been shown to increase the identification of
women at high risk for depression. A CBC or urine dipstick is recommended only for patients who
have an indication for them, and should not be routinely ordered. Thyroid function tests and glucose
tolerance testing are recommended for patients who are either symptomatic or at high risk for
disease.
A. Azithromycin (Zithromax). Several clinical trials suggest that 7-day regimens of erythromycin or
amoxicillin, and single-dose regimens of azithromycin, are effective for treating chlamydial infections
during pregnancy. Doxycycline and levofloxacin are contraindicated during pregnancy due to
potential ill effects on the fetus, and metronidazole is not effective for the treatment of chlamydial
infections.
1086.
E. Gallstones. Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive
alcohol use. Gastroesophageal reflux disease, pyelonephritis, drug abuse (other than alcohol), and angiotensin
receptor blocker use are not risk factors for the development of pancreatitis.
A.
Gastroesophageal
reflux disease
B. Intravenous
drug abuse
C. Angiotensin
receptor blocker
use
D. Pyelonephritis
E. Gallstones
1087.
A. Polycystic ovary syndrome. Patients with persistent hyperestrogenic states are at heightened risk for the
development of endometrial cancer. The chronic anovulation and consequent hyperstimulation of the
endometrium seen with polycystic ovary syndrome predispose women to endometrial hyperplasia and
carcinoma. Conversely, multiparity and late menarche are protective of the endometrium. Combination oral
contraceptive use seems to decrease the risk for endometrial cancer. There is no evidence that IUD use leads to
endometrial cancer, and it is thought that copper-containing IUDs may in fact provide some protection against
endometrial cancer.
A. Polycystic
ovary syndrome
B. Multiparity
C. Late menarche
D. Use of an IUD
E. Use of oral
contraceptives
1088.
C. Diabetes mellitus. Diabetes mellitus and cigarette smoking are significant risk factors for intermittent
claudication, as are hypertension and dyslipidemia. Hyperthyroidism, hypercalcemia, and hypogonadism are
not closely associated with intermittent claudication. Elevation of angiotensin-converting enzyme occurs with
sarcoidosis.
1089.
E. Obesity. Risk factors for osteoarthritis of the hip include obesity, high bone mass, old age,
participation in weight-bearing sports, and hypothyroidism.
A. Lifelong functional
gastrointestinal disorders
B. Lifelong headache
disorders
C. Obesity
D. Recurrent syncope
1091.
1092.
B. Vision or hearing impairment. Delirium occurs in 11%-42% of hospitalized patients. Risk factors for
delirium in hospitalized patients
include vision impairment, hearing impairment, dehydration, immobility, cognitive impairment, and
sleep
deprivation. Repeated reorientation of patients with cognitive impairment, early mobilization, and
minimizing unnecessary noise or stimulation are all effective interventions for reducing the risk of
delirium
in hospitalized patients. Not having family members available at the time of admission has no effect
on
the incidence of delirium.
1093.
B. A longer second stage of labor. Studies have shown that epidural analgesia increases the length of both the
first and second stage of labor. Although there is an increase in the rate of instrument-assisted delivery and
fourth degree laceration, an increase in the rate of cesarean sections has not been shown. An increase in the
rate of urinary incontinence also has not been shown.
A. A shorter first
stage of labor
B. A longer second
stage of labor
C. An increased
rate of cesarean
delivery
D. An increased
likelihood of
postpartum
urinary
incontinence
1094.
B. Increased use of restraints. When a patient or nursing-home resident is losing weight or has suffered an
acute change in the ability to perform activities of daily living, a decision must be made as to whether or not to
place a PEG tube to provide artificial nutrition. Studies have shown that PEG tubes do not improve nutritional
status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia,
although aspiration risk may possibly be decreased if the feeding tube is placed below the gastroduodenal
junction (SOR B). Feeding tubes can also cause discomfort and agitation, leading to an increased use of
restraints (SOR B).
1095.
Which one of
the following is
associated with
ulcerative
colitis rather
than Crohn's
disease? (check
one)
E. An increased risk of carcinoma of the colon. Long-standing ulcerative colitis (UC) is associated with an increased
risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial
colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed
up with surveillance examinations every 1-2 years, even if the disease is in remission. All of the other options listed
are features typically associated with Crohn's disease. Virtually all patients with UC have rectal involvement, even if
that is the only area affected. In Crohn's disease, rectal involvement is variable. Noncontinuous and transmural
inflammation are also more common with Crohn's disease. Transmural inflammation can lead to eventual fistula
formation, which is not seen in UC.
A. The absence
of rectal
involvement
B. Transmural
involvement of
the colon
C. Segmental
noncontinuous
distribution of
inflammation
D. Fistula
formation
E. An increased
risk of
carcinoma of
the colon
1096.
Which one of
the following is
associated with
vacuumassisted
delivery?
(check one)
A. Lower fetal
risk than with
forceps
delivery
B. More
maternal softtissue trauma
than forceps
delivery
C. A reduced
likelihood of
severe perineal
laceration
compared to
spontaneous
delivery
D. An increased
incidence of
shoulder
dystocia
D. An increased incidence of shoulder dystocia. Vacuum-assisted delivery is associated with higher rates of
neonatal cephalhematoma and retinal hemorrhage compared with forceps delivery. A systematic review of 10
trials found that vacuum-assisted deliveries are associated with less maternal soft-tissue trauma when compared to
forceps delivery. Compared with spontaneous vaginal delivery, the likelihood of a severe perineal laceration is
increased in women who have vacuum-assisted delivery without episiotomy, and the odds are even higher in
vacuum-assisted delivery with episiotomy. Operative vaginal delivery is a risk factor for shoulder dystocia, which is
more common with vacuum-assisted delivery than with forceps delivery.
1097.
B. Symptomatic heart block. According to several randomized, controlled trials, mortality rates are improved in
patients with heart failure who receive beta-blockers in addition to diuretics, ACE inhibitors, and occasionally,
digoxin. Contraindications to beta-blocker use include hemodynamic instability, heart block, bradycardia, and
severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored
for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III
heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease
mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification.
A. Mild asthma
B. Symptomatic
heart block
C. New York
Heart Association
(NYHA) Class III
heart failure
D. NYHA Class I
heart failure in a
patient with a
history of a
previous
myocardial
infarction
E. An ejection
fraction <30%
1098.
B. Propranolol (Inderal). Propranolol is a first-line therapy for migraine prophylaxis in adults (SOR A). In a review
of 26 placebocontrolled trials using data pooled from nine studies, the calculated responder ratio (comparable to
relative risk) was 1.9 (95% confidence interval 1.6-2.35). Other first-line agents include timolol, amitriptyline,
divalproex sodium, sodium valproate, and topiramate.
Gabapentin, fluoxetine, vitamin B , and naproxen are considered second-line therapies for migraine
prophylaxis in adults (SOR B), and should be used when no first-line agent or combination is effective or
tolerable.
1099.
1100.
D. Vitamin B6. A number of alternative therapies have been used for problems related to pregnancy,
although vigorous studies are not always possible. For nausea and vomiting, however, vitamin B6 is
considered first-line therapy, sometimes combined with doxylamine. Other measures that have been
found to be somewhat useful include ginger and acupressure.
Cranberry products can be useful for preventing urinary tract infections, and could be recommended
for patients if this is a concern. Blue cohosh is used by many midwives as a partus preparator, but
there are concerns about its safety. Fenugreek has been used to increase milk production in
breastfeeding mothers, but no rigorous trials have been performed.
C. Pain relieved by sitting. Causes of low back pain include vertebral disk herniation and spinal
stenosis. Numbness and muscle weakness may be present in both. Pain from spinal stenosis is relieved
by sitting and aggravated by standing, whereas the opposite is true for pain from a herniated disk.
A. Numbness
B. Muscle weakness
C. Pain relieved by sitting
D. Pain relieved by
standing
1101.
A. Atypical squamous cellscannot exclude HSIL (ASC-H). In the 2001 Bethesda System, atypical
squamous cells of unknown significance (ASCUS) was replaced by atypical squamous cells (ASC). ASC is
divided into atypical squamous cells-cannot exclude HSIL (ASC-H) and atypical squamous cells of
unknown significance (ASC-US). ASCUS-favor reactive has been downgraded to negative in the 2001
system. Atypical glandular cells of unknown significance (AGUS) has been replaced by atypical
glandular cells (AGC).
1102.
1103.
1104.
A. A fasting plasma glucose level 126 mg/dL on two separate occasions. The American Diabetes
Association (ADA) first published guidelines for the diagnosis of diabetes mellitus in 1997 and
updated its diagnostic criteria in 2010. With the increasing incidence of obesity, it is estimated
that over 5 million Americans have undiagnosed type 2 diabetes mellitus. Given the long-term
risks of microvascular (renal, ocular) and macrovascular (cardiac) complications, clear guidelines
for screening are critical. The ADA recommends screening for all asymptomatic adults with a BMI
>25.0 kg/m whohave one or more additional risk factors for diabetes mellitus, and screening for
all adults with no risk factors every 3 years beginning at age 45.
Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c6.5%, a fasting
plasma glucose level 126 mg/dL, a 2-hour plasma glucose leve l200 mg/dL, or, in a symptomatic
patient, a random blood glucose level 200 mg/dL. In the absence of unequivocal hyperglycemia,
results require confirmation by repeat testing.
E. Doxycycline. In controlled studies, it has been shown that a single 200-mg dose of doxycycline
given within 72 hours after an Ixodes scapularis tick bite can prevent the development of Lyme
disease.
A. Azithromycin (Zithromax)
B. Amoxicillin
C. Cefuroxime (Ceftin)
D.
Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
E. Doxycycline
1105.
C. Abdominal pain. A large review of multiple studies identified abdominal pain as the most
consistent feature found in irritable bowel syndrome (IBS), and its absence makes the diagnosis
less likely. Of the symptoms listed, passage of blood is least likely with IBS, and passage of mucus,
constipation, and diarrhea are less consistent than abdominal pain (SOR A).
1106.
1107.
B. Amiodarone (Cordarone). Amiodarone is 37% iodine and is the most common source of iodine excess in
the United States.
Excessive iodine intake from dietary sources, radiographic contrast media, or amiodarone increases the
production and release of thyroid hormone in iodine-deficient individuals and in older persons with
multinodular goiter. Additionally, like other medications such as interferon and interleukin-2, amiodarone
can trigger thyroiditis in patients with normal thyroid glands. These characteristics combine to induce
hyperthyroidism in slightly over 10% of patients treated with amiodarone. -Blockers such as propranolol
may be useful in controlling the symptoms of hyperthyroidism. Methimazole and propylthiouracil
interfere with organification of iodine, thereby suppressing thyroid hormone production; they are
commonly used as antithyroid agents when treating hyperthyroidism. Research is ongoing to determine if
methotrexate plus prednisone is an effective treatment for the ophthalmopathy associated with Graves'
hyperthyroidism.
B. Hypoglycemia. Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages
over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in
patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which
often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining
or even a weight loss effect. Gastrointestinal distress is a common side effect of metformin, particularly
early in therapy.
A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal
distress
1108.
B. Hypoglycemia. Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages
over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in
patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which
often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining
or even a weight loss effect. Gastrointestinal distress is a common side-effect of metformin, particularly
early in therapy.
1109.
Which one of
the following
is most
accurate
regarding
somatization
disorder?
(check one)
E. The incidence is increased among female first degree relatives of patients with the disorder. Somatization disorder
is a psychological disorder characterized by the chronic presence of several unexplained symptoms beginning
before the age of 30 years. It is diagnostically grouped with conversion disorder, hypochondriasis, and body
dysmorphic disorder. By definition, the symptom complex must include a minimum of two symptoms relating to the
gastrointestinal system, one neurologic complaint, one sexual complaint, and four pain complaints. The condition is
more common in women than in men, and the incidence is increased as much as tenfold in female first degree
relatives of affected patients.
