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5/17/2014

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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)

Alphabetical

D. Admitting the patient to the hospital,


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

A. Strict bed rest at home and


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

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Which one of the following is the most


common cause of hypertension in children
under 6 years of age? (check one)
A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caffeine use

A 70-year-old male with a history of


hypertension and type 2 diabetes mellitus
presents with a 2-month history of
increasing paroxysmal nocturnal dyspnea
and shortness of breath with minimal
exertion. An echocardiogram shows an
ejection fraction of 25%. Which one of the
patients current medications should be
discontinued? (check one)
A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)

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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.
B. Pioglitazone (Actos). According to the
American Diabetes Association guidelines,
thiazolidinediones (TZDs) are associated
with fluid retention, and their use can be
complicated by the development of heart
failure. Caution is necessary when
prescribing TZDs in patients with known
heart failure or other heart diseases, those
with preexisting edema, and those on
concurrent insulin therapy (SOR C). Older
patients can be treated with the same drug
regimens as younger patients, but special
care is required when prescribing and
monitoring drug therapy. Metformin is
often contraindicated because of renal
insufficiency or heart failure. Sulfonylureas
and other insulin secretagogues can cause
hypoglycemia. Insulin can also cause
hypoglycemia, and injecting it requires
good visual and motor skills and cognitive
ability on the part of the patient or a
caregiver. TZDs should not be used in
patients with New York Heart
Association class III or IV heart failure.

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A 72-year-old African-American male


with New York Heart Association Class
III heart failure sees you for follow-up. He
has shortness of breath with minimal
exertion. The patient is adherent to his
medication regimen. His current
medications include lisinopril (Prinivil,
Zestril), 40 mg twice daily; carvedilol
(Coreg), 25 mg twice daily; and
furosemide (Lasix), 80 mg daily. His
blood pressure is 100/60 mm Hg, and his
pulse rate is 68 beats/min and regular.
Findings include a few scattered bibasilar
rales on examination of the lungs, an S3
gallop on examination of the heart, and no
edema on examination of the legs. An
EKG reveals a left bundle branch block,
and echocardiography reveals an ejection
fraction of 25%, but no other
abnormalities. Which one of the following
would be most appropriate at this time?
(check one)
A. Increase the lisinopril dosage to 80 mg
twice daily
B. Increase the carvedilol dosage to 50
mg twice daily
C. Increase the furosemide dosage to 160
mg daily
D. Refer for coronary angiography
E. Refer for cardiac resynchronization
therapy

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E. Refer for cardiac resynchronization


therapy. This patient is already receiving
maximal medical therapy. The 2002 joint
guidelines of the American College of
Cardiology, the American Heart
Association (AHA), and the North
American Society of Pacing and
Electrophysiology endorse the use of
cardiac resynchronization therapy (CRT)
in patients with medically refractory,
symptomatic, New York Heart
Association (NYHA) class III or IV
disease with a QRS interval of at least 130
msec, a left ventricular end-diastolic
diameter of at least 55 mm, and a left
ventricular ejection fraction (LVEF)
30%. Using a pacemaker-like device,
CRT aims to get both ventricles
contracting simultaneously, overcoming the
delayed contraction of the left ventricle
caused by the left bundle-branch block.
These guidelines were refined by an April
2005 AHA Science Advisory, which
stated that optimal candidates for CRT
have a dilated cardiomyopathy on an
ischemic or nonischemic basis, an LVEF
0.35, a QRS complex 120 msec, and
sinus rhythm, and are NYHA functional
class III or IV despite maximal medical
therapy for heart failure.

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Of the following dietary factors


recommended for the prevention and
treatment of cardiovascular disease, which
one has been shown to decrease the rate
of sudden death? (check one)
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)

A 75-year-old male presents to the


emergency department with a several-hour
history of back pain in the interscapular
region. His medical history includes a
previous myocardial infarction (MI)
several years ago, a history of cigarette
smoking until the time of the MI, and
hypertension that is well controlled with
hydrochlorothiazide and lisinopril (Prinivil,
Zestril). The patient appears anxious, but
all pulses are intact. His blood pressure is
170/110 mm Hg and his pulse rate is 110
beats/min. An EKG shows evidence of an
old inferior wall MI but no acute changes.
A chest radiograph shows a widened
mediastinum and a normal aortic arch, and
CT of the chest shows a dissecting
aneurysm of the descending aorta that is
distal to the proximal abdominal aorta but
does not involve the renal arteries. Which
one of the following would be the most
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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.
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,
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appropriate next step in the management


of this patient? (check one)
A. Immediate surgical intervention
B. Arteriography of the aorta
C. Intravenous nitroprusside (Nipride)
D. A nitroglycerin drip
E. Intravenous labetalol (Normodyne,
Trandate)

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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
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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).
According to the U.S. Preventive Services
Task Force, which one of the following
patients should be screened for an
abdominal aortic aneurysm? (check one)
A. A 52-year-old male with type 2
diabetes mellitus
B. An asymptomatic 67-year-old male
smoker with no chronic illness
C. A 72-year-old male with a history of
chronic renal failure
D. A 69-year-old female with a history of
coronary artery disease
E. A 75-year-old female with
hypertension and hypothyroidism
A 36-year-old white female presents to
the emergency department with
palpitations. Her pulse rate is 180
beats/min. An EKG reveals a regular
tachycardia with a narrow complex QRS
and no apparent P waves. The patient fails
to respond to carotid massage or to two
doses of intravenous adenosine
(Adenocard), 6 mg and 12 mg. The most
appropriate next step would be to
administer intravenous (check one)
A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)
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B. 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 6575 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.
E. verapamil (Calan). If supraventricular
tachycardia is refractory to adenosine or
rapidly recurs, the tachycardia can usually
be terminated by the administration of
intravenous verapamil or a -blocker. If
that fails, intravenous propafenone or
flecainide may be necessary. It is also
important to look for and treat possible
contributing causes such as hypovolemia,
hypoxia, or electrolyte disturbances.
Electrical cardioversion may be necessary
if these measures fail to terminate the
tachyarrhythmia.

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A 60-year-old African-American female


has a history of hypertension that has been
well controlled with hydrochlorothiazide.
However, she has developed an allergy to
the medication. Successful monotherapy
for her hypertension would be most likely
with which one of the following? (check
one)

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E. Diltiazem (Cardizem). Monotherapy for


hypertension in African-American patients
is more likely to consist of diuretics or
calcium channel blockers than -blockers
or ACE inhibitors. It has been suggested
that hypertension in African-Americans is
not as angiotensin II-dependent as it
appears to be in Caucasians.

A. Lisinopril (Prinivil, Zestril)


B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem)
A 60-year-old African-American male
was recently diagnosed with an abdominal
aortic aneurysm. A lipid profile performed
a few months ago revealed an LDL level
of 125 mg/dL. You would now advise him
that his goal LDL level is: (check one)
A. <100 mg/dL
B. <130 mg/dL
C. <150 mg/dL
D. <160 mg/dL

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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.

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

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D. Still's murmur. There are several benign


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

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A 57-year-old male with severe renal


disease presents with acute coronary
syndrome. Which one of the following
would most likely require a significant
dosage adjustment from the standard
protocol? (check one)
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA)

A 55-year-old male who has a long


history of marginally-controlled
hypertension presents with gradually
increasing shortness of breath and reduced
exercise tolerance. His physical
examination is normal except for a blood
pressure of 140/90 mm Hg, bilateral
basilar rales, and trace pitting edema.
Which one of the following ancillary
studies would be the preferred diagnostic
tool for evaluating this patient? (check
one)
A. 12-lead electrocardiography
B. Posteroanterior and lateral chest
radiographs
C. 2-dimensional echocardiography with
Doppler
D. Radionuclide ventriculography
E. Cardiac MRI

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A. Enoxaparin (Lovenox). Enoxaparin is


eliminated mostly by the kidneys. When it
is used in patients with severe renal
impairment the dosage must be
significantly reduced. For some indications
the dose normally given every 12 hours is
given only every 24 hours. Although some
-blockers require a dosage adjustment,
metoprolol and carvedilol are metabolized
by the liver and do not require dosage
adjustment in patients with renal failure.
Clopidogrel is currently recommended at
the standard dosage for patients with renal
failure and acute coronary syndrome.
Thrombolytics like tPA are given at the
standard dosage in renal failure, although
hemorrhagic complications are increased.
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.