A. Onset
before age 40
is atypical
B. It is a form
of malingering
C. Symptoms
tend to
resolve
spontaneously
within weeks
of onset
D. Symptoms
are limited to
one organ
system or
bodily
function
E. The
incidence is
increased
among female
first degree
relatives of
patients with
the disorder
1110.
Which one of
the following
is most
appropriate
for the initial
treatment of
claudication?
(check one)
A. Regular
exercise
B. Chelation
C.
Vasodilating
agents
D. Warfarin
(Coumadin)
A. Regular exercise. Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved
by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular
disease are asymptomatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients
who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better
results. Risk factors include diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional
treatments such as chelation have not been shown to be effective. Vasodilating agents are of no benefit. There is no
evidence that anticoagulants such as aspirin have a role in the treatment of claudication.
1111.
A. Metaxalone
(Skelaxin)
B. Hydrocodone
C. Naproxen
D. Tizanidine
(Zanaflex)
E. Amitriptyline
1112.
C. Inadequate hip abductor strength. Patellofemoral pain syndrome is a common overuse injury observed in
adolescent girls. The condition is characterized by anterior knee pain associated with activity. The pain is
exacerbated by going up or down stairs or running in hilly terrain. It is associated with inadequate hip
abductor and core strength; therefore, a prescription for a rehabilitation program is recommended. Surgical
intervention is rarely required.
A. Posterior knee
pain
B. Pain
exacerbated by
walking on a flat
surface
C. Inadequate hip
abductor strength
D. A high rate of
surgical
intervention
1113.
E. Antibiotics. Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drugrelated cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other
drugs listed may cause renal injury, but not acute interstitial nephritis.
1114.
D. Reticulocytosis about 1 week after administration of iron. In iron deficiency anemia, serum iron is low but
iron-binding capacity is high. Serum ferritin is one-tenth of normal. Bone marrow iron stores are depleted.
Oral replacement, which is safer than parenteral administration and more acceptable to patients, should
raise the hemoglobin level by 0.2 g/dL/day. A reticulocyte response should be seen in a week to 10 days
unless factors such as a concomitant folic acid deficiency prevent a full response to therapy.
A. Low iron-binding
capacity
B. An elevated
methylmalonic acid
level
C. Increased serum
ferritin
D. Reticulocytosis
about 1 week after
administration of iron
1115.
C. Topiramate (Topamax). Treatments likely to be beneficial for essential tremor of the hands include
propranolol and topiramate. Topiramate has been shown to improve tremor scores after 2 weeks of
treatment, but is associated with appetite suppression, weight loss, and paresthesias. Medications with
unknown effectiveness include benzodiazepines, -blockers other than propranolol, calcium channel
blockers, clonidine, gabapentin, and isoniazid.
1116.
A. Venlafaxine (Effexor). The abrupt discontinuation of venlafaxine, or a reduction in dosage, is associated with
withdrawal symptoms much more severe than those seen with other SSRIs such as fluoxetine. Although more
pronounced with higher dosages and prolonged administration, they also occur at lower dosages. These
symptoms include agitation, anorexia, confusion, impaired coordination, seizures, sweating, tremor, and
vomiting. To avoid this withdrawal symptom, dosage changes should be instituted gradually. Abrupt
discontinuation of mood stabilizers such as divalproex, and atypical antipsychotics such as olanzapine, can
result in the return of psychiatric symptoms, but not severe physiologic dysfunction. Similarly, stopping
anticholinesterase inhibitors such as donepezil will not cause a withdrawal syndrome.
A. Venlafaxine
(Effexor)
B. Divalproex
(Depakote)
C. Fluoxetine
(Prozac)
D. Olanzapine
(Zyprexa)
E. Donepezil
(Aricept)
1117.
E. Renal insufficiency (creatinine 2.0 mg/dL). Clinical predictors of increased perioperative cardiovascular risk
for elderly patients include major risk factors such as unstable coronary syndrome (acute or recent myocardial
infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV
block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate),
and severe valvular disease. Intermediate predictors are mild angina, previous myocardial infarction,
compensated congestive heart failure, diabetes mellitus, and renal insufficiency. Minor predictors are
advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave
abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled
hypertension.
1118.
1119.
A. Joint swelling
B. Early morning stiffness
C. Reduction of symptoms
with high-dose NSAID
therapy
D. An erythrocyte
sedimentation rate 60
mm/hr
E. Bilateral shoulder or hip
stiffness and aching
1120.
D. ACE inhibitors. ACE inhibitors are the preferred drugs for congestive heart failure due to left
ventricular systolic dysfunction, because they are associated with the lowest mortality. The
combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be
used cautiously. It is not known whether digoxin affects mortality, although it can help with
symptoms.
A. Diuretics
B. Digoxin
C. Calcium channel blockers
D. ACE inhibitors
E. Hydralazine (Apresoline)
plus isosorbide dinitrate
(Isordil, Sorbitrate)
1121.
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.
1122.
D. Cryotherapy with liquid nitrogen. Genital warts can proliferate and fragment during pregnancy, and many
specialists recommend that they be eliminated. Imiquimod, podophyllin, and podofilox are not recommended
for use during pregnancy. For the treatment of vaginal warts, the Centers for Disease Control and Prevention
(CDC) recommends the use of cryotherapy. Liquid nitrogen, rather than a cryoprobe, should be used to avoid
possible vaginal perforation and subsequent fistula formation. An alternative is the use of trichloroacetic acid or
bichloroacetic acid carefully applied to the lesions to avoid damage to adjacent tissue. Interferon is no longer
recommended for routine use in treating genital warts, due to a high frequency of systemic adverse effects.
1123.
1124.
E. Short-acting inhaled 2 -agonists such as albuterol (Ventolin HFA), as needed for dyspnea.
Short-acting bronchodilators such as albuterol and ipratropium are recommended on an asneeded basis for treatment of breathlessness in stage I (mild) COPD. They are also
recommended for as-needed use in stage II (moderate), stage III (severe), and stage IV (very
severe) COPD. Long-acting bronchodilators such as salmeterol or tiotropium are recommended
for stages II, III, and IV. Inhaled corticosteroids are recommended for stages III and IV. Mucolytics
can be considered for stages III and IV.
D. Having the infant sleep in a separate bed. Home cardiorespiratory monitoring has not been
shown to be effective for preventing sudden infant death syndrome (SIDS). The risk of SIDS
increases with higher room temperatures and soft bedding. Placing the infant in a supine
position will significantly decrease the risk of SIDS, and is probably the most important
preventive measure that can be taken. Bed sharing has been shown to increase the risk of SIDS.
C. Nitrofurantoin (Macrodantin). The FDA has established a fetal risk summary dividing drugs
into categories. Category A drugs have been shown in controlled studies to pose no risk. At
present there are no category A antibiotics. Most fall into categories B and C, with category B
drugs thought to be relatively safe in pregnancy. When possible, a category B antibiotic should
be chosen for treatment of a pregnant patient. Category C drugs have unknown fetal risk with
no adequate human studies, and the possibility of risks and benefits must be considered before
prescribing them for pregnant women. Category D drugs show some evidence for fetal risk;
although there may be times when use of these drugs is necessary, they should not be used
unless there is a very serious or life-threatening situation. Category X drugs have proven fetal
risk and are contraindicated in pregnancy. Of the drugs listed, only nitrofurantoin is in category
B. The others are all category C drugs. The FDA is currently in the process of revising their
classification and labeling for drugs in pregnancy and lactation.
1126.
E. 25-hydroxyvitamin D. Undiagnosed vitamin D deficiency is not uncommon, and 25hydroxyvitamin D is the barometer for vitamin D status. Although there is no consensus on
optimal levels of 25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by
most experts as a 25-hydroxyvitamin D level of <20 ng/mL (50 nmol/L).
A. Ionized calcium
B. Serum phosphorus
C. 24-hour urine for calcium
D. 1,25-hydroxyvitamin D
E. 25-hydroxyvitamin D
1127.
1128.
D. Intravenous saline. The initial management of hypercalcemic crisis involves volume repletion
and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic
patients to conserve free water can lead to calcium levels over 14-15 mg/dL. Because patients
often have a fluid deficiency of 4-5 liters, delivering 1000 mL of normal saline during the first
hour, followed by 250-300 mL/hour, may decrease the hypercalcemia to less than critical levels
(<13 mg/dL). If the clinical status is not satisfactory after hydration alone, then renal excretion of
calcium can be enhanced by saline diuresis using furosemide. Intravenous pamidronate, a
diphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute
setting, since calcium levels do not start to fall for 24 hours. The same is true for intravenous
plicamycin.
C. CT. CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are
superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be
missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.
A. A KUB radiograph
B. Ultrasonography
C. CT
D. Intravenous pyelography
E. MRI
1129.
A. Ceftriaxone (Rocephin)
B. Amoxicillin
C. Azithromycin (Zithromax)
D. Cefuroxime (Ceftin)
E.
Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
1130.
A. Cigarette smoking. Cigarette smokers are five times more likely than nonsmokers to develop
an abdominal aortic aneurysm (AAA). The risk is associated with the number of years the patient
has smoked, and declines with cessation. Diabetes mellitus is protective, decreasing the risk of
AAA by half. Women tend to develop AAA in their sixties, 10 years later than men. Whites are at
greater risk than African-Americans. Hypertension is less of a risk factor than cigarette smoking
(SOR A).
1131.
C. Macular degeneration. Age-related macular degeneration (AMD) is the leading cause of blindness
in the U.S. in individuals over age 65. AMD currently affects more than 1.75 million individuals in the
U.S. Due to the rapid aging of the population, this number will increase to almost 3 million by 2020.
A. Pulmonary embolism. Pulmonary emboli, anastomotic leaks, and respiratory failure are responsible
for 80% of deaths in the 30 days following bariatric surgery, with death from pulmonary embolism
being the most frequent cause. Wound infections and marginal ulcers are common complications of
this type of surgery.
A. Pulmonary embolism
B. Adult respiratory
distress syndrome
C. Peritonitis secondary to
an anastomotic leak
D. Sepsis related to a
wound infection
E. Hemorrhage from an
anastomotic ulcer
1133.
E. Cardiovascular disease. Cardiovascular disease is the leading cause of death among women.
According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular
disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third
most common cause of cancer death in women, and ovarian cancer is the fifth most common.
A. Breast cancer
B. Lung cancer
C. Ovarian cancer
D. Osteoporosis
E. Cardiovascular disease
1134.
D. Sertraline (Zoloft). Results of randomized clinical trials demonstrate that medications such as SSRIs,
tricyclic antidepressants, and monoamine oxidase inhibitors alleviate the symptoms of post-traumatic
stress disorder (PTSD) and are associated with improvements in overall functioning. SSRIs are a firstline medication because they are safer and better tolerated than other types of psychotropic
medications. Sertraline and paroxetine are the only agents that have been approved by the FDA for
the treatment of PTSD.
1135.
D. Campylobacter jejuni. The treatment of acute and significant diarrhea often requires a specific diagnosis.
Epidemiologic studies have shown that Campylobacter infections are the leading cause of bacterial diarrhea
in the U.S.
A. Listeria
monocytogenes
B. Escherichia coli
O157:H7
C. Shigella
dysenteriae
D. Campylobacter
jejuni
E. Salmonella enterica
1136.
C. Renal parenchymal disease. Although essential hypertension is most common in adolescents and adults,
it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common
cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal
ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes,
such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further
testing and/or investigation should be ordered as clinically indicated.
A. Essential
hypertension
B.
Pheochromocytoma
C. Renal parenchymal
disease
D. Hyperthyroidism
E. Excessive caffeine
use
1137.
1138.
1139.
1140.
A. Posterior detachment of the vitreous. Vitreous detachment is very common after age 60 and
occurs frequently in younger persons with myopia. The separation of the posterior aspect of the
vitreous from the retina exerts traction on the retina, with the attendant risks of a retinal tear and
detachment. Symptoms of retinal detachment may include light flashes (photopsia), a sudden
appearance or increase in "floaters," or peripheral visual field loss, any of which should prompt an
ophthalmology referral. Cataract surgery can result in premature shrinkage of the vitreous and
thereby poses an increased risk, but vitreous detachment resulting from other processes is more
common. Hyphema, glaucoma, and diabetic retinopathy are not specific risk factors for retinal
detachment.
A. Diabetes mellitus. Although most cases of nephrotic syndrome are caused by primary kidney
disease, the most common secondary cause of nephrotic syndrome in adults is diabetes mellitus.
Other secondary causes include systemic lupus erythematosus, hepatitis B, hepatitis C, NSAIDs,
amyloidosis, multiple myeloma, HIV, and preeclampsia. Primary causes include membranous
nephropathy and focal segmental glomerulosclerosis, each accounting for approximately one
third of cases.
C. The seat belt should be positioned under the abdomen over both the anterior superior iliac
spines and the pubic symphysis; the shoulder harness should be positioned between the breasts;
the belt should be applied as snugly as comfort will allow. Pregnant women can and should always
wear a seat belt when driving or riding in a car. The seat belt should be positioned under the
pregnant woman's abdomen over both the anterior superior iliac spines and the pubic
symphysis. The shoulder harness should be positioned between the breasts.
1141.
E. Naltrexone (ReVia). Drug therapy should be considered for all patients with alcohol dependence who do not
have medical contraindications to the use of the drug and who are willing to take it. Of the several drugs
studied for the treatment of dependence, the evidence of efficacy is strongest for naltrexone and acamprosate.
Naltrexone is currently available in the U.S.; acamprosate and tiapride are currently available in Europe but
not in the U.S.
A. Disulfiram
(Antabuse)
B. Diazepam
(Valium)
C. Amitriptyline
(Elavil)
D. Fluoxetine
(Prozac)
E. Naltrexone
(ReVia)
1142.
E. Malathion (Ovide). Malathion is currently the most effective treatment for head lice and is less toxic than
lindane. Permethrin and pyrethrins are less effective than malathion, although they are acceptable
alternatives. These insecticides, as well as lindane, are not recommended in children 2 years of age or younger.
Wet combing may be effective, but is less than half as effective as malathion. Head shaving is only temporarily
effective and is traumatic. Petrolatum is not proven to be effective.
A. Lindane (Kwell)
B. Wet combing
every 4 days, to
continue for 2
weeks after any
louse is found
C. Head shaving
D. Nightly
application of
petrolatum to the
scalp, covered by a
shower cap
E. Malathion
(Ovide)
1143.
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, with septal deviation being 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.
1144.
D. Lentigo maligna melanoma. This patient has a malignant melanoma, often called lentigo maligna melanoma.
These lesions typically appear during the seventh or eighth decade of life, and are most often located on the
face. This patient's age, health status, and wishes must be considered in any treatment plans. The other skin
lesions listed can be seen in this age group, but they are easily distinguished from this malignant lesion.
A. Actinic keratosis
B. Metastatic breast
carcinoma
C. Seborrheic
keratosis
D. Lentigo maligna
melanoma
E. Basal cell
carcinoma
1145.
B. Vitamin B12 deficiency anemia. The blood smear shows a hypersegmented polymorphonuclear (PMN)
white blood cell, typical of vitamin B12deficiency with pernicious anemia. The anemia is of the macrocytic type
(MCV >100 m ). There is no evidence of hemolysis or
leukemia. While iron deficiency anemia can be a coexisting problem, the hypersegmented PMN is classic for
vitamin B12 deficiencyIt is important to note that elderly patients with vitamin B12 deficiency may have
neurologic signs and symptoms before developing hematologic abnormalities.
A. Iron deficiency
anemia
B. Vitamin B12
deficiency anemia
C. Hemolytic
anemia
D. Acute
myelogenous
leukemia
E. Chronic
myelogenous
leukemia
1146.
D. Fetal distress. Fetal distress has proven to be the most reliable clinical symptom of uterine rupture. The
"classic" signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of
uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding
occur in as few as 10% of cases. Even ruptures monitored with an intrauterine pressure catheter fail to show
loss of uterine tone. Signs of fetal distress are often the only manifestation of uterine rupture.
1147.
A. Lithium carbonate
B. Alprazolam (Xanax)
C. Fluoxetine (Prozac)
D. Amitriptyline (Elavil)
E. Valproic acid
(Depakene)
1148.
1149.
C. Topical permethrin (Elimite), 5%. Permethrin and lindane are the two most studied topical treatments
for scabies. A Cochrane meta-analysis of four randomized trials comparing these agents indicates that a
single overnight application of permethrin is more effective than lindane (odds ratio for clinical failure,
0.66; 95% confidence interval, 0.46-0.95). The potential neurotoxicity of lindane, especially with repeated
applications, has limited its use.
Other topical treatments include benzoyl benzoate and crotamiton. Crotamiton has significantly less
efficacy than permethrin at 4 weeks (61% versus 89%). Several controlled trials have assessed the
efficacy of a single dose of ivermectin (200 g/kg) for the treatment of scabies. In one placebo-controlled
trial, 37 of 50 patients treated with ivermectin (74%) were cured.
E. 1 year. The recommended duration of dual antiplatelet therapy following placement of a drug-eluting
coronary artery stent is 1 year (SOR C). The recommended dosages of dual antiplatelet therapy are
aspirin, 162-325 mg, and clopidogrel, 75 mg, or prasugrel, 10 mg. Ticlopidine is an option for patients
who do not tolerate clopidogrel or prasugrel. The minimum recommended duration of dual antiplatelet
therapy is 1 month with bare-metal stents, 3 months with sirolimus-eluting stents, and 6 months with
other drug-eluting stents.
1150.
Which one of
the following
is true about
end-of-life
care? (check
one)
A. Physicians
underestimate
life
expectancies
B. Most
physicians are
comfortable
with their
level of
education in
palliative care
and pain
control
C. Most
patients who
qualify for
hospice care
receive
services early
in the course
of their illness
D. Most
terminal
patients want
their lives
prolonged as
much as
possible
E. Most
terminal
patients
express a
desire for a
sense of
control
E. Most terminal patients express a desire for a sense of control. End-of-life issues are a challenge to primary care
physicians because of concerns about a lack of education in pain control and palliative care. Trying to determine the
prognosis of patients is difficult, and even with established criteria, the estimated prognosis is right only 50% of the
time. There is a tendency for most physicians to overestimate life expectancy in a terminal patient. Most patients
who are appropriate candidates for hospice care do not receive referrals until late in their illness, if at all. Patients at
the end of life have five main areas of concern: control of pain and other symptoms; avoiding a prolongation of the
dying process; having a sense of control; relieving burdens on family and loved ones; and strengthening
relationships with family and friends.
1151.
D. Strength training can prevent ACL tears. Three trials have shown that neuromuscular training with
plyometrics and strengthening reduces anterior cruciate ligament (ACL) tears. Females have a higher rate of
ACL tears than males. Early-onset osteoarthritis occurs in the affected knee in an estimated 50% of patients
with ACL tears. The ACL typically pops audibly when it is torn, usually with no physical contact.
A. The incidence of
ACL tears is higher in
males than in females
B. ACL tears are not
associated with
early-onset
osteoarthritis
C. The majority of
ACL tears are caused
by physical contact
D. Strength training
can prevent ACL tears
1152.
D. It has resulted in an increase in the diagnosis of localized disease. Breast cancer screening has resulted in
an increase in the diagnosis of localized disease without a commensurate decrease in the incidence of more
widespread disease. Unfortunately, it cannot predict which of the discovered cancers are more aggressive,
and cannot accurately detect premalignant lesions. The decrease in the mortality rate of breast cancer is due
both to earlier detection and better follow-up medical care.
1153.
Which one
of the
following is
true
concerning
falls in the
elderly?
(check one)
A. Treating
depression
with SSRIs
reduces the
risk of falling
B. Patients
tend to fall
less often
immediately
after coming
home from
the hospital
C.
Ambulatory
blood
pressure
monitoring
should be
ordered for
all patients
who fall
D. Arthritis
and vision
impairment
are not
associated
with an
increased
risk of falling
E. Reducing
the number
of
medications
a patient
takes
reduces the
risk of falling
E. Reducing the number of medications a patient takes reduces the risk of falling. Falling is one of the most common
adverse events associated with drugs. The elderly frequently take many medications; reducing these medications also
reduces the risk of falling. SSRIs, tricyclic antidepressants, benzodiazepines, and anticonvulsants have the strongest
association with falls in the elderly. The highest risk for falling occurs immediately after hospital stays and lasts for
about a month. Ambulatory blood pressure monitoring is associated with so many false-negative and false-positive
results that it cannot be recommended for all patients who fall. Arthritis and vision problems are both strongly
associated with an increased risk of falls.
1154.
D. If nausea and vomiting begin after 9 weeks' gestation, secondary causes are more likely to be present.
While the exact etiology of nausea and vomiting in pregnancy remains unclear, there are few data to support
the theory that psychological factors play a role. Although nausea is usually a self-limited condition, other
causes must be ruled out. Secondary causes are more likely to be present if the onset of symptoms occurs
after 9 weeks' gestation. Several pharmacologic treatments are proven safe and are superior to placebo in
relieving symptoms and preventing hospitalization. Metoclopramide is more effective than placebo and has
not been associated with an increased risk of adverse effects on the fetus.
1155.
B. Viral shedding continues long after the acute illness. Outbreaks of Norwalk gastroenteritis occur in a wide
variety of settings, involve all ages, and are more likely to involve high-risk groups such as immunocompromised
patients or the elderly. Not only does viral shedding of the Norwalk virus often precede the onset of illness, but it
can continue long after the illness has clinically ended. The virus persists on environmental surfaces and can
tolerate a broad range of temperatures. There are multiple strains of the virus, so a single infection does not
confer immunity, and repeated infections occur throughout life. It is the most common cause of diarrhea in
adults.
1156.
Which one of
the following
is true
concerning
Paget's
disease of
bone? (check
one)
A. It is a
precursor of
multiple
myeloma
B. Both bone
formation
and bone
resorption
are increased
C. The
treatment of
choice for
symptomatic
disease is a
calcium
channel
blocker
D. Pagetic
bone pain is
difficult to
relieve and
resistant to
medical
treatment
E.
Extracellular
calcium
homeostasis
is typically
abnormal
B. Both bone formation and bone resorption are increased. Paget's disease of bone is a focal disorder of skeletal
metabolism in which all elements of skeletal remodeling (resorption, formation, and mineralization) are increased.
There is no known relationship between Paget's disease and multiple myeloma, although most cases of sarcoma in
patients over 50 arise in pagetic bone. The preferred treatment for nearly all patients with symptomatic disease is one
of the newer bisphosphonates. Treatment of bone pain resulting from Paget's disease is generally very satisfactory,
and in fact, relief may continue for many months or years after treatment is stopped, lending support for intermittent
symptomatic therapy. Finally, despite the massive bone turnover, extracellular calcium homeostasis is almost
invariably normal.
1157.
Which one of
the following
is true
concerning
postpartum
depression?
(check one)
A. It has no
effect on
cognitive
development
of the child
B. It is directly
related to the
desired gender
of the infant
C. It is usually
transient,
lasting about
10 days
D. Thyroid
function
should always
be assessed in
women with
postpartum
depression
D. Thyroid function should always be assessed in women with postpartum depression. Thyroid function must be
evaluated in women with postpartum depression since both hyperthyroidism and hypothyroidism are more
common post partum. Postpartum depression may impair cognitive and behavioral development in the child. It is
not related to the desired gender of the child, breastfeeding, or education level of the mother. It should be
differentiated from the short-term "baby blues" that resolve within about 10 days. Sertraline is considered first-line
treatment for postpartum depression in women who are breastfeeding.