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A 23-year-old female sees you with a


complaint of intermittent irregular
heartbeats that occur once every week or
two, but do not cause her to feel
lightheaded or fatigued. They last only a
few seconds and resolve spontaneously.
She has never passed out, had chest pain,
or had difficulty with exertion. She is
otherwise healthy, and a physical
examination is normal. Which one of the
following cardiac studies should be
ordered initially? (check one)
A. 24-hour ambulatory EKG monitoring
(Holter monitor)
B. 30-day continuous closed-loop event
recording
C. Echocardiography
D. An EKG
E. Electrophysiologic studies
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)

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D. An EKG. The symptom of an


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

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.
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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 ST-segment 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

A 68-year-old female has an average


blood pressure of 150/70 mm Hg despite
appropriate lifestyle modification efforts.
Her only other medical problems are
osteoporosis and mild depression. The
most appropriate treatment at this time
would be (check one)
A. lisinopril (Prinivil, Zestril)
B. clonidine (Catapres)
C. propranolol (Inderal)
D. amlodipine (Norvasc)
E. hydrochlorothiazide

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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.
E. hydrochlorothiazide. Randomized,
placebo-controlled trials have shown that
isolated systolic hypertension in the elderly
responds best to diuretics and to a lesser
extent, -blockers. Diuretics are
preferred, although long-acting
dihydropyridine calcium channel blockers
may also be used. In the case described,
-blockers or clonidine may worsen the
depression. Thiazide diuretics may also
improve osteoporosis, and would be the
most cost-effective and useful agent in this
instance.

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A 31-year-old healthy female is admitted


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

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B. a compressive anomaly in the thoracic


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

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A 56-year-old white male presents with a


2-week history of intermittent pain in his
left leg. The pain usually occurs while he is
walking and is primarily in the calf muscle
or Achilles region. Sometimes he will
awaken at night with cramps in the
affected leg. He has no known risk factors
for atherosclerosis. Which one of the
following would be the best initial test for
peripheral vascular occlusive disease?
(check one)
A. Ankle-brachial index
B. Arterial Doppler ultrasonography
C. Arteriography
D. Magnetic resonance angiography
(MRA)
E. Venous ultrasonography

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A. Ankle-brachial index. The anklebrachial index (ABI) is an inexpensive,


sensitive screening tool and is the most
appropriate first test for peripheral
vascular occlusive disease (PVOD) in this
patient. The ABI is the ratio of systolic
blood pressure measured in the ankle to
systolic pressure using the standard
brachial measurement. A ratio of 0.9-1.2
is considered normal. Severe disease is
defined as a ratio <0.50. More invasive
and expensive testing using Doppler
ultrasonography, arteriography, or
magnetic resonance angiography may be
useful if the ABI suggests an abnormality.
Venous ultrasonography would not detect
PVOD, but it could rule out deep venous
thrombosis, which is another common
etiology for calf pain.

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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)

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B. 3 months. For patients with a first


episode of unprovoked deep venous
thrombosis, evidence supports treatment
with a vitamin K antagonist for at least 3
months (SOR A). The American College
of Chest Physicians recommends that
patients be evaluated at that point for the
potential risks and benefits of long-term
therapy (SOR C).

A. 1 month
B. 3 months
C. 6 months
D. 12 months

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

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B. Enoxaparin (Lovenox) should be


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

15/870

5/17/2014

Which one of the following historical


features is most suggestive of congestive
heart failure in a 6-month-old white male
presenting with tachypnea? (check one)
A. Diaphoresis with feeding
B. Fever
C. Nasal congestion
D. Noisy respiration or wheezing
E. Staccato cough

Which one of the following procedures


carries the highest risk for postoperative
deep venous thrombosis? (check one)
A. Abdominal hysterectomy
B. Coronary artery bypass graft
C. Transurethral prostatectomy
D. Lumbar laminectomy
E. Total knee replacement

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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.
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%.

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5/17/2014

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A 13-year-old male is found to have


hypertrophic cardiomyopathy. His father
also had hypertrophic cardiomyopathy,
and died suddenly at age 38 following a
game of tennis. The boy's mother asks you
for advice regarding his condition. What
advice should you give her? (check one)
A. He may participate in noncontact
sports
B. He should receive lifelong treatment
with beta-blockers
C. His condition usually decreases lifespan
D. His hypertrophy will regress with age
E. His siblings should undergo
echocardiography
A 70-year-old white male has a slowly
enlarging, asymptomatic abdominal aortic
aneurysm. You should usually recommend
surgical intervention when the diameter of
the aneurysm approaches: (check one)
A. 3.5 cm
B. 4.5 cm
C. 5.5 cm
D. 6.5 cm
E. 7.5 cm

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E. His siblings should undergo


echocardiography. Hypertrophic
cardiomyopathy is an autosomal dominant
condition and close relatives of affected
individuals should be screened. The
hypertrophy usually stays the same or
worsens with age. This patient should not
participate in strenuous sports, even those
considered noncontact. Beta-blockers
have not been shown to alter the progress
of the disease. The mortality rate is
believed to be about 1%, with some series
estimating 5%. Thus, in most cases
lifespan is normal.

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 6year 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 evidencebased threshold has not yet been defined.

17/870

5/17/2014

Which one of the following drug classes is


preferred for treating hypertension in
patients who also have diabetes mellitus?
(check one)
A. Centrally-acting sympatholytics
B. Alpha-blocking agents
C. Beta-blocking agents
D. ACE inhibitors
E. Calcium channel blockers
A 75-year-old Hispanic male presents
with dyspnea on exertion which has
worsened over the last several months. He
denies chest pain and syncope, and was
fairly active until the shortness of breath
slowed him down recently. You hear a
grade 3/6 systolic ejection murmur at the
right upper sternal border which radiates
into the neck. Echocardiography reveals
aortic stenosis, with a mean transvalvular
gradient of 55 mm Hg and a calculated
valve area of 0.6 cm2. Left ventricular
function is normal. Which one of the
following is appropriate management for
this patient? (check one)
A. Aortic valve replacement
B. Aortic balloon valvotomy
C. Medical management with betablockers and nitrates
D. Watchful waiting until the gradient is
severe enough for treatment
E. Deferring the decision pending results
of an exercise stress test

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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. Aortic valve replacement. Since this
patient's mean aortic-valve gradient
exceeds 50 mm Hg and the aortic-valve
area is not larger than 1 cm2, it is likely
that his symptoms are due to aortic
stenosis. As patients with symptomatic
aortic stenosis have a dismal prognosis
without treatment, prompt correction of
his mechanical obstruction with aortic
valve replacement is indicated. Medical
management is not effective, and balloon
valvotomy only temporarily relieves the
symptoms and does not prolong survival.
Patients who present with dyspnea have
only a 50% chance of being alive in 2
years unless the valve is promptly
replaced. Exercise testing is unwarranted
and dangerous in patients with
symptomatic aortic stenosis.

18/870

5/17/2014

Which one of the following is considered a


contraindication to the use of betablockers for congestive heart failure?
(check one)
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%

Which one of the following is the leading


cause of death in women? (check one)
A. Breast cancer
B. Lung cancer
C. Ovarian cancer
D. Osteoporosis
E. Cardiovascular disease

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B. Symptomatic heart block. According to


several randomized, controlled trials,
mortality rates are improved in patients
with heart failure who receive betablockers 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.
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.

19/870

5/17/2014

A 72-year-old African-American male


comes to your office for surgical clearance
to undergo elective hemicolectomy for
recurrent diverticulitis. The patient suffered
an uncomplicated acute anterior-wall
myocardial infarction approximately 18
months ago. A stress test was normal 2
months after he was discharged from the
hospital. Currently, the patient feels well,
walks while playing nine holes of golf three
times per week, and is able to walk up a
flight of stairs without chest pain or
significant dyspnea. Findings are normal
on a physical examination. Which one of
the following would be most appropriate
for this patient prior to surgery? (check
one)
A. A 12-lead resting EKG
B. A graded exercise stress test
C. A stress echocardiogram
D. A persantine stressed nuclear tracer
study (technetium or thallium)
E. Coronary angiography

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A. A 12-lead resting EKG. The current


recommendations from the American
College of Cardiology and the American
Heart Association on preoperative
clearance for noncardiac surgery state that
preoperative intervention is rarely needed
to lower surgical risk. Patients who are not
currently experiencing unstable coronary
syndrome, severe valvular disease,
uncompensated congestive heart failure, or
a significant arrhythmia are not considered
at high risk, and should be evaluated for
most surgery primarily on the basis of their
functional status. If these patients are
capable of moderate activity (greater than
4 METs) without cardiac symptoms, they
can be cleared with no stress testing or
coronary angiography for an elective
minor or intermediate-risk operation such
as the one this patient is to undergo. A
resting 12-lead EKG is recommended for
males over 45, females over 55, and
patients with diabetes, symptoms of chest
pain, or a previous history of cardiac
disease.