1158.
E. Nicotine causes physical dependence. Nicotine causes both physical dependence and tolerance.
Withdrawal from nicotine can last several weeks or months. Physicians' advice to stop smoking increases the
rate of stopping smoking by about 30%. Bupropion is no more or less effective than other products for
smoking cessation. Nicotine replacement therapy is safe in patients with stable angina.
A. Tobacco
withdrawal symptoms
abate in 3 days
B. Physicians' advice
to patients to stop
smoking is ineffectual
C. Of all the products
available for smoking
cessation, only
bupropion
(Wellbutrin) is
consistently effective
D. Nicotine
replacement therapy
is dangerous for
patients with stable
angina
E. Nicotine causes
physical dependence
1159.
A. A single dose is adequate for treatment. Treatment with corticosteroids is now routinely recommended
for acute laryngotracheitis (croup). A single dose of dexamethasone, either orally or intramuscularly, is
appropriate. Prolonged courses of corticosteroids provide no additional benefit and may lead to secondary
bacterial or fungal infections. Secondary infections rarely occur with single-dose treatment. Corticosteroid
therapy shortens emergency department stays and decreases the need for return visits and
hospitalizations. It is indicated for patients with croup of any severity.
1160.
E. Their effects begin within 5 minutes and last 4-6 hours. The effects of short-acting inhaled -agonists begin
within 5 minutes and last 4-6 hours. In the past, giving inhaled -agonists just before inhaled corticosteroids was
felt to improve the delivery and effectiveness of the corticosteroids. However, this has been proven to be
ineffective and is no longer recommended. -Blockers do diminish the effectiveness of inhaled -agonists, but
this effect is not severe enough to contraindicate using these drugs together. Oral -agonists are less potent
than inhaled forms. Similarly, anticholinergic drugs cause less bronchodilation than inhaled -agonists and are
not recommended as
first-line therapy.
1161.
B. A physician can certify a death from a natural cause but a coroner or medical examiner must certify a death
due to any other cause. It would be difficult to overstate the importance of death certificates, especially in an era
of increasing reliance on evidence-based medicine, yet physicians receive inadequate training in this important
area, and their performance on this task remains less than ideal. Death certificates are the primary tool for
measuring the mortality rate and its many ramifications in socioeconomic matters such as research funding,
estate settlement, financial matters, and other legal concerns. Most problems with death certificates stem from a
failure to complete them correctly. Notably, one study showed a 50% decrease in errors after primary care
physicians attended a 75-minute educational session.
Only coroners and medical examiners can complete a death certificate when the manner of death is not natural.
The immediate cause of death is a specific etiology, not a general concept. "Uncertain" is not a manner of death,
but "undetermined" may be used by coroners and medical examiners. The death certificate is a public
document when filed.
1162.
D. Patients prefer to receive apologies and explanations when an error has been made. When a medical error
has been made, patients prefer that their physician disclose the error and offer an explanation of events.
Withholding that information from a patient is not ethical and is counter to standards set forth by various
organizations such as the Joint Commission on Accreditation of Health Care Organizations. Using the word
"error" is acceptable and does not lead to an increase in litigation. In fact, there is no evidence that malpractice
litigation rates increase when an error is admitted, and rates often decrease. Private-practice physicians are
less likely to admit errors to patients. It is surmised that these physicians have less access to training in
disclosure than those employed by hospitals or health care organizations.
1163.
E. A reduction of dose, an increase in dosing interval, or both may be necessary. Many medications require
dosage adjustments in patients with chronic kidney disease. Medications are adjusted based on the estimated
glomerular filtration rate (GFR) or creatinine clearance. Most medication adjustments require a reduction in the
dose, lengthening of the dosing interval, or both. Loading doses of medications usually do not need to be
adjusted. Medication adjustments are divided into three groups, based on whether the GFR is >50
mL/min/1.73m2, 10-50 mL/min/1.73m2, or <10 mL/min/1.73m2. The production and excretion of creatinine
decreases in older patients, so a normal serum creatinine level does not always correlate with normal kidney
function. Serum drug levels typically are not required for adjusting medications in patients with chronic kidney
disease.
A. Loading doses
should usually
be adjusted
B. Adjustments
typically are not
necessary until
the glomerular
filtration rate is
<20
mL/min/1.73m2>
C. A normal
serum creatinine
value indicates
that no
adjustment is
necessary
D. Serum drug
levels are usually
required for
making
adjustments
E. A reduction of
dose, an increase
in dosing
interval, or both
may be necessary
1164.
B. They should be avoided in persons with cirrhotic liver disease. NSAIDs are prescribed commonly and many
are available over the counter. It is important for clinicians to understand when they are not appropriate for
clinical use. They should be avoided, if possible, in persons with hepatic cirrhosis (SOR C). While hepatotoxicity
with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet
function. In addition, NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in
patients with cirrhosis.
NSAIDs differ from aspirin in terms of their cardiovascular effects. They have the potential to increase
cardiovascular morbidity, worsen heart failure, increase blood pressure, and increase events such as ischemia
and acute myocardial infarction.
There are no known teratogenic effects of NSAIDs in humans. This drug class is considered to be safe in
pregnancy in low, intermittent doses, although discontinuation of NSAID use within 6-8 weeks of term is
recommended. Ibuprofen, indomethacin, and naproxen are considered safe for lactating women, according to
the American Academy of Pediatrics.
1165.
1166.
A. Patients who have converted within the past year should be treated, regardless of age. Because the risk of
developing active disease is highest in patients within 2 years after conversion, recent converters should
generally be treated regardless of age. BCG vaccination has a limited effect on PPD reactivity; tests should not
be interpreted any differently in patients who have previously received BCG. The use of a two-step
approach (i.e., retesting 1-4 weeks later in patients who initially test negative) is designed to decrease the
false-negative rate of PPD testing. The significance of a positive result on either phase of the test is the same.
Patients who are HIV positive are at higher risk for false-negative PPDs and active disease, but PPD testing is
not contraindicated.
D. The majority of cases resolve without treatment. Temporomandibular joint (TMJ) disorders occur in a large
number of adults. The etiology is varied, but includes dental malocclusion, bruxism (teeth grinding), anxiety,
stress disorders, and, rarely, rheumatoid arthritis. Dental occlusion problems, once thought to be the primary
etiology, are not more common in persons with TMJ disorder. While dental splints have been commonly
recommended, the evidence for and against their use is insufficient to make a recommendation either way.
Physical therapy modalities such as iontophoresis or phonophoresis may benefit some patients, but there is
no clearly preferred treatment. Radiologic imaging is unnecessary in the vast majority of patients, and should
therefore be reserved for chronic or severe cases. In fact, the majority of patients with TMJ disorders have
spontaneous resolution of symptoms, so noninvasive symptomatic treatments and tincture of time are the
best approach for most.
1167.
A. CT of the chest is associated with a greater risk than CT of the head. CT of the chest or abdomen leads
to significantly more radiation exposure and cancer risk than CT of the brain. Younger patients,
including neonates, have a greater lifetime risk of developing cancer after radiation exposure, and CT
imaging carries substantially more risk than plain radiographs of the same area. Women are at greater
risk for developing lung cancer after a chest CT than men, and CT also increases their risk of developing
breast cancer.
1168.
Which one of
the following is
true regarding
the risk of
physical
spouse abuse?
(check one)
A. It decreases
during
pregnancy
B. It decreases
when a woman
exits an
abusive
relationship
C. It increases
with alcohol
and substance
abuse
D. It increases
as
socioeconomic
status rises
E. It is higher
among
patients from
racial
minorities
C. It increases with alcohol and substance abuse. Pregnancy represents a time of heightened risk for battery, and
prompts a shift in the area of physical abuse from the head and neck to the breasts and abdomen. Although some
studies have shown a higher prevalence of partner abuse among minority women, a National Crime Victimization
Survey concluded that women of all races and ethnic backgrounds are equally likely to be abused by an intimate.
Alcohol and/or substance abuse is a significant risk factor associated with the occurrence of partner abuse and
family violence in general. Less education and lower occupational status or income (particularly when total family
income is less than $10,000 per year) have been found to increase the risk of violence. Women who have separated
from their spouses are 3 times more likely to be victimized than are those who are already divorced and 25 times
more likely than women who are married. A woman's danger substantially increases at the point of exiting an
abusive relationship.
1169.
Which one of
the following is
true regarding
the treatment of
generalized
anxiety
disorder? (check
one)
A. Cognitivebehavioral
therapy has
been shown to
be at least as
effective as
pharmacologic
therapy
B. Buspirone
(BuSpar) is as
effective as SSRI
therapy for
patients with
comorbid
depression
C.
Benzodiazepines
are no more
effective than
placebo
D. Duloxetine
(Cymbalta) is no
more effective
than placebo
E. Escitalopram
(Lexapro) is no
more effective
than placebo
A. Cognitive-behavioral therapy has been shown to be at least as effective as pharmacologic therapy. Cognitivebehavioral therapy has been shown to be at least as effective as medication for treatment of generalized anxiety
disorder (GAD), but with less attrition and more durable effects. Many SSRIs and SNRIs have proven effective for
GAD in clinical trials, but only paroxetine, escitalopram, duloxetine, and venlafaxine are approved by the FDA for
this indication. Benzodiazepines have been widely used because of their rapid onset of action and proven
effectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneficial than benzodiazepine or
buspirone therapy for patients with GAD and comorbid depression.
1170.
A. It must be refitted if the patient gains more than 15 lb. The diaphragm is an effective method of contraception
if used correctly. A weight change of more than 15 lb, pregnancy, or pelvic surgery may necessitate refitting. If
used with nonoxynol-9, a diaphragm may actually increase the risk of HIV transmission. Diaphragms are made
of latex, but a wide seal rim model made of silicone is available for those who are latex sensitive. Diaphragm use
is contraindicated in women with a history of toxic shock syndrome. The diaphragm should remain in place for
6-24 hours after intercourse.
1171.
Which one of
the following is
true regarding
the use of
opiates in
terminally ill
patients? (check
one)
A. They are
frequently
addictive
B. They are
indicated for
relieving
dyspnea
C. A medication
contract is
required by law
D. Respiratory
depression is
the first sign of
excessive
dosage
E.
Gastrointestinal
hypermotility is
a common side
effect
B. They are indicated for relieving dyspnea. In terminally ill patients, the most common physical symptoms are
pain, fatigue, and dyspnea. Opiates are useful for controlling pain and relieving dyspnea as well. Even small doses
of a weaker opiate can reduce the sensation of shortness of breath in cancer patients and in those with heart
failure or chronic obstructive lung disease. Addiction is rare in terminally ill patients who are being treated with
opiates for pain and/or dyspnea. A medication contract between physician and patient is not required by law and
generally is not necessary in this situation, unless diversion of the medication from the patient by the caregivers is
suspected. Constipation due to decreased gastrointestinal motility is a very common, if not universal, side effect.
Respiratory depression is a late, not early, sign of excessive opiate dosage. Another sign of opiate excess, pinpoint
pupils, occurs before respiratory depression and is therefore a useful parameter for monitoring these patients.
1172.
D. Topical antibiotics should not be used for more than 2 weeks at a time. Trials have not definitively
shown that nutritional supplements speed ulcer healing. The head of the bed should be elevated only
as necessary, and should be kept to less than 30 to reduce shearing forces.Systemic antibiotics should
only be used for cellulitis, osteomyelitis, and bacteremia. Topical antibiotics may be used for periods of up
to 2 weeks (SOR C).
A. Multiple controlled
trials have shown that
nutritional supplements
hasten ulcer healing
B. Keeping the head of
the bed elevated to 45
during the day promotes
healing by minimizing
shearing forces
C. Systemic antibiotics
are most helpful when
used intermittently to
reduce bacterial counts
D. Topical antibiotics
should not be used for
more than 2 weeks at a
time
1173.
C. High methylmalonic acid (MMA). Patients with renal failure often have normal vitamin B12 levels
despite an actual deficiency. In this situation, the clinician can order a methylmalonic acid (MMA) level to
confirm the diagnosis. Vitamin B12 is the necessary coenzyme in the metabolism of MMA to succinyl-CoA.
Thus, in the absence of vitamin B12, MMA levels increase. Additionally, homocysteine levels would be
elevated in the presence of vitamin B12 deficiency (SOR A).
1174.
1175.
E. 9 mm induration on a hospital-based nurse who had a test with 2 mm induration 1 year ago. Three
different cutoff levels defining a positive reaction on a tuberculin skin test are recommended by the CDC,
each based on the level of risk and consideration of immunocompetence. For those who are at highest risk
and/or immunocompromised, including HIV-positive patients, transplant patients, and household contacts
of a tuberculosis patient, an induration 5 mm is considered positive. For those at low risk of exposure, a
screening test is not recommended, but if one is performed, induration 15 mm is considered positive.
For those who have an increased probability of exposure or risk, an induration 10 mm should be read as
positive. This group includes children; employees or residents of nursing homes, correctional facilities, or
homeless shelters; recent immigrants; intravenous drug users; hospital workers; and those with chronic
illnesses. For individuals who are subject to repeated testing, such as health-care workers, an increase in
induration of 10 mm or more within a 2-year period would be considered positive and an indication of a
recent infection with Mycobacterium tuberculosis. A nurse with a 9-mm induration would be considered to
have a negative PPD.
E. Alendronate (Fosamax). Ibandronate, raloxifene, denosumab, and etidronate have been shown to
reduce new vertebral fractures, but are not proven to prevent hip fracture. Only zoledronic acid,
risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture,
and these are the anti-osteoporosis drugs of choice.
1176.
A. Atropine
B. Bretylium tosylate
(Bretylol)
C. Lidocaine
(Xylocaine)
D. Procainamide
(Pronestyl)
E. Adenosine
(Adenocard)
1177.
A. Exenatide (Byetta). Delayed gastric emptying may be caused or exacerbated by medications for diabetes,
including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). Delayed gastric
emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of
postprandial hyperglycemia. In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting
occurred in 19%, which led to the cessation of treatment in about one-third of patients. The other
medications listed do not cause delayed gastric emptying.
A. Exenatide (Byetta)
B. Benazepril
(Lotensin)
C. Metformin
(Glucophage)
D.
Hydrochlorothiazide
E. Prochlorperazine
maleate
1178.
A. Metformin (Glucophage). Metformin increases insulin sensitivity much more than sulfonylureas or insulin.
This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight
changes are less likely to be seen in diabetic patients on metformin. Acarbose is an -glucosidase inhibitor
that delays glucose absorption.
1179.
D. Adequate protein intake. Very few nutritional interventions have been shown to accelerate pressure
ulcer healing in the elderly.
Maintaining a protein intake of at least 1.2-1.5 g/kg/day is recommended, and some authorities
recommend 2 g/kg/day with stage III or IV ulcers. Increased caloric intake is also necessary to promote
healing. The role of vitamins and minerals in preventing and treating pressure ulcers is unclear.
A. Supplemental
arginine
B. Oral vitamin C and
zinc
C. High-dose
multivitamins
D. Adequate protein
intake
1180.
C. Atypical glandular cells not otherwise specified (AGC-NOS). Papanicolaou (Pap) tests are intended to
screen for cervical cancer, but most abnormal Pap tests are associated with precancerous lesions or with
no abnormality. The category of atypical glandular cells not otherwise specified (AGC-NOS) has a benign
sound to it, although it is associated with a 17% rate of cancer (8% carcinoma in situ and 9% invasive
carcinoma). High-grade squamous intraepithelial lesion (HSIL), which would seem worse intuitively, has
only a 3% associated cancer rate. AGC-NOS is associated with higher rates of cancer than the other choices
listed.
1181.
E. A 40-year old recent immigrant from India. Each of the individuals listed is at increased risk for hepatitis
A infection or its complications, except for the Indian immigrant. Hepatitis A is so prevalent in developing
countries such as India that virtually everyone is infected by the end of childhood, and therefore immune.
Infection with hepatitis A confers lifelong immunity, so an adult from a highly endemic area such as India
has little to gain from vaccination.
A. A missionary
traveling to Mexico
B. A man who has sex
with men
C. A
methamphetamine
addict
D. A patient with
chronic hepatitis
E. A 40-year old recent
immigrant from India
1182.
A. 10,000/L. The threshold for prophylactic platelet transfusion is 10,000/L (SOR A). Platelet transfusion
decreases the risk of spontaneous bleeding in such patients. A count below 50,000/L is an indication for
platelet transfusion in patients undergoing an invasive procedure.
A. 10,000/L
B. 25,000/L
C. 40,000/L
D. 50,000/L
E. 100,000/L
1183.
B. Hepatitis A vaccine. More than a dozen vaccines are available for diseases with a high prevalence in
developing countries. The primary care physician should make sure that international travelers are up to
date on routine immunizations, given that vaccine-based immunity to tetanus, diphtheria, polio, and
measles wanes over time, and that these diseases are highly prevalent abroad. While location-specific
situations may require particular immunizations such as typhoid, yellow fever, or hepatitis B vaccine,
and/or administration of -globulin, hepatitis A vaccine is recommended for nearly all international
travelers.
1184.
Which one of
the following
procedures
carries the
highest risk for
postoperative
deep venous
thrombosis?
(check one)
E. Total knee replacement. Neurosurgical procedures, particularly those with penetration of the brain or
meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of
venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of
natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the
prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic
procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT
after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after
abdominal hysterectomy approximately 16%.
A. Abdominal
hysterectomy
B. Coronary
artery bypass
graft
C. Transurethral
prostatectomy
D. Lumbar
laminectomy
E. Total knee
replacement
1185.
Which one of
the following
provides the
best evidence
for a given
therapeutic
intervention?
(check one)
A. An individual
randomized,
controlled trial
B. A prospective
case-control
study
C. A systematic
review of
cohort studies
D. A systematic
review of
randomized,
controlled trials
D. A systematic review of randomized, controlled trials. A systematic review is a literature review focused on a
research question that tries to identify, appraise, select, and synthesize all high-quality research evidence relevant
to that question. A randomized, controlled trial (RCT) involves a group of patients who are randomized into an
experimental group and a control group. These groups are followed for the outcomes of interest. The process of
randomization minimizes bias and is thus the individual study type that is most likely to provide accurate results
about an intervention's effectiveness.
A cohort study is a nonexperimental study design that follows a group of people (a cohort), and then looks at how
events differ among people within the group. A study that examines a cohort of persons who differ in respect to
exposure to some suspected risk factor such as smoking is useful for trying to ascertain whether exposure is likely
to cause specified events such as lung cancer. This study design is less reliable due to inherent biases that may not
be accounted for and may exist in the groupings of patients.
Retrospective and prospective case-control studies compare people with a disease or specific diagnosis with
people who do not have the disease. The groups are studied to find out if other characteristics are also different
between the two groups. This type of study often overestimates the benefit of a trial and is of lower quality than a
randomized, controlled trial.
1186.
1187.
Which one of
the following
reduces the
incidence of
atopic
dermatitis in
children?
(check one)
A. Exclusive breastfeeding until the infant is 4 months of age. Atopic dermatitis is a pruritic, inflammatory skin
disorder affecting nearly 1 in 5 children residing in developed countries. The vast majority of those eventually
afflicted experience the onset of symptoms by the age of 5 years, and more than half will present before the age of 1
year. The etiology is not fully understood, but it seems clear that environmental, immune, genetic, metabolic,
infectious, and neuroendocrine factors all play a role. Environmental factors that may be involved include harsh
detergents, abrasive clothing, Staphylococcus aureus skin infection, food allergens (cow's milk, eggs, peanuts, tree
nuts, etc.), overheating, and psychological stress. Aeroallergens that are problematic for asthmatics, such as animal
dander, dust mites, and pollen, have not been clearly linked to atopic dermatitis.
A. Exclusive
breastfeeding
until the
infant is 4
months of
age
B. Prenatal
ingestion of
probiotics by
the mother
C. Delayed
introduction
of solid food
until after 6
months of
age
D.
Application
of emollients
E. Early
exposure to
dust mites
Large, well-designed studies have found no evidence that delaying the introduction of solid foods until after 6
months of age reduces the likelihood of atopic dermatitis. Ingestion of probiotic agents during pregnancy has also not
been shown to have any effect, and studies of probiotic use in breastfeeding mothers and their infants have yielded
conflicting results. Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative
incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so
beyond 4 months does not appear to provide additional benefit. Maternal dietary restriction during pregnancy and
lactation has not been associated with significant benefit. Limited studies have demonstrated that emollients and
moisturizers can reduce associated xerosis and are thought to be helpful treatments, but the data is not convincing.
Which one of
the following
seafood
poisonings
requires
more than
just
supportive
treatment?
(check one)
D. Scombroid fish. Only symptomatic treatment is indicated for ciguatera poisoning, as there is no specific treatment.
The same is true for shellfish poisoning, although potential respiratory distress or failure must be kept in mind.
A. Ciguatera
B.
Neurotoxic
shellfish
C. Paralytic
shellfish
D.
Scombroid
fish
Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish
such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties such as mahi-mahi, amberjack, sardines, and
herring can also cause this problem. The poisoning is due to high levels of histamine and saurine resulting from
bacterial catabolism of histidine. Symptoms occur within minutes to hours, and include flushing of the skin, oral
paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia,
tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually
lead to resolution of symptoms within several hours.
1188.
Which one of
the following
serum
proteins is
typically
DECREASED in
a hospitalized
patient with
sepsis? (check
one)
D. Albumin. The acute phase response refers to the multiple physiologic changes that occur with tissue injury. The
synthesis of acute-phase proteins by hepatocytes is altered, leading to decreased serum levels of several of these
proteins, including albumin and transferrin. Serum levels rise for other proteins, such as ceruloplasmin,
complement proteins, haptoglobin, fibrinogen, and C-reactive protein. Serum levels of ferritin may be extremely
high in certain conditions, but are also influenced by total-body iron stores.
A.
Complement
C3
B. Ferritin
C. C-reactive
protein (CRP)
D. Albumin
E. Fibrinogen
1189.
Which one of
the following
should be
avoided in the
treatment and
prophylaxis of
migraine
during early
pregnancy?
(check one)
C. Triptans. Headaches, and migraines in particular, are very common in women of childbearing age. Migraine
sufferers usually have improvement of symptoms in pregnancy and many have complete remission. Most
medications used for prophylaxis and abortive treatment of migraines in the nonpregnant patient can also be used
in pregnant patients. Most beta-blockers and calcium channel blockers are safe. Acetaminophen and narcotics can
be used for acute pain. Ibuprofen can also be used but should be avoided late in pregnancy because it is
associated with premature closure of the ductus arteriosus and oligohydramnios. Ergotamines should be avoided
as they are uterotonic and have abortifacient properties. They have also been associated with case reports of fetal
birth defects. Triptans have the potential to cause vasoconstriction of the placental and uterine vessels and should
be used only if the benefit clearly outweighs the harm.
A. Calcium
channel
blockers
B. Betablockers
C. Triptans
D. NSAIDS
1190.
Which one of
the following
should be
avoided when
treating pain
in the elderly?
(check one)
A. Fentanyl
(Sublimaze)
B.
Hydrocodone
C. Meperidine
(Demerol)
D. Morphine
E. Oxycodone
(OxyContin)
C. Meperidine (Demerol). According to the Beers criteria, a list of drugs that should generally be avoided in older
adults, meperidine should not be used in the elderly because its metabolite can accumulate and cause seizures.