20/870

5/17/2014

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

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

21/870

5/17/2014

A 25-year-old female at 36 weeks


gestation presents for a routine prenatal
visit. Her blood pressure is 118/78 mm
Hg and her urine has no signs of protein or
glucose. Her fundal height shows
appropriate fetal size and she says that she
feels well. On palpation of her legs, you
note 2+ pitting edema bilaterally. Which
one of the following is true regarding this
patient's condition? (check one)
A. You should order a 24-hr urine for
protein
B. A workup for possible cardiac
abnormalities is necessary
C. Her leg swelling requires no further
evaluation
D. She most likely has preeclampsia
E. She most likely has deep venous
thrombosis

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C. Her leg swelling requires no further


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

22/870

5/17/2014

A 72-year-old male with a history of


previous inferior myocardial infarction sees
you prior to surgery for symptomatic
gallstones. He denies chest pain or
dyspnea. His current medications include
aspirin, 81 mg daily; ramipril (Altace), 10
mg daily; and pravastatin (Pravachol), 40
mg daily. He is in good health otherwise
and has no other health complaints. He
has been cleared for surgery by his
cardiologist. Which one of the following
should be considered before and after
surgery, assuming no contraindications?
(check one)
A. Atenolol (Tenormin)
B. Verapamil (Calan, Isoptin)
C. Digoxin
D. Transdermal nitroglycerin
E. Intravenous nitroglycerin

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A. Atenolol (Tenormin). A recent


development in the prophylaxis of surgeryrelated cardiac complications is the use of
beta-blockers perioperatively for patients
with cardiac risk factors. In a randomized,
double-blind, placebo-controlled trial
involving 200 patients who were
undergoing elective noncardiac surgery
that required general anesthesia, the effect
of atenolol on perioperative cardiac
complications was evaluated. Patients
were eligible for beta-blocker therapy if
they had known coronary artery disease
or two or more risk factors. Atenolol was
not used if the resting heart rate was <55
beats/min, systolic blood pressure was
<100 mm Hg, or there was evidence of
congestive heart failure, third degree heart
block, or bronchospasm. A 5-mg dose of
intravenous atenolol was given 30 minutes
before surgery and then again immediately
after surgery. Oral atenolol, 50-100 mg,
was then given until hospital discharge or 7
days postoperatively. The results of the
study showed that mortality from cardiac
causes was 65% lower in the patients
receiving atenolol. Another study showed
similar perioperative benefit using the
beta-blocker bisoprolol.

23/870

5/17/2014

In prescribing an exercise program for


elderly, community-dwelling 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
A 52-year-old white male is being
considered for pharmacologic treatment of
hyperlipidemia because of an LDL
cholesterol level of 180 mg/dL. Before
beginning medication for his
hyperlipidemia, he should be screened for:
(check one)
A. Hyperthyroidism
B. Hypothyroidism
C. Addison's disease
D. Cushing's disease
E. Pernicious anemia

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C. 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.
B. Hypothyroidism. According to the
Summary of the National Cholesterol
Education Program (NCEP) Adult
Treatment Panel III Report of 2001, any
person with elevated LDL cholesterol or
any other form of hyperlipidemia should
undergo clinical or laboratory assessment
to rule out secondary dyslipidemia before
initiation of lipid-lowering therapy. Causes
of secondary dyslipidemia include diabetes
mellitus, hypothyroidism, obstructive liver
disease, chronic renal failure, and some
medications.

24/870

5/17/2014

A 56-year-old African-American male


with longstanding hypertension and a 30pack-year smoking history has a 2-day
history of dyspnea on exertion. Physical
examination is unremarkable except for
rare crackles at the bases. Which one of
the following serologic tests would be
most helpful for detecting left ventricular
dysfunction? (check one)
A. Beta-natriuretic peptide (BNP)
B. Troponin-T
C. C-reactive protein (CRP)
D. D dimer
E. Cardiac interleukin-2
Patients with Wolff-Parkinson-White
syndrome who have episodic symptomatic
supraventricular tachycardia or atrial
fibrillation benefit most from: (check one)
A. Episodic intravenous digoxin
B. Long-term oral digitalis
C. Episodic beta-blockers
D. Radiofrequency catheter ablation of
bypass tracts

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A. Beta-natriuretic peptide (BNP). Betanatriuretic peptide (BNP) is a 32-amino


acid polypeptide secreted from the
cardiac ventricles in response to
ventricular volume expansion and pressure
overload. The major source of BNP is the
cardiac ventricles, and because of its
minimal presence in storage granules, its
release is directly proportional to
ventricular dysfunction. It is a simple and
rapid test that reliably predicts the
presence or absence of left ventricular
dysfunction on an echocardiogram.

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.

25/870

5/17/2014

A 72-year-old male with class III


congestive heart failure (CHF) due to
systolic dysfunction asks if he can take
ibuprofen for his "aches and pains."
Appropriate counseling regarding NSAID
use and heart failure should include which
one of the following? (check one)
A. NSAIDs are a good choice for pain
relief, as they decrease systemic vascular
resistance
B. NSAIDs are a good choice for pain
relief, as they augment the effect of his
diuretic
C. High-dose aspirin (325 mg/day) is
preferable to other NSAIDs for patients
taking ACE inhibitors
D. NSAIDs, including high-dose aspirin,
should be avoided in CHF patients
because they can cause fluid retention

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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.

26/870

5/17/2014

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

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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 betablockers. Digoxin is less effective for rate
control and should be reserved as an addon 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.

27/870

5/17/2014

Cilostazol (Pletal) has been found to be a


useful drug for the treatment of intermittent
claudication. This drug is contraindicated
in patients with: (check one)
A. Congestive heart failure
B. A past history of stroke
C. Diabetes mellitus
D. Third degree heart block
E. Hyperlipidemia

============================
===========================
Cardiovascular Board Review Questions
05
============================
===========================
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)

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A. Congestive heart failure. Cilostazol is a


drug with phosphodiesterase inhibitor
activity introduced for the symptomatic
treatment of arterial occlusive disease and
intermittent claudication. Cilostazol should
be avoided in patients with congestive
heart failure. There are no limitations on its
use in patients with previous stroke or a
history of diabetes. It has been found to
have beneficial effects on HDL cholesterol
levels and in the treatment of third degree
heart block.
D. Torsades de pointes. Patients with long
QT syndrome that have sudden arrhythmia
death syndrome usually have either
torsades de pointes or ventricular
fibrillation. Sinus tachycardia would not
explain the syncope, and atrial flutter and
asystole are not usual in long QT
syndrome.

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

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28/870

5/17/2014

An 83-year-old female presents to your


office as a new patient. She recently
moved to the area to be closer to her
family. A history reveals that she has been
in excellent health, has no complaints, and
is on no medications except occasional
acetaminophen for knee pain. She has
never been in the hospital and has not had
any operations. She says that she feels
well. The examination is normal, with
expected age-related changes, except that
her blood pressure on three different
readings averages 175/70 mm Hg. These
readings are confirmed on a subsequent
follow-up visit. In addition to lifestyle
changes, which one of the following would
be most appropriate for the initial
management of this patient's hypertension?
(check one)

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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. Alphablockers 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

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29/870

5/17/2014

Of the following, the INITIAL treatment


of choice in the management of severe
hypertension during pregnancy is: (check
one)
A. Labetalol (Trandate, Normodyne)
intravenously
B. Reserpine (Serpasil) intramuscularly
C. Nifedipine (Procardia, Adalat)
sublingually
D. Enalapril (Vasotec) intravenously

Which one of the following has been


shown to decrease mortality late after a
myocardial infarction? (check one)
A. Nitrates
B. Beta-blockers
C. Digoxin
D. Thiazide diuretics
E. Calcium channel antagonists
Which one of the following is preferred for
chronic treatment of congestive heart
failure due to left ventricular systolic
dysfunction? (check one)
A. Diuretics
B. Digoxin
C. Calcium channel blockers
D. ACE inhibitors
E. Hydralazine (Apresoline) plus
isosorbide dinitrate (Isordil, Sorbitrate)

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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.
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.
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.