The other medications are not listed in the Beers criteria and are not contraindicated in the elderly.
1191.
1192.
C. Lorazepam (Ativan). Status epilepticus refers to continuous seizures or repetitive, discrete seizures with
impaired consciousness in the interictal period. It is an emergency and must be treated immediately, since
cardiopulmonary dysfunction, hyperthermia, and metabolic derangement can develop, leading to
irreversible neuronal damage. Lorazepam, 0.1-0.15 mg/kg intravenously, should be given as anticonvulsant
therapy after cardiopulmonary resuscitation. This is followed by phenytoin, given via a dedicated
peripheral intravenous line. Fosphenytoin, midazolam, or phenobarbital can be used if there is no
response to lorazepam.
Propofol has been used for refractory status epilepticus to induce general anesthesia when the initial drugs
have failed, but reports of fatal propofol infusion syndrome have led to a decline in its use.
A. Akathisia. Rigidity, sialorrhea, and stooped posture are parkinsonian side effects of neuroleptic drugs.
These are treated with anticholinergic drugs such as benztropine or amantadine. Dystonia, often
manifested as an acute spasm of the muscles of the head and neck, also responds to anticholinergics.
Akathisia (motor restlessness and an inability to sit still) can be treated with either anticholinergic drugs or
beta-blockers.
1193.
1194.
B. Stabilizing an injured victim at the scene of an automobile accident until EMS arrives. Laws providing
immunity from civil damages for injuries or death resulting from care deemed reasonable under the
circumstance (ordinary negligence) are generally described as Good Samaritan laws. Good Samaritan
statutes have been enacted in some form in all 50 states, the District of Columbia, and Puerto Rico to protect
physicians from liability (in the absence of gross negligence) if they provide emergency care to individuals
with whom they share no preexisting obligation to provide medical care. In most states such protection is
limited to emergency care provided outside of the hospital setting, although a few states offer protection for
hospital care in certain circumstances. While there is no legal obligation to provide Good Samaritan care in
most states, in some states (e.g., Louisiana, Minnesota, and Vermont) not doing so is a violation of "duty to
assist" laws.
A preexisting obligation to provide care exists in each of the examples given, except for the provision of care
at the scene of a traffic accident. Providing stabilizing care at the scene of an accident clearly fits within the
protections defined by Good Samaritan laws. The obligation to provide care when volunteering at an event
such as a football game or concert is implied even if it is provided without charge. An obligation to provide
care for someone identified as your patient exists even outside of the office setting; a similar responsibility to
provide emergency care for office employees is generally accepted.
Federal law provides for similar Good Samaritan protection from liability to physicians who respond to inflight emergencies originating in the United States. Protection is also offered by statute in the U.K., Canada,
and other countries; Australian law also includes a legal obligation to provide emergency care.
A. Tinea capitis. Most tinea infections respond to topical therapy, but oral therapy is required for tinea
capitis so that the drug will penetrate the hair shafts (SOR B). Tinea corporis may require oral therapy in
severe cases, but usually responds to topical therapy (SOR A). Oral therapy has a higher likelihood of side
effects. Erythrasma and mycosis fungoides are not fungal diseases.
1195.
A. Shift-work insomnia. Shift-work insomnia is the only circadian sleep disorder listed. It may respond
to bright-light therapy. Alcoholism is a behavioral disorder that may respond to gradual
discontinuance. Inadequate sleep hygiene (use of stimulants at night, sleeping other than at bedtime,
etc.) may respond to habit changes. Sleep-related myoclonus is an intrinsic sleep disorder and can be
treated with levodopa or clonazepam.
A. Shift-work insomnia
B. Alcohol-dependent sleep
disorder
C. Inadequate sleep hygiene
D. Sleep-related myoclonus
1196.
1197.
Which one of
the following
statements is
true about
celiac disease
(glutensensitive
enteropathy) in
adults? (check
one)
A. It is more
common
among AfricanAmericans
B. Symptoms
are limited to
gastrointestinal
complaints
C. Type 2
diabetics are at
increased risk
for the disease
D. Serum
antibody tests
are sensitive
and specific
E. Colonoscopy
with mucosal
biopsy is
required to
make the
diagnosis
D. Serum antibody tests are sensitive and specific. Celiac disease is thought to be greatly underdiagnosed in the
United States. Antibody tests indicate that the prevalence is approximately 1:250 among adult Americans of
European ancestry. Approximately 7% of type 1 diabetics have celiac disease. A number of other autoimmune
syndromes have been associated with celiac disease, including thyroid disease and rheumatoid arthritis. There is
no reported association with type 2 diabetes. Gastrointestinal involvement may manifest as diarrhea, constipation,
or other symptoms of malabsorption, such as bloating, flatus, or belching. Fatigue, depression, fibromyalgia-like
symptoms, aphthous stomatitis, bone pain, dyspepsia, gastroesophageal reflux, and other nonspecific symptoms
may be present and can make the diagnosis quite challenging. Dermatitis herpetiformis is seen in 10% of patients
with celiac disease. Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific
and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires
esophagogastroduodenoscopy with a biopsy of the distal duodenum to detect characteristic villous flattening.
1198.
C. Patients unresponsive after 6 weeks should have their treatment altered. An adequate trial of
antidepressant therapy is 4-6 weeks. Patients who are unresponsive to treatment may respond to another
antidepressant with a different mechanism of action. Patients who are partially responsive may benefit
from dosage titration or the addition of a second antidepressant in combination. Electroconvulsive therapy
is the most effective treatment in patients with severe resistance to medical antidepressant therapy or
those with psychotic depression.
1199.
C. In nonobese women, lack of weight gain is associated with an increased risk of fetal growth retardation. The
greatest demand for iron is during the latter half of pregnancy. Only vegetarians and those with actual serum
vitamin B12 deficiency require vitamin B12 supplementation. Unless there are complications, e.g., hypertension
or cardiovascular disease, there is no reason the pregnant patient cannot salt her food to taste. Obstetric risk
factors for teenagers include poor nutrition, smoking, alcohol and drug abuse, and genital infections. In women
of average or low weight, lack of weight gain throughout pregnancy is often associated with fetal growth
retardation.
1200.
E. A unilateral varicocele on the right side should be referred for further evaluation. Most varicoceles appear
in adolescence, occur on the left side, and are asymptomatic. About 10% are bilateral. Surgical repair of large
varicoceles can reverse testicular growth arrest, with catch-up growth occurring within 1-2 years. Varicoceles
are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize
chances for fertility. Varicoceles in men are common, with an incidence of approximately 15%. The appearance
of a varicocele on the right side only, or in a child less than 10 years of age, is abnormal and may indicate an
abdominal or retroperitoneal mass.
A. Repair of
varicoceles usually
results in infertility
B. The incidence of
varicoceles in adult
males is <5%
C. Most varicoceles
are bilateral
D. Varicoceles
usually begin
between 5 and 8
years of age
E. A unilateral
varicocele on the
right side should be
referred for further
evaluation
1201.
A. Femoropopliteal bypass. When deciding whether or not to recommend preoperative noninvasive cardiac
testing, both patient risk factors and surgical risk factors should be taken into account. Surgical procedures
associated with a high (>5%) risk of perioperative myocardial ischemia include aortic and peripheral vascular
surgery and emergent major operations, especially in patients over 75 years of age. Head and neck surgery,
intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery carry an intermediate
risk (1%-5%). Endoscopic procedures and cataract and breast surgeries are considered low-risk (<1%)
procedures.
1202.
1203.
A. Dihydroergotamine (D.H.E.
45)
B. Amitriptyline (Elavil)
C. Sumatriptan (Imitrex)
D. Aspirin/caffeine/butalbital
(Fiorinal)
E.
Acetaminophen/hydrocodone
bitartrate (Vicodin)
1204.
C. Tinea capitis. Dermatophyte infections caused by aerobic fungi produce infections in many
areas. Tinea capitis requires systemic therapy to penetrate the affected hair shafts. Tinea cruris
and tinea pedis rarely require systemic therapy. Extensive outbreaks of tinea corporis and tinea
versicolor benefit from both oral and topical treatment (SOR A), but more localized infections
require only topical treatment.
A. Tinea cruris
B. Tinea corporis
C. Tinea capitis
D. Tinea pedis
E. Tinea versicolor
1205.
A. Isoniazid daily for 9 months. Latent tuberculosis infection carries a risk of progression to active
disease, especially among patients who are immunosuppressed. Isoniazid monotherapy is the
treatment of choice for most patients with latent tuberculosis infection. Rifampin is not
recommended as monotherapy in patients with HIV infection because of increased rates of
resistance and drug interactions with many antiretrovirals. Rifampin plus pyrazinamide is no
longer recommended for treatment of latent tuberculosis infection because cases of significant
hepatotoxicity have occurred with preventive therapy. Combination drug therapy is reserved for
treatment of active tuberculosis in order to prevent drug resistance.
1206.
A. Bed-wetting alarms. Treatments available for childhood nocturnal enuresis include nonpharmacologic
and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the bedwetting alarm has a higher success rate (75%) and a lower relapse rate (41%).
A. Bed-wetting alarms
B. Positive
reinforcement
C. Responsibility
training
D. Desmopressin
(DDAVP)
E. Imipramine (Tofranil)
1207.
1208.
E. Pioglitazone (Actos). Repaglinide and nateglinide are nonsulfonylureas that act on a portion of the
sulfonylurea receptor to stimulate insulin secretion. Pioglitazone is a thiazolidinedione, which reduces
insulin resistance. It is believed that the mechanism for this is activation of PPAR-Y, a receptor that affects
several insulin-responsive genes. Acarbose is a competitive inhibitor of -glucosidases, enzymes that
break down complex carbohydrates into monosaccharides. This delays the absorption of carbohydrates
such as starch, sucrose, and maltose, but does not affect the absorption of glucose. Sitagliptin is a DPP-IV
inhibitor, and this class of drugs inhibits the enzyme responsible for the breakdown of the incretins GLP-1
and GIP. Exenatide is an incretin mimetic that stimulates insulin secretion in a glucose-dependent fashion,
slows gastric emptying, and may promote satiety.
E. Supportive care only. Respiratory viruses appear to be the most common cause of acute bronchitis;
however, the organism responsible is rarely identified in clinical practice because viral cultures and
serologic assays are not routinely performed. Fewer than 10% of patients will have a bacterial infection
diagnosed as the cause of bronchitis. For this reason, for patients with a putative diagnosis of acute
bronchitis, routine treatment with antibiotics is not justified and should not be offered. Antitussive agents
are occasionally useful and can be offered as therapy for short-term symptomatic relief of coughing.
1209.
A. A 5-year-old with asthma. Two doses of influenza vaccine are recommended for children under the age
of 9 years unless they have been vaccinated previously. Children 3-8 years of age should receive one or
two 0.5-mL doses of split-virus vaccine intramuscularly.
A. A 5-year-old with
asthma
B. A 10-year-old with
cystic fibrosis
C. A 15-year-old with
sickle cell anemia
D. A 30-year-old with
HIV infection
E. A 65-year-old with
bullous emphysema
1210.
D. Gender. Domestic violence can affect children, intimate partners, and older adults. It is a serious
medical problem that should be considered in the care of patients and families. There is great variation in
the profiles of patients affected by domestic violence. Neither demographic factors nor psychological
problems have been found to be consistent predictors of victimization or violence. Domestic violence cuts
across all racial, socioeconomic, religious, and ethnic lines. The only consistent risk factor for being a victim
of domestic violence is female gender.
A. Educational
background
B. Psychological
problems
C. Race
D. Gender
E. Socioeconomic
status
1211.
E. A hemoglobin A1c of 7.0%. An international expert committee issued a report in 2009 recommending
that a hemoglobin A1c level 6.5% be used to diagnose diabetes mellitus. Other criteria include a fasting
plasma glucose level 126 mg/dL, a random glucose leve l200 mg/dL in a patient with symptoms of
diabetes, or a 2-hour oral glucose tolerance test value 200 mg/dL. While a urine dipstick may be used to
screen for diabetes, it is not a diagnostic test.
1212.
B. Echocardiography. Echocardiography is the most effective imaging study for the diagnosis of
pericardial effusion. It is a simple, sensitive, specific, noninvasive test that can be used at the patient's
beside (SOR A). The test also helps to quantify the amount of pericardial fluid and to detect the
presence of any accompanying cardiac tamponade. The erythrocyte sedimentation rate, WBC count,
and antinuclear antibody titer are helpful for guiding the follow-up care of patients with systemic lupus
erythematosus, but not for diagnosing precordial pain. Cardiac angiography has no role in the
diagnosis of pericardial effusion.
A. Cardiac angiography
B. Echocardiography
C. An erythrocyte
sedimentation rate
D. A CBC
E. An antinuclear
antibody titer
1213.
1214.
D. Warfarin (Coumadin). The CHADS2 score is a validated clinical prediction rule for determining the
risk of stroke and who should be anticoagulated. Points are assigned based on the patient's
comorbidities. One point is given for each of the following: history of congestive heart failure (C),
hypertension (H), age75 (A), and diabetes mellitus (D). Two points are assigned for a previous stroke
or TIA (S2 ).
For patients with a score of 0 or 1, the risk of stroke is low and warfarin would not be recommended.
Warfarin is the agent of choice for the prevention of stroke in patients with atrial fibrillation and a score
2. In these patients, the risk of stroke is higher than the risks associated with taking warfarin.
Enoxaparin is an expensive injectable anticoagulant and is not indicated for the long-term prevention
of stroke.
B. Penicillin. Many dental conditions causing inflammation do not require antibiotic therapy. Dental
caries, reversible pulpitis, gingivitis, periodontitis, and periapical abscesses usually are treated with local
procedures without antibiotics. Cellulitis, however, requires either outpatient antibiotics or inpatient
antibiotic treatment if the cellulitis spreads to the deeper spaces of the head and neck. The antibiotic of
choice, especially for outpatient treatment, is oral penicillin G, 500 mg 3 times daily.
A. Erythromycin
B. Penicillin
C. Dicloxacillin (Dynapen)
D. Tetracycline
E. Cefixime (Suprax)
1215.
D. Adenosine (Adenocard). The patient has paroxysmal supraventricular tachycardia (PSVT) with a
heart rate of approximately 170 beats/min. Intravenous adenosine is the treatment of choice for PSVT.
Because the patient is hemodynamically stable, DC cardioversion is not indicated. Metoprolol may slow
the heart rate but likely will not convert it to sinus rhythm. Amiodarone is indicated for
hemodynamically stable ventricular tachycardia. Atropine is contraindicated in this or any other
tachyarrhythmia.
1216.
E. Foul-smelling flatus. The diagnosis of giardiasis is suggested by its most characteristic symptoms:
foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and
the virtual absence of mucus or blood in the stool. Stools are usually mushy between exacerbations,
though constipation may occur. If eosinophilia occurs, it is more likely to be related to some other
concomitant cause rather than to giardiasis.
A. Fecal leukocytosis
B. Mucus in the stool
C. Eosinophilia
D. Hematochezia
E. Foul-smelling flatus
1217.
1218.
B. An age of 9 months. Sudden infant death syndrome (SIDS) is the most common cause of death
during the first 6 months of life in the United States, with a peak incidence at 2-4 months of age and
a quick dropoff by the age of 6 months. The cause of death is a retrospective diagnosis of exclusion,
and is supported by a history of quiet death during sleep in a previously healthy infant younger
than 6 months of age. Evidence of terminal activity may be present, such as clenched fists or a
serosanguineous, blood-tinged, or mucoid discharge from the mouth or nose. Lividity and mottling
are frequently present in dependent areas.
The reported history and autopsy findings of deliberate suffocation may mirror the findings of
SIDS, but suffocation should be considered when there is documentation of any of the following:
infant age older than 6 months, previous similar sibling deaths, simultaneous twin deaths, or
evidence of pulmonary hemorrhage. A history of recurrent apnea or cyanosis has not been
causally linked to SIDS; when such reported events have only been witnessed by one caretaker,
deliberate suffocation should be suspected.
D. Transdermal absorption of the drugs. Transdermal absorption of medications changes very little
with age. Due to an increase in the ratio of fat to lean body weight, the volume of distribution
changes with aging, especially for fat-soluble drugs. Both liver metabolism and renal excretion of
drugs decrease with aging, increasing serum concentrations.
A. apraxia. Apraxia is a transmission disturbance on the output side, which interferes with skilled
movements. Even though the patient understands the request, he is unable to perform the task
when asked, but may then perform it after a time delay. Agnosia is the inability to recognize
previously familiar sensory input, and is a modality-bound deficit. For example, it results in a loss of
ability to recognize objects. Aphasia is a language disorder, and expressive aphasia is a loss of the
ability to express language. The ability to recognize objects by palpation in one hand but not the
other is called astereognosis.
1220.
A. Heart rate
B. Coronary flow rate
C. Metabolic demand
D. Contractility of cardiac myocytes
E. The P-R interval
1223.
1224.
A. Morphine
B. Oxygen
C. Albuterol (Proventil, Ventolin)
D. Haloperidol
1226.
B. The decision to enter hospice care is reversible. The decision to utilize the
Medicare hospice benefit is reversible, and patients may elect to return to
Medicare Part A. Individuals who reside in nursing homes and assisted-living
facilities are eligible for the Medicare hospice benefit. Patients with end-stage
Alzheimer's disease are eligible for the Medicare hospice benefit if they meet
criteria for hospice. If the patient lacks decision-making capacity, a family member
or guardian may elect the Medicare hospice benefit for the patient. The patient
must be certified by the hospice medical director and primary physician to have a
life expectancy of less than 6 months to qualify for hospice services. This
requirement is the same whether or not the patient resides in a nursing home.
1227.
1228.
D. 50. The relative risk reduction (RRR) is the proportional decrease in disease
incidence in the treated group relative to the incidence in the control group. In
this example the 3% incidence in the treated group is 40% less than the 5%
incidence in the control group: (5%-3%)/5% = 40%. The absolute risk reduction
(ARR) is the difference between the incidence of disease in the treatment group
and the incidence in the control group. In this example the ARR is 5% minus 3%
= 2%. The number needed to treat (NNT) equals the reciprocal of the ARR: 1/.02
= 50. The RRR is not a very useful statistic in clinical practice. It amplifies small
differences and makes clinically insignificant findings appear significant because
it essentially ignores the baseline risk of the outcome event. The ARR provides a
more useful measure of clinical effect. It answers the question "How much will I
decrease my patient's risk of an adverse outcome by this treatment?" The NNT is
also very useful for clinicians, as it answers the question, "How many patients will
I need to treat to prevent one adverse outcome?"
1229.
A. Alprazolam (Xanax)
B. Haloperidol (Haldol)
C. Chlorpromazine (Thorazine)
D. Olanzapine (Zyprexa)
E. Thiothixene (Navane)
1230.
A. A chest radiograph
B. A CBC
C. A C-reactive protein level
D. Oxygen saturation by pulse oximetry
1231.
1232.
A. Colposcopy
B. Endocervical curettage
C. Human papillomavirus (HPV) testing
D. Cervical staining
E. A cervical biopsy
1233.
A. Sebaceous hyperplasia
B. Actinic keratosis
C. Seborrheic keratosis
D. A de Morgan spot
E. A halo nevus
1234.
A. Terazosin (Hytrin)
B. Finasteride (Proscar)
C. Tamsulosin (Flomax)
D. Doxazosin (Cardura)
E. Lycopene
1235.
1236.
E. After 5 days, if the INR has been 2.0 for 24 hours. For patients with a pulmonary embolus, American
College of Chest Physicians guidelines recommend initial treatment with low molecular weight heparin
(LMWH), unfractionated heparin, or fondaparinux for at least 5 days, and then can be stopped if the INR
has been 2.0 for at least 24 hours (SOR C). Warfarin reduces the activity of coagulation factors II, VII, IX, and
X produced in the liver. Coagulation factors produced prior to initiating warfarin remain active for their
usual several-day lifespan, which is why LMWH and warfarin must be given concomitantly for at least 5 days.
The INR may reach levels >2.0 before coagulation factors II and X have reached their new plateau levels,
accounting for the need for an additional 24 hours of combined therapy before stopping LMWH.
D. decrease the risk of post-thrombotic syndrome. Post-thrombotic syndrome (PTS) is a complication of acute
deep-vein thrombosis (DVT), and is characterized by chronic pain, swelling, and skin changes in the affected
limb. Within 5 years of experiencing a DVT, one in three patients will develop PTS. A Cochrane review
identified three randomized, controlled trials examining the use of compression therapy in patients
diagnosed with a new DVT. The use of elastic compression stockings was associated with a highly statistically
significant reduction in the incidence of PTS, with an odds ratio of 0.31 (confidence interval of 0.20-0.48). A
separate trial cited in the Cochrane review documented no increased incidence of pulmonary embolism,
and a reduction in pain and swelling in the treatment group. Compression stockings should be applied
when anticoagulation therapy is started, not when it has been completed. The studies did not examine the
rates of recurrent DVT.
1238.
A. Intranasal glucocorticoids
B. Intranasal cromolyn sodium
C. Intranasal decongestants
D. Intranasal antihistamines
1239.
C. Metronidazole, 500 mg orally twice a day for 7 days. The preferred treatment for
Trichomonas vaginitis is metronidazole, 2 g given in a single oral dose. Certain strains of
Trichomonas vaginalis, however, have diminished sensitivity to metronidazole. Patients who
fail initial treatment with metronidazole should be retreated with 500 mg orally twice a day
for 7 days. If treatment fails again, the patient should be treated with 2 g daily for 3-5 days.
Metronidazole gel and clindamycin cream are useful for treating bacterial vaginosis, but are
not effective in the treatment of Trichomonas vaginitis. Sulfadiazine and pyrimethamine are
used to treat toxoplasmosis.
1240.
1241.
1242.
1243.
A. lithium bicarbonate
B. high-dose triiodothyronine
C. an atypical antipsychotic, such as
olanzapine (Zyprexa)
D. an anticonvulsant, such as gabapentin
(Neurontin)
1244.
A. Fluoxetine (Prozac). SSRIs have been shown to benefit children and adolescents with
depression, but there are concerns regarding their association with suicidal behavior.
Fluoxetine seems to be the most favorable SSRI, and is the only one recommended by
the FDA for treatment of depression in children 8-17 years old. There is limited or no
evidence to support the use of lithium, venlafaxine, or St. John's wort in children and
adolescents. Amitriptyline and other tricyclic antidepressants are ineffective in children
and have limited effectiveness in adolescents, and safety is an issue in both of these
groups.
A. Fluoxetine (Prozac)
B. Lithium
C. Amitriptyline
D. Venlafaxine (Effexor)
E. St. John's wort
1245.
D. 100 mg/dL. High-risk patients should have a target LDL-cholesterol level of <100
mg/dL. High risk is defined as the presence of known coronary heart disease (CHD),
diabetes mellitus, noncoronary atherosclerotic disease, or multiple risk factors for CHD
(SOR C). Patients at very high risk (known CHD and multiple additional risk factors)
have an optional target of <70 mg/dL.
1246.
You have just diagnosed posttraumatic stress disorder in a 32year-old male. You immediately
begin a program of patient
education for him and his family,
and connect them with a support
group. Since his symptoms are quite
severe you decide to begin
pharmacotherapy before initiating
trauma-focused psychotherapy.
Based on available evidence, which
one of the following medications is
the best INITIAL treatment choice?