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Which one of the following is most


predictive of increased perioperative
cardiovascular events associated with
noncardiac surgery in the elderly? (check
one)
A. An age of 80 years
B. Left bundle-branch block
C. Atrial fibrillation with a rate of 80
beats/min
D. A history of previous stroke
E. Renal insufficiency (creatinine 2.0
mg/dL)

The use of automated external


defibrillators by lay persons in out-ofhospital settings: (check one)
A. Has been frustrated by liability
concerns
B. Has been hampered by an
unwillingness to place the devices in public
areas
C. Has been shown to contribute to
significant gains in full neurologic and
functional recovery
D. Has been eclipsed by the widespread
use of internal cardiac defibrillators in
high-risk patients

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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.
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 wellintentioned 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 at-risk patients, but the
use of AEDs is for the population at large.
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A 74-year-old white male complains of


pain in the right calf that recurs on a
regular basis. He smokes 1 pack of
cigarettes per day and is hypertensive. He
has a history of a previous heart attack but
is otherwise in fair health. Which one of
the following findings would support a
diagnostic impression of peripheral
vascular disease? (check one)
A. Pain during rest and exercise and the
presence of swelling and soreness behind
the knee and in the calf
B. Pain that begins immediately upon
walking and is unrelieved by rest
C. Doppler waveform analysis showing
accentuated waveforms at a point of
decreased blood flow
D. Treadmill arterial flow studies showing
a 20-mm Hg decrease in ankle systolic
blood pressure immediately following
exercise
E. An ankle-brachial index of 1.15

In a 34-year-old primigravida at 35
weeks' gestation, which one of the
following supports a diagnosis of MILD
preeclampsia rather than severe
preeclampsia? (check one)
A. A blood pressure of 150/100 mm Hg
B. A 24-hr protein level of 6 g
C. A platelet count <100,000/mm3
D. Liver enzyme elevation with epigastric
tenderness
E. Altered mental status

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D. Treadmill arterial flow studies showing


a 20-mm Hg decrease in ankle systolic
blood pressure immediately following
exercise. Peripheral vascular disease
(PVD) is a clinical manifestation of
atherosclerotic disease and is caused by
occlusion of the arteries to the legs.
Patients with significant arterial occlusive
disease will have a prominent decrease in
the ankle-brachial index from baseline
following exercise, and usually a 20-mm
Hg or greater decrease in systolic blood
pressure. Pain during rest and exercise
and the presence of swelling and soreness
behind the knee and in the calf is found in
those with Baker's cysts. Peripheral nerve
pain commonly begins immediately upon
walking and is unrelieved by rest. Doppler
waveform analysis is useful in the diagnosis
of PVD and will reveal attenuated
waveforms at a point of decreased blood
flow. Employment of the ankle-brachial
index is encouraged in daily practice as a
simple means to diagnose the presence of
PVD. Generally, ankle-brachial indices in
the range of 0.91-1.30 are thought to be
normal.
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.

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A 72-year-old white female is scheduled


to undergo a total knee replacement for
symptomatic osteoarthritis. She is
otherwise healthy, with no history of
vascular disease or deep vein thrombosis.
She takes no routine medications. Which
one of the following is most appropriate
for prophylaxis against deep vein
thrombosis? (check one)

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E. Enoxaparin (Lovenox), 30 mg
subcutaneously every 12 hours.
Prophylaxis is indicated with total knee or
hip replacements. The two regimens
recommended are low-molecular-weight
heparin and adjusted-dose warfarin.
These may be augmented by intermittent
pneumatic compression.

A. No prophylaxis if there are no surgical


complications
B. Aspirin, 325 mg daily
C. Unfractionated heparin, 5000 U
subcutaneously every 12 hours
D. Thigh-high compression stockings
E. Enoxaparin (Lovenox), 30 mg
subcutaneously every 12 hours

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============================
===========================
Endocrine Board Review Questions 01
============================
===========================
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)

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A. Lithium. Lithium therapy can elevate


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

A. Lithium
B. Furosemide (Lasix)
C. Raloxifene (Evista)
D. Calcium carbonate
E. Vitamin D
Which one of the following medications
should be discontinued in a patient with
diabetic gastroparesis? (check one)
A. Exenatide (Byetta)
B. Benazepril (Lotensin)
C. Metformin (Glucophage)
D. Hydrochlorothiazide
E. Prochlorperazine maleate

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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.

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A frail 83-year-old male with a 10-year


history of diabetes mellitus is admitted to a
nursing home. His blood glucose level,
which he rarely checks, is typically over
200 mg/dL. His serum creatinine level is
1.9 mg/dL. He also has had several
episodes of heart failure. His current
medications include glipizide (Glucotrol),
lisinopril (Prinivil, Zestril), and furosemide
(Lasix). Which one of the following would
be most appropriate to add to this patients
regimen to treat his diabetes mellitus?
(check one)

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E. Insulin glargine (Lantus). For geriatric


patients in long-term care facilities, the
predictable glucose control of glargine is
the best approach to consider initially. The
American Diabetes Association does not
recommend a strict diet for frail diabetic
patients in nursing homes. Exenatide is not
recommended for the frail elderly because
of concerns about weight loss and nausea.
Heart failure precludes the use of
pioglitazone, and renal failure precludes
the use of metformin.

A. The American Diabetes Association


1800-calorie/day diet
B. Metformin (Glucophage)
C. Pioglitazone (Actos)
D. Exenatide (Byetta)
E. Insulin glargine (Lantus)
A 54-year-old female takes levothyroxine
(Synthroid), 0.125 mg/day, for central
hypothyroidism secondary to a pituitary
adenoma. The nurse practitioner in your
office orders a TSH level, which is found
to be 0.1 mIU/mL (N 0.5-5.0). Which
one of the following would you
recommend? (check one)
A. Decrease the dosage of levothyroxine
B. Increase the dosage of levothyroxine
C. Order a free T4 level
D. Order a TRH stimulation test
E. Repeat the TSH level in 3 months

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C. Order a free T4 level. Although


uncommon, pituitary disease can cause
secondary hypothyroidism. The
characteristic laboratory findings are a low
serum free T4 and a low TSH. A free T4
level is needed to evaluate the proper
dosage of replacement therapy in
secondary hypothyroidism. The TSH level
is not useful for determining the adequacy
of thyroid replacement in secondary
hypothyroidism since the pituitary is
malfunctioning. In the initial evaluation of
secondary hypothyroidism, a TRH
stimulation test would be useful if TSH
failed to rise in response to stimulation. It
is not necessary in this case, since the
diagnosis has already been made.

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A 55-year-old white male sees you for a


routine annual visit. His fasting blood
glucose level is 187 mg/dL. Repeat testing
1 week later reveals a fasting glucose level
of 155 mg/dL and an HbA1c of 9.4%.
His BMI is 30 kg/m2. He does not seem
to have any symptoms of diabetes mellitus.
In addition to lifestyle changes, which one
of the following would you prescribe
initially? (check one)
A. Metformin (Glucophage)
B. Glyburide (DiaBeta, Micronase)
C. Poiglitazone (Actos)
D. Bedtime long-acting insulin (Lantus,
Levamir)
E. Bedtime long-acting insulin and rapidacting insulin (NovoLog, Humalog) with
each meal
Which one of the following most increases
insulin sensitivity in an overweight patient
with diabetes mellitus? (check one)
A. Metformin (Glucophage)
B. Acarbose (Precose)
C. Glyburide (DiaBeta, Micronase)
D. NPH insulin

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A. Metformin (Glucophage). Metformin is


widely accepted as the first-line drug for
type 2 diabetes mellitus. It is relatively
effective, safe, and inexpensive, and has
been used widely for many years. Unlike
other oral hypoglycemics and insulin, it
does not cause weight gain. It should be
started at the same time as lifestyle
modifications, rather than waiting to see if
a diet and exercise regimen alone will
work. If metformin is not effective, a
sulfonylurea, a thiazolidinedione, or insulin
can be added, with the choice based on
the severity of the hyperglycemia.

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.

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A 40-year-old female comes to your


office for a routine examination. She has
been in good health and has no complaints
other than obesity. Her mother is diabetic
and the patient has had a child that
weighed 9 lb at birth. Her examination is
negative except for her obesity. A fasting
glucose level is 128 mg/dL, and when
repeated 2 days later it is 135 mg/dL.
Which one of the following would be most
appropriate at this point? (check one)
A. Diagnose type 2 diabetes mellitus and
begin diet and exercise therapy
B. Begin an oral hypoglycemic agent
C. Order a glucose tolerance test
D. Tell the patient that she has impaired
glucose homeostasis but is not diabetic

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A. Diagnose type 2 diabetes mellitus and


begin diet and exercise therapy. The
criteria for diagnosing diabetes mellitus
include any one of the following:
symptoms of diabetes (polyuria,
polydipsia, weight loss) plus a casual
glucose level 200 mg/dL; a fasting
plasma glucose level 126 mg/dL; or a 2hour postprandial glucose level 200
mg/dL after a 75 gram glucose load. In the
absence of unequivocal hyperglycemia the
test must be repeated on a different day.
The criteria for impaired glucose
homeostasis include either a fasting
glucose level of 100-125 mg/dL (impaired
fasting glucose) or a 2-hour glucose level
of 140-199 mg/dL on an oral glucose
tolerance test. Normal values are now
considered <100 mg/dL for fasting
glucose and <140 mg/dL for the 2-hour
glucose level on an oral glucose tolerance
test.

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A 35-year-old male with a previous


history of kidney stones presents with
symptoms consistent with a recurrence of
this problem. The initial workup reveals
elevated serum calcium. Which one of the
following tests would be most appropriate
at this point? (check one)
A. Serum calcitonin
B. 24-hour urine for calcium and
phosphate
C. Serum phosphate and magnesium
D. Serum parathyroid hormone
E. Spot urine for microalbumin

============================
===========================
Endocrine Board Review Questions 02
============================
===========================
In a patient with a solitary thyroid nodule,
which one of the following is associated
with a higher incidence of malignancy?
(check one)

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D. Serum parathyroid hormone. A patient


with a recurrent kidney stone and an
elevated serum calcium level most likely
has hyperparathyroidism, and a
parathyroid hormone (PTH) level would
be appropriate. Elevated PTH is caused
by a single parathyroid adenoma in
approximately 80% of cases. The resultant
hypercalcemia is often discovered in
asymptomatic persons having laboratory
work for other reasons. An elevated PTH
by immunoassay confirms the diagnosis. In
the past, tests based on renal responses to
elevated PTH were used to make the
diagnosis. These included blood
phosphate, chloride, and magnesium, as
well as urinary or nephrogenous cyclic
adenosine monophosphate. These tests
are not specific for this problem, however,
and are therefore not cost-effective.
Serum calcitonin levels have no practical
clinical use.
A. Hoarseness. When evaluating a patient
with a solitary thyroid nodule, red flags
indicating possible thyroid cancer include
male gender; age <20 years or >65 years;
rapid growth of the nodule; symptoms of
local invasion such as dysphagia, neck
pain, and hoarseness; a history of head or
neck radiation; a family history of thyroid
cancer; a hard, fixed nodule >4 cm; and
cervical lymphadenopathy.

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

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Which one of the following can contribute


to serum calcium elevation? (check one)
A. Furosemide (Lasix)
B. Verapamil (Calan, Isoptin)
C. Enalapril (Vasotec)
D. Hydrochlorothiazide
E. Allopurinol (Zyloprim)

A 60-year-old type 2 diabetic requires


urgent appendectomy. Which one of the
following should be withheld until normal
kidney function is documented at 24 and
48 hours after the surgery? (check one)
A. Acarbose (Precose)
B. Glimepiride (Amaryl)
C. Metformin (Glucophage)
D. Nateglinide (Starlix)

Which one of the following is more likely


to occur with glipizide (Glucotrol) than
with metformin (Glucophage)? (check
one)
A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal distress

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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.
C. Metformin (Glucophage).
Administration of general anesthesia may
cause hypotension, which leads to renal
hypoperfusion and peripheral tissue
hypoxia, with subsequent lactate
accumulation. Therefore, if administration
of radiocontrast material is required or
urgent surgery is needed, metformin
should be withheld and hydration
maintained until preserved kidney function
is documented at 24 and 48 hours after
the intervention.
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.

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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,
well-controlled 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 small child with failure to thrive is found


to have a bone age that is markedly
delayed relative to height age and
chronologic age. The most likely etiology
is: (check one)
A. Cystic fibrosis
B. Hypothyroidism
C. Down syndrome
D. Fetal alcohol syndrome
E. Gonadal dysgenesis
Chronic excess thyroid hormone
replacement over a number of years in
postmenopausal women can lead to:
(check one)
A. Diffuse nontoxic goiter
B. Osteoarthritis
C. Osteoporosis
D. Hyperparathyroidism

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A. A 38-year-old male type 1 diabetic,


well-controlled on insulin, whose last
HbA1c was 6.0% (N 3.8-6.4). Insulindependent 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 wellcompensated controlled heart disease are
both allowed. Blood pressure of 160/90
mm Hg or less merits an unrestricted 2year 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.
B. Hypothyroidism. Hypothyroidism is
associated with markedly delayed bone
age relative to height age and chronologic
age. In cystic fibrosis, bone age and height
age are equivalent, but both lag behind
chronologic age. Children with
chromosomal anomalies such as trisomy
21 (Down syndrome) or XO have a height
age which is delayed relative to bone age.
This pattern is also seen as a result of
maternal substance abuse.
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.

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In evaluating an adult with anemia, which


one of the following findings most reliably
indicates a diagnosis of iron deficiency
anemia? (check one)
A. Low total iron-binding capacity
B. Low serum iron
C. Low serum ferritin
D. Microcytosis
E. Hypochromia

Routine blood tests frequently reveal


elevated calcium levels. When this
elevation is associated with elevated
parathyroid hormone levels, which one of
the following is an indication for
parathyroid surgery? (check one)

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C. Low serum ferritin. The total ironbinding capacity is elevated, not


decreased, in iron deficiency anemia. As
an acute-phase reactant, serum iron may
be decreased in response to inflammation
even when total body stores of iron are
not decreased. Microcytosis and
hypochromia are both features of iron
deficiency anemia occurring late in its
development, but both can also be seen in
the thalassemias. Serum ferritin is also an
acute-phase reactant but is normal or
elevated in the face of an inflammatory
process. A low serum ferritin, however, is
diagnostic for iron deficiency even in its
early stages.
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.

A. Age >50
B. Kidney stones
C. Serum calcium 0.5 mg/dL above the
upper limit of normal
D. Concurrent hyperthyroidism
E. Increased bone density

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At a routine visit, a 50-year-old white


female with a 10-year history of type 2
diabetes mellitus has a blood pressure of
145/90 mm Hg and significant
microalbuminuria. Which one of the
following would be an absolute
contraindication to use of an ACE inhibitor
in this patient? (check one)
A. A previous history of angioneurotic
edema
B. Renal insufficiency
C. Asthma
D. A history of recent myocardial
infarction
E. A cardiac ejection fraction <25%

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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.

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============================
===========================
Gastrointestinal Board Review Questions
01
============================
===========================
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
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
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B. Continue breastfeeding, evaluate for


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

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
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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

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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
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in the first year and a peak incidence at 611 months of age. The disorder occurs
predominantly in males. The classic triad
of intermittent colicky abdominal pain,
vomiting, and bloody, mucous stools is
encountered in only 20%-40% of cases.
At 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, foulsmelling stool, classically described as
currant jelly. An air enema using
fluoroscopic guidance is useful for both
diagnosis and treatment.

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A previously healthy 3-year-old male is


brought to your office with a 4-hour
history of abdominal pain followed by
vomiting. Just after arriving at your office
he passes bloody stool. A physical
examination reveals normal vital signs, and
guarding and tenderness in the right lower
quadrant. A rectal examination shows
blood on the examining finger. Which one
of the following is the most likely
diagnosis? (check one)
A. Appendicitis
B. Viral gastroenteritis
C. Midgut volvulus
D. Meckels diverticulum
E. Necrotizing enterocolitis

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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.

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The mother of an 4-week-old male asks


about the viral gastroenteritis vaccine. You
advise that it is (check one)
A. routinely given at the 12-month visit
B. associated with an increased risk for
intussusception
C. initiated at 6-12 weeks of age
D. indicated only for immunocompromised
children
E. indicated only for children attending day
care

Which one of the following is a risk factor


for acute pancreatitis? (check one)
A. Gastroesophageal reflux disease
B. Intravenous drug abuse
C. Angiotensin receptor blocker use
D. Pyelonephritis
E. Gallstones
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

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C. initiated at 6-12 weeks of age.