(check one)
A. Sertraline (Zoloft)
B. Amitriptyline
C. Phenelzine (Nardil)
D. Alprazolam (Xanax)
E. Haloperidol (Haldol)
A. Sertraline (Zoloft). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline have
the broadest range of efficacy in treating posttraumatic stress disorder (PTSD) since they
are able to reduce all three clusters of PTSD symptoms. Studies on the effectiveness of
tricyclic antidepressants such as amitriptyline demonstrate modest lessening of the
symptoms of reexperiencing, with minimal or no effect on avoidance or arousal symptoms.
Patients treated with monoamine oxidase inhibitors such as phenelzine have shown
moderate to good improvement in reexperiencing and avoidance symptoms, but little
improvement in hyperarousal. Benzodiazepines such as alprazolam have been used to
treat PTSD, but their efficacy against the major symptoms has not been proven in controlled
studies.
1248.
D. Ask the patient to designate someone with whom you can discuss the results
and prognosis. In a patient-centered approach to communication regarding endof-life care, a patient's wishes to not know about a diagnosis or prognosis should
be respected. However, it is reasonable to ask the patient to name a proxy with
whom you may discuss the issues. The other options listed do not respect the
patient's desire to not know her diagnosis or prognosis.
1250.
A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)
1252.
1253.
A. Escherichia coli
B. Vibrio cholerae
C. Campylobacter jejuni
D. Giardia lamblia
E. Rotavirus
1254.
C. Anticipate vaginal delivery with close fetal monitoring. Most infants with
face presentation, mentum anterior, can be delivered vaginally, either
spontaneously or with low forceps. Cesarean section is indicated for fetal
distress and failure to progress. Midforceps delivery is not indicated. If fetal
electrodes are attached, the chin is the preferred location.
A. The medical record should be released only with written permission from a
patient or legal representative. Permission for the release of patient
information should always be in writing. Although the actual medical record is
the property of the physician, the information in the chart is the property of
the patient. Ethically and legally, patients have a right to the information in
their medical records, and it cannot be withheld from the patient or a third
party (at the request of the patient), even if medical bills are unpaid or the
physician is concerned about the patient.
1256.
1258.
1259.
A. Supportive care only. This child has a respiratory syncytial virus (RSV) infection. Supportive
care is the mainstay of therapy. If the child can take in fluids by mouth and tolerate room air,
outpatient management with close physician contact as needed is reasonable, especially in
the absence of significant underlying risk factors. Routine use of corticosteroids is not
recommended (SOR B). Although up to 60% of infants hospitalized for bronchiolitis receive
corticosteroid therapy, studies have not provided sufficient evidence to support their use.
Inhaled corticosteroids have not been shown to be beneficial, and the safety of high doses in
infants is unclear. Supplemental oxygen should be administered if functional oxygen
saturation (SpO2) persistently falls below 90% and can be discontinued when an adequate
level returns (SOR C). Antiviral therapy for RSV bronchiolitis is controversial because of its
marginal benefit, cumbersome delivery, potential risk to caregivers, and high cost (SOR B).
Studies of ribavirin in patients with bronchiolitis have produced inconsistent findings.
Palivizumab is a preventive measure, and is not used for treatment of the active disease. It
may be considered in select infants and children with prematurity, chronic lung disease of
prematurity, or congenital heart disease (SOR A). If used, it should be administered
intramuscularly in five monthly doses of 15 mg/kg, usually beginning in November or
December (SOR C).
B. mild persistent. The 2007 update to the guidelines for the diagnosis and management of
asthma published by the National Heart, Lung, and Blood Institute outlines clear definitions
of asthma severity. Severity is determined by the most severe category in which any feature
occurs. This patient has mild persistent asthma, based on her symptoms occurring more than
2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week,
but not daily. Clinicians can use this assessment to help guide therapy.
1261.
D. Topical benzoyl peroxide. The American Academy of Dermatology grades acne as mild,
moderate, and severe. Mild acne is limited to a few to several papules and pustules without any
nodules. Patients with moderate acne have several to many papules and pustules with a few to
several nodules. Patients with severe acne have many or extensive papules, pustules, and
nodules. The patient has mild acne according to the American Academy of Dermatology
classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical
antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line
therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to
topical agents and as first-line therapy in more severe acne. Caution must be used to avoid
tetracycline in pregnant females. Oral isotretinoin is used in severe nodular acne, but also must be
used with extreme caution in females who may become pregnant. Special registration is required
by physicians who use isotretinoin, because of its teratogenicity.
A. Oral tetracycline
B. Oral isotretinoin (Accutane)
C. Topical sulfacetamide
(Sulamyd)
D. Topical benzoyl peroxide
1262.
1263.
1264.
A. No further evaluation at this visit unless indicated by history. Policy statements from
major organizations based on reviews of relevant medical literature support the
practice of prescribing initial hormonal contraception after performing only a careful
review of the medical history plus measurement of blood pressure. Requiring that
patients undergo pelvic and breast examinations leads many young women to avoid
this most reliable method of contraception, resulting in a much higher rate of unwanted
pregnancy. Follow-up blood pressure measurements are important. Often, younger
women will be willing to undergo Papanicolaou (Pap) tests and STD screening later, and
periodic follow-up must be scheduled. Sexually active adolescents should have annual
screening for cervical cancer and sexually transmitted diseases, but these are not
necessary before prescribing oral contraceptives. The longest period of time a
prescription should be given without a Pap test is 1 year, but this restriction is under
study. Obviously, any history indicative of high risk would modify this approach.
E. No diagnostic studies at this time. This patient had a classic simple febrile seizure and
no additional diagnostic studies are recommended. A lumbar puncture following a
seizure is not routinely recommended in a child over 18 months of age, since by that
age a patient with meningitis would be expected to demonstrate meningeal signs and
symptoms or clinical findings suggesting an intracranial infection. There is no evidence
to suggest that routine blood tests or neuroimaging studies are useful in a patient
following a first simple febrile seizure, and it has not been shown that
electroencephalography performed either at the time of presentation or within the
following month will predict the likelihood of recurrence.
1265.
D. Immobilize in a thumb spica splint for 1-2 weeks and then order repeat
radiographs. Snuffbox tenderness and tenderness over the scaphoid tubercle
are very sensitive for fracture of the scaphoid, but their specificity is only 40% and
60% respectively. Therefore, while the lack of tenderness at these sites almost
rules out fracture, further imaging is needed in positive cases. Plain films are
recommended as the next step. A bone scan or follow-up films after
immobilization for 2 weeks should be done if the initial films are negative. Bone
scans may be negative until enough time has passed for osteoblastic activity to
begin. Ultrasonography is not helpful for evaluation of scaphoid fractures.
1267.
B. Chronic somatization disorder. Conversion disorder usually involves a single symptom which is
neurologic or pain-related. Symptoms of chronic somatization differ from psychoses in that the symptoms
of the psychotic patient are bizarre and more vivid, persist over time, are unaltered by reasoned
argument, and are not congruent with the patient's social or cultural background. The delusional nature
of psychotic somatic symptoms usually unfolds as the patient talks. The essential feature of the histrionic
(hysterical) personality is a pervasive pattern of excessive emotionality and attention seeking. People with
this disorder constantly seek to be the center of attention. Emotions are often expressed with
inappropriate exaggeration. People with this disorder tend to be very self-centered and have little
tolerance for delayed gratification. These people are typically attractive and seductive, often to the point of
looking flamboyant and acting inappropriately. Features of primary hypochondriasis include the patient's
fixed conviction that he or she is ill, the interpretation of all somatic changes as confirmation of this, and a
relentless pursuit of medical assistance despite persistent dissatisfaction with the results. The patient's
symptoms remain consistent for years. Physicians frequently feel overwhelmed when initially presented
with a patient with somatization disorder. This disorder begins before age 30 and is rarely seen in males.
The patient complains of multiple symptoms which involve many organ systems and do not readily
conform to patterns seen in organic diseases. The patient skips back and forth from symptom to symptom
during the interview. Anxiety and depressed mood are frequent in this disorder, and suicide attempts
are common.
1268.
A. 12 months of age AND weighs 20 lb. If a child faces forward in a crash, the force is
distributed via the harness system across the shoulders, torso, and hips, but the
head and neck have no support. Without support, the infant's head moves rapidly
forward in flexion while the body stays restrained, causing potential injury to the
neck, spinal cord, and brain. In a rear-facing position, the force of the crash is
distributed evenly across the baby's torso, and the back of the child safety seat
supports and protects the head and neck. For these reasons, the rear-facing position
should be used until the child is at least 12 months old and weighs at least 20 lb (9 kg).
For example, a 13-month-old child who weighs 19 lb should face rearward, and a 6month-old child who
weighs 21 lb should also face rearward.
1271.
A. Antiviral drugs for hepatitis B. Effective oral antiviral drugs are now available for chronic
hepatitis B (at a cost of about $20 per day) and can be added to highly active antiretrovirals.
The recent trend in the treatment of newly diagnosed patients with AIDS and hepatitis B is to
treat both problems initially, selecting AIDS drugs that are also active against hepatitis B.
Various agents to stimulate appetite are used in declining HIV patients, but have little benefit.
Liver transplantation has been done in a few cases of coinfection with hepatitis B and HIV, but
the hepatitis B viremia has to be suppressed first.
1273.
1274.
D. Tdap. Tetanus vaccine is indicated for adults with clean minor wounds who have received
fewer than three previous doses of tetanus toxoid, or whose immune status is unknown.
Tetanus immune globulin is not recommended if the wound is clean.
The CDC recommends that adults aged 65 years and older who have not received Tdap and
are likely to have close contact with an infant less than 12 months of age (e.g., grandparents,
child-care providers, and health-care practitioners) should receive a single dose to protect
against pertussis and reduce the likelihood of transmission. For other adults aged 65 years and
older, a single dose of Tdap vaccine should be given instead of a scheduled dose of Td vaccine if
they have not previously received Tdap. Tdap can be administered regardless of the interval
since the last vaccine containing tetanus or diphtheria toxoid, and either Tdap vaccine product
may be used. After receiving Tdap, persons should continue to receive Td for routine booster
immunizations against tetanus and diphtheria, according to previously published guidelines.
A. rowing. Students with uncontrolled stage 2 hypertension should not participate in sports
associated with static exercise, in which the blood pressure load is more significantly increased
(SOR C). Rowing involves both a high static and a high dynamic load. Soccer, tennis, fencing, and
baseball have relatively few static exercise components and blood pressure spikes are less
likely.
1275.
You would
recommend
pneumococcal
vaccine for
which one of the
following?
(check one)
A. A 20-year-old
male who
smokes 1 pack of
cigarettes daily
B. A 52-year-old
male with type 2
diabetes mellitus
who received
pneumococcal
vaccine 6 years
ago
C. A 60-year-old
male who is a
long-term
resident of a
nursing home
because of a
previous stroke,
and who
received
pneumococcal
vaccine at age 54
D. A 62-year-old
male with
chronic renal
failure who
received
pneumococcal
vaccine at age 50
and age 55
E. A 71-year-old
male with no
medical
problems who
received
pneumococcal
vaccine at age 65
A. A 20-year-old male who smokes 1 pack of cigarettes daily. In October 2008 the Advisory Committee on
Immunization Practices (ACIP) of the Centers for Disease Control and Prevention recommended adding cigarette
smoking to the list of high-risk conditions that are indications for the 23-valent pneumococcal polysaccharide
vaccine. All persons between the ages of 19 and 64 who smoke should receive this vaccine. One-time
revaccination after 5 years is recommended for persons with chronic renal failure, asplenia (functional or
anatomic), or other immunocompromising conditions. The patient with chronic renal failure in this question has
already received two immunizations. The diabetic patient and the nursing-home resident have both received
one immunization and should not receive a second dose until age 65. The 71-year-old has already been
immunized after age 65, and a repeat immunization is not recommended.