Rotavirus vaccine (RotaTeq) was licensed
in February 2006 to protect against viral
gastroenteritis. The Advisory Committee
on Immunization Practices recommends
the routine vaccination of infants with three
doses to be given at 2, 4, and 6 months of
age. The first dose should be given
between 6 and 12 weeks of age, and
subsequent doses should be given at 4- to
10-week intervals, but all three doses
should be administered by 32 weeks of
age. Unlike the vaccine RotaShield, which
was marketed in 1999, RotaTeq is not
known to increase the risk for
intussusception.
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. 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.

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Which one of the following is associated


with ulcerative colitis rather than Crohn's
disease? (check one)
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

A 54-year-old white female has been


taking amoxicillin for 1 week for sinusitis.
She has developed diarrhea and has had
6-8 stools per day for the past 2 days.
Examination shows the patient to be well
hydrated with normal vital signs and a
normal physical examination. The stool is
positive for occult blood, and a stool
screen for Clostridium difficile toxin is
positive. The most appropriate treatment
at this time would be (check one)
A. vancomycin (Vancocin) intravenously
B. metronidazole (Flagyl) orally
C. trimethoprim/sulfamethoxazole
(Bactrim, Septra) orally
D. ciprofloxacin (Cipro) orally

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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.
B. metronidazole (Flagyl) orally. Many
antibiotics can induce pseudomembranous
colitis. Although oral vancomycin was
once the initial drug of choice for C.
difficile, oral metronidazole is now the
first-line agent because of cost
considerations and because of concerns
about the development of vancomycinresistant organisms. If the patient has
refractory symptoms despite treatment
with oral metronidazole, then oral
vancomycin would be appropriate.
Vancomycin given orally is not absorbed,
leading to high intraluminal levels of the
drug.

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Current thinking regarding infantile colic is


that the cause is (check one)
A. malabsorption
B. overfeeding
C. excessive air swallowing
D. unknown
E. parental anxiety
An outbreak of pediatric diarrhea has
swept your community. You evaluate a
30-month-old male who developed
diarrhea yesterday. He is still breastfed.
He is alert, his mucous membranes are
moist, and his skin turgor is good. He
passes a liquid stool in your office. Which
one of the following would be the best
advice with regard to his diet? (check one)
A. The mother should withhold
breastfeeding
B. He should consume a normal ageappropriate diet, and continue
breastfeeding
C. Fasting will promote intestinal mucosal
recovery
D. Oral intake should be limited to clear
fluids, bananas, rice, applesauce, and toast
(BRAT diet)

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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.
B. He should consume a normal ageappropriate diet, and continue
breastfeeding. Continued oral feeding in
diarrhea aids in recovery, and an ageappropriate diet should be given.
Breastfeeding or regular formula should be
continued. Foods with complex
carbohydrates (e.g., rice, wheat, potatoes,
bread, and cereals), lean meats, yogurt,
fruits, and vegetables are well tolerated.
Foods high in simple sugars (e.g., juices,
carbonated sodas) should be avoided
because the osmotic load can worsen the
diarrhea. Fatty foods should be avoided
as well. The BRAT diet has not been
shown to be effective.

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============================
===========================
Gastrointestinal Board Review Questions
02
============================
===========================
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)

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C. Neutrophil count >300/mL. Diagnostic


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

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

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A pregnant patient is positive for hepatitis


B surface antigen (HBsAg). Which one of
the following would be most appropriate
for her infant? (check one)
A. Hepatitis B immune globulin (HBIG)
and hepatitis B vaccine at birth
B. Hepatitis B vaccine only, at birth
C. HBIG only, at birth
D. Testing for HBsAg before any
immunization
E. No immunization until 1 year of age
Your community recently experienced an
outbreak of infectious diarrheal illness due
to the protozoan Cryptosporidium, a
chlorine-resistant organism. A reporter
from the local newspaper asks you if there
are other chlorine-resistant fecal organisms
that could contaminate public drinking
water. You would tell the reporter that
such organisms include: (check one)
A. Escherichia coli
B. Vibrio cholerae
C. Campylobacter jejuni
D. Giardia lamblia
E. Rotavirus
Hepatitis C screening is routinely
recommended in which one of the
following? (check one)
A. Pregnant women
B. Nonsexual household contacts of
hepatitis C-positive persons
C. Health care workers
D. Persons with a history of illicit
intravenous drug use

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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.

D. Giardia lamblia. Organisms that can


persist in water environments and survive
disinfection, especially chlorination, are
most likely to cause disease outbreaks
related to drinking water.
Cryptosporidium oocysts and Giardia
cysts are resistant to chlorine and are
important causes of gastroenteritis from
drinking water. Entamoeba histolytica and
hepatitis A virus are also relatively chlorine
resistant. The other organisms listed are
chlorine sensitive.

D. Persons with a history of illicit


intravenous drug use. Patients should be
routinely screened for hepatitis C if they
have a history of any of the following:
intravenous drug abuse no matter how
long or how often, receiving clotting factor
produced before 1987, persistent alanine
aminotransferase elevations, or recent
needle stick with HCV-positive blood.

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A nurse who completed a hepatitis B


vaccine series a year ago is accidentally
stuck by a needle that has just been used
on a dialysis patient. The patient is known
to be HBsAg-positive. Your first response
should be to: (check one)
A. Provide reassurance only
B. Test the nurse for hepatitis B antibody
C. Repeat the hepatitis B vaccine series
D. Administer hepatitis B immune globulin
(HBIG) only
E. Administer HBIG plus a booster of
hepatitis B vaccine

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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).

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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 27-29)
C. Cancer antigen 125 (CA-125)
D. Carcinoembryonic antigen (CEA)
E. Alpha-fetoprotein

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D. Carcinoembryonic antigen (CEA).


Prostate-specific antigen (PSA) is a
marker that is used to screen for prostate
cancer. It is elevated in more than 70% of
organ-confined prostate cancers. Alphatetoprotein is a marker for hepatocellular
carcinoma and nonseminomatous germ
cell tumor, and is elevated in 80% of
hepatocellular carcinomas. CA-125 is a
marker for ovarian cancer. Although it is
elevated in 85% of ovarian cancers, it is
elevated in only 50% of early-stage
ovarian cancers. Carcinoembryonic
antigen (CEA) is a marker for colon,
esophageal, and hepatic cancers. It is
expressed in normal mucosal cells and is
overexpressed in adenocarcinoma,
especially colon cancer. Though not
specific for colon cancer, levels above 10
ng/mL are rarely due to benign disease.
CEA levels typically return to normal
within 4-6 weeks after successful surgical
resection. CEA elevation occurs in nearly
half of patients with a normal preoperative
CEA level that have cancer recurrence.
Cancer antigen 27.29 (CA 27-29) is a
tumor marker for breast cancer. It is
elevated in about 33% of early-stage
breast cancers and about 67% of latestage breast cancers. Some tumor
markers, such as CEA, alpha-fetoprotein,
and CA-125, may be more helpful in
monitoring response to therapy than in
detecting the primary tumor.

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A 65-year-old white female comes to


your office with evidence of a fecal
impaction which you successfully treat.
She relates a history of chronic laxative
use for most of her adult years. After
proper preparation, you perform
sigmoidoscopy and note that the anal and
rectal mucosa contain scattered areas of
bluish-black discoloration. Which one of
the following is the most likely explanation
for the sigmoidoscopic findings? (check
one)
A. Endometriosis
B. Collagenous colitis
C. Melanosis coli
D. Metastatic malignant melanoma
E. Arteriovenous malformations

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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.

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A 55-year-old white male smoker has had


daily severe gastroesophageal reflux
symptoms unrelieved by intensive medical
therapy with proton pump inhibitors. A
recent biopsy performed during upper
endoscopy identified Barrett's esophagus.
Which one of the following is true about
this condition? (check one)
A. It will regress after antireflux surgery
B. It will regress following esophageal
dilation
C. It will regress after Helicobacter pylori
treatment
D. It is associated with an increased risk
of adenocarcinoma

Which one of the following is the most


common cause of bacterial diarrhea?
(check one)
A. Listeria monocytogenes
B. Escherichia coli O157:H7
C. Shigella dysenteriae
D. Campylobacter jejuni
E. Salmonella enterica

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D. It is associated with an increased risk


of adenocarcinoma. Barrett's esophagus is
an acquired intestinal metaplasia of the
distal esophagus associated with
longstanding gastroesophageal acid reflux,
although a quarter of patients with
Barrett's esophagus have no reflux
symptoms. It is more common in white
and Hispanic men over 50 with
longstanding severe reflux symptoms, and
possible risk factors include obesity and
tobacco use. It is a risk factor for
adenocarcinoma of the esophagus, with a
rate of about one case in every 200
patients with Barrett's esophagus per year.
Treatment is directed at reducing reflux,
thus reducing symptoms. Neither medical
nor surgical treatment has been shown to
reduce the carcinoma risk. One
reasonable screening suggestion is to
perform esophagoduodenoscopy in all
men over 50 with gastroesophageal reflux
disease (GERD), but these
recommendations are based only on
expert opinion (level C evidence), and no
outcomes-based guidelines are available.
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.

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A 25-year-old white male truck driver


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

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C. Elliptical excision of the thrombosed


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

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

C. Norwalk virus. Recent reports of


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

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

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A 38-year-old male who is a new patient


reports mild intermittent jaundice without
other associated symptoms for the past
several years. His liver function tests are
normal except for a total bilirubin of 1.3
mg/dL (N 0.3-1.0) and an indirect or
unconjugated bilirubin of 1.0 mg/dL (N
0.2-0.8). His CBC is normal. His past
medical and surgical history is
unremarkable. Findings are similar on
repeat laboratory testing. The most likely
cause of these findings is: (check one)

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D. Gilbert's syndrome. Gilbert's syndrome


is the most common inherited disorder of
bilirubin metabolism. In patients with a
normal CBC and liver function tests,
except for recurrent mildly elevated total
and unconjugated hyperbilirubinemia, the
most likely diagnosis is Gilbert's
syndrome. Fasting, heavy physical
exertion, sickle cell anemia, and drug
toxicity can also cause hyperbilirubinemia.

A. Hepatitis C
B. Wilson's disease
C. Sickle cell anemia
D. Gilbert's syndrome
E. Drug toxicity
A 24-year-old white female presents to
the office with a 6-month history of
abdominal pain. A physical examination,
including pelvic and rectal examinations, is
normal. Which one of the following would
indicate a need for further evaluation?
(check one)
A. Relief of symptoms with defecation
B. Changes in stool consistency from
loose and watery to constipation
C. Passage of mucus with bowel
movements
D. Abdominal bloating
E. Worsening of symptoms at night

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E. Worsening of symptoms at night.


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

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A 36-year-old female makes an


appointment because her husband of 12
years was just diagnosed with hepatitis C
when he tried to become a blood donor
for the first time. He recalls multiple blood
transfusions following a motorcycle crash
in 1988. His wife denies past liver disease,
blood transfusions, and intravenous drug
use. She has had no other sexual partners.
The couple has three children. Which one
of the following is the best advice about
testing the wife and their three children?
(check one)
A. No testing is required in the absence of
jaundice or gastrointestinal symptoms
B. No testing is required if her husband
has normal liver enzyme levels
C. No testing is required because tests
have low sensitivity
D. She should be offered testing because
sexual transmission is possible
E. All family members should be tested
because of possible household fecal-oral
spread

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D. She should be offered testing because


sexual transmission is possible. Key risk
factors for hepatitis C infection are longterm hemodialysis, intravenous drug use,
blood transfusion or organ transplantation
prior to 1992, and receipt of clotting
factors before 1987. Sexual transmission
is very low but possible, and the likelihood
increases with multiple partners. The
lifetime transmission risk of hepatitis C in a
monogamous relationship is less than 1%,
but the patient should be offered testing
because she may choose to confirm that
her test is negative. If the mother is
seronegative, the children are at no risk.
Maternal-fetal transmission is rare except
in the setting of co-infection with HIV.
Hepatitis C is insidious, and symptoms do
not correlate with the extent of the
disease. Normal liver enzyme levels do not
indicate lack of infectivity. There is no risk
to household contacts. Current HCV
antibody tests are more than 99%
sensitive and specific and are
recommended for screening at-risk
populations.

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5/17/2014

A moderately obese 50-year-old AfricanAmerican female presents with colicky


right upper quadrant pain that radiates to
her right shoulder. Which one of the
following is considered the best study to
confirm the likely cause of the patient's
symptoms? (check one)
A. Plain abdominal radiography
B. Oral cholecystography
C. Abdominal ultrasonography
D. A barium swallow
E. Esophagogastroscopy

A 32-year-old white female at 16 weeks'


gestation presents to your office with right
lower quadrant pain. Which one of the
following imaging studies would be most
appropriate for initial evaluation of this
patient? (check one)
A. CT of the abdomen
B. MRI of the abdomen
C. Ultrasonography of the abdomen
D. A small bowel series
E. Intravenous pyelography

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C. Abdominal ultrasonography. The


symptom complex presented is typical of
cholelithiasis. Plain radiography of the
abdomen may reveal radiopaque
gallstones, but will not reveal radiolucent
stones or biliary dilatation. Although rarely
used, oral cholecystography is 98%
accurate, but only when compliance is
assured, the contrast agent is absorbed,
and liver function is normal. Abdominal
ultrasonography is considered the best
study to confirm this diagnosis because of
its high sensitivity and its accuracy in
detecting gallstones. A barium swallow
will identify some functional and structural
esophageal abnormalities, but will not
focus on the suspected organ in this case.
The same is true of esophagogastroscopy.
C. Ultrasonography of the abdomen. CT
has demonstrated superiority over
transabdominal ultrasonography for
identifying appendicitis, associated
abscess, and alternative diagnoses.
However, ultrasonography is indicated for
the evaluation of women who are pregnant
and women in whom there is a high degree
of suspicion for gynecologic disease.

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5/17/2014

A positive spot urine test for homovanillic


acid (HMA) and vanillylmandelic acid
(VMA) is a marker for which one of the
following? (check one)
A. Hepatoblastoma
B. Wilms' tumor
C. Lymphoma
D. Malignant teratoma
E. Neuroblastoma

A slender 22-year-old female is


concerned about a recent weight loss of
10 lb, frequent mild abdominal pain, and
significant diarrhea of 2 months' duration.
Her physical examination is unremarkable,
and laboratory studies reveal only a
moderate microcytic, hypochromic
anemia. Based on this presentation, which
one of the following is the most likely
diagnosis? (check one)

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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.
D. Celiac disease. This constellation of
symptoms strongly suggests celiac disease,
a surprisingly common disease with a
prevalence of 1:13 in the U.S. Half the
adults in the U.S. with celiac disease or
gluten-sensitive enteropathy present with
anemia or osteoporosis, without
gastrointestinal symptoms. Individuals with
more significant mucosal involvement
present with watery diarrhea, weight loss,
and vitamin and mineral deficiencies.

A. Irritable bowel syndrome


B. Villous adenoma
C. Infectious colitis
D. Celiac disease
E. Ulcerative colitis

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A 62-year-old male presents for surgical


clearance prior to transurethral resection
of the prostate. His past history is
significant for a pulmonary embolus after a
cholecystectomy 15 years ago. His
examination is unremarkable except that
he is 23 kg (50 lb) overweight. The most
appropriate recommendation to the
urologist would be to: (check one)
A. Cancel the surgery indefinitely
B. Place the patient on 650 mg of aspirin
daily prior to surgery
C. Start the patient on subcutaneous
enoxaparin (Lovenox), 40 mg 1-2 hr prior
to surgery and once a day after surgery
D. Start warfarin (Coumadin) after surgery
with a goal INR of 1.5
E. Start intravenous heparin according to a
weight-based protocol 24 hours after
surgery
A 60-year-old male indicates that he
occasionally brings up what appears to be
undigested food long after his meal. He
also admits that he sometimes chokes on
food, and that his wife says he has bad
breath. The most likely diagnosis is:
(check one)

C. Start the patient on subcutaneous


enoxaparin (Lovenox), 40 mg 1-2 hr prior
to surgery and once a day after surgery. A
patient with a past history of postoperative
venous thromboembolism is at risk for
similar events with subsequent major
operations. The most appropriate
treatment of the choices listed would be
subcutaneous enoxaparin. Aspirin is
ineffective for prophylaxis of venous
thromboembolism. Warfarin is effective at
an INR of 2.0-3.0. Full anticoagulation
with heparin is unnecessary for
prophylaxis and can result in a higher rate
of postoperative hemorrhage.

D. Zenker's diverticulum. The combination


of halitosis, late regurgitation of undigested
food, and choking suggests Zenker's
diverticulum. Patients may also have
dysphagia and weight loss. The diagnosis
is usually made with a barium swallow.
The treatment is surgical.

A. Achalasia
B. Esophageal reflux
C. Cancer of the esophagus
D. Zenker's diverticulum
E. Large cervical bone spur

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

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E. perform a biopsy of the lesion.


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

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5/17/2014

A 4-year-old white male is brought to


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

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


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

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5/17/2014

A 65-year-old white male comes to your


office with a 0.5-cm nodule that has
developed on his right forearm over the
past 4 weeks. The lesion is dome shaped
and has a central plug. You schedule a
biopsy but he does not return to your
office for 1 year. At that time the lesion
appears to have healed spontaneously.
The most likely diagnosis is (check one)

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E. keratoacanthoma. Keratoacanthoma
grows rapidly and may heal within 6
months to a year. Squamous cell
carcinoma may appear grossly and
histologically similar to keratoacanthoma
but does not heal spontaneously. The
other lesions do not resemble
keratoacanthoma.

A. benign lentigo
B. lentigo maligna
C. basal cell carcinoma
D. squamous cell carcinoma
E. keratoacanthoma

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65/870

5/17/2014

A 72-year-old white male in otherwise


good health complains of generalized
pruritus that worsens in the winter. The
itching is most intense after he bathes. He
recently noticed a rash on his abdomen
and legs as well. On examination you note
poorly defined red, scaly plaques with fine
fissures on the abdomen. No eruption is
present at other pruritic sites. Which one
of the following is the most likely cause of
this problem? (check one)
A. Stasis dermatitis
B. Lichen simplex chronicus
C. Xerosis
D. Rosacea
E. Candidiasis

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C. Xerosis. Xerosis is a pathologic


dryness of the skin that is especially
prominent in the elderly. It is probably
caused by minor abnormalities in
maturation of the epidermis that lead to
decreased hydration of the superficial
portion of the stratum corneum. Xerosis
often intensifies in winter, because of the
lower humidity and cold temperatures.
Stasis dermatitis, due to chronic venous
insufficiency, appears as a reddish-brown
discoloration of the lower leg. Lichen
simplex chronicus, the end result of
habitual scratching or rubbing, usually
presents as isolated hyperpigmented,
edematous lesions, which become scaly
and thickened in the center. Rosacea is
most often seen on the face as an
erythematous, acneiform eruption, which
flushes easily and is surrounded by
telangiectasia. Candidiasis is an
opportunistic infection favoring areas that
are warm, moist, and macerated, such as
the perianal and inguinal folds,
inframammary folds, axillae, interdigital
areas, and corners of the mouth.

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5/17/2014

A 32-year-old farmer comes to your


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

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D. perform an elliptical excision as soon as


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


forehead, nose, and cheeks. The lesions
are mostly closed comedones with a few
open comedones, papules, and pustules.
No significant erythema is seen. Which
one of the following is the most likely
diagnosis? (check one)
A. Erythema toxicum neonatorum
B. Localized superficial Candida infection
C. Herpes simplex
D. Milia
E. Acne neonatorum

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E. Acne neonatorum. Acne neonatorum


occurs in up to 20% of newborns. It
typically consists of closed comedones on
the forehead, nose, and cheeks, and is
thought to result from stimulation of
sebaceous glands by maternal and infant
androgens. Parents should be counseled
that lesions usually resolve spontaneously
within 4 months without scarring. Findings
in erythema toxicum neonatorum include
papules, pustules, and erythema. Candida
and herpes lesions usually present with
vesiculopustular lesions in the neonatal
period. Milia consists of 1- to 2-mm
pearly keratin plugs without erythema, and
may occur on the trunk and limbs.

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5/17/2014

A 5-year-old white male has an itchy


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

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A. Dog or cat hookworm (Ancylostoma


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

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5/17/2014

A middle-aged hairdresser presents with a


complaint of soreness of the proximal nail
folds of several fingers on either hand,
which has slowly worsened over the last 6
months. The nails appear thickened and
distorted. Otherwise she is healthy and has
no evidence of systemic disease. Which
one of the following would be the most
effective initial treatment? (check one)
A. Soaking in a dilute iodine solution twice
daily to cleanse and sterilize the nail beds
B. Oral amoxicillin/clavulanate
(Augmentin) for up to 4-6 weeks
C. Topical betamethasone dipropionate
(Diprolene) applied twice daily to the nail
folds for 3-4 weeks
D. Evaluation for HIV, hepatitis C,
psoriasis, and rheumatoid arthritis

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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.

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5/17/2014

A 6-month-old Hispanic female has had


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

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E. A corticosteroid. This child has atopic


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

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

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C. No definite clinical evidence has shown


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

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5/17/2014

A 36-year-old member of the National


Guard who has just returned from Iraq
consults you because of several "boils" on
the back of his neck that have failed to
heal over the last 6 months, despite two
week-long courses of cephalexin (Keflex).
You observe three 1- to 2-cm raised
minimally tender lesions with central
ulceration and crust formation. He denies
any fever or systemic symptoms. The most
likely cause of these lesions is: (check one)
A. Pyogenic granuloma
B. Leishmaniasis
C. Atypical mycobacterial infection
D. Squamous cell carcinoma
E. Epidermal inclusion cysts

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B. Leishmaniasis. The most likely


diagnosis is cutaneous leishmaniasis,
caused by an intracellular parasite
transmitted by the bite of small sandflies.
Lesions develop gradually, and are often
misdiagnosed as folliculitis or as infected
epidermal inclusion cysts, but they fail to
respond to usual skin antibiotics.
Hundreds of cases have been diagnosed in
troops returning from Iraq, most due to
Leishmania major. Treatment is not always
required, as most lesions will resolve over
several months; however, scarring is
frequent. U.S. military medical facilities
and the CDC are coordinating treatment
when indicated with sodium
stibogluconate. Family physicians can play
a key role in correctly identifying these
lesions.

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5/17/2014

A 23-year-old Hispanic female at 18


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

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C. Melasma (chloasma). Melasma or


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

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You see a 16-year-old white female for a


preparticipation evaluation for sports, and
she asks for advice about the treatment of
acne. She has a few inflammatory papules
on her face. No nodules are noted. She
says she has not tried any over-thecounter acne treatments. Which one of the
following would be considered first-line
therapy for this condition? (check one)
A. Oral tetracycline
B. Oral isotretinoin (Accutane)
C. Topical sulfacetamide (Sulamyd)
D. Topical benzoyl peroxide

The most appropriate initial treatment for


scabies in an 8-year-old male is: (check
one)
A. 0.5% malathion lotion (Ovide)
B. 5% permethrin cream (Elimite)
C. 5% precipitated sulfur in petroleum
D. trimethoprim/sulfamethoxazole
(Bactrim, Septra) orally for 10 days

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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.
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.

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Painful ingrown toenails that display


granulation tissue and lateral nail fold
hypertrophy are best treated by: (check
one)
A. Antibiotic therapy
B. Cotton-wick elevation of the affected
nail corner
C. Removal of the entire nail
D. Excision of the lateral nail plate
combined with lateral matricectomy

A 23-year-old male returns from a Florida


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

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

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A 55-year-old white female presents with


redness at the scar from a lumpectomy
performed for stage I cancer of her right
breast 4 months ago. The patient has
completed radiation treatments to the
breast. She is afebrile and there is no
axillary adenopathy. There is no wound
drainage, crepitance, or bullous lesions.
Which one of the following organisms
would be the most likely cause of cellulitis
in this patient? (check one)
A. Non-group A Streptococcus
B. Pneumococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Pasteurella multocida

A 12-year-old male middle-school


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

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A. Non-group A Streptococcus. Cellulitis


in patients after breast lumpectomy is
thought to be related to lymphedema.
Axillary dissection and radiation
predispose to these infections. Non-group
A hemolytic Streptococcus is the most
common organism associated with this
infection. The onset is often several weeks
to several months after surgery.
Pneumococcus is more frequently a cause
of periorbital cellulitis. It is also seen in
patients who have bacteremia with
immunocompromised status.
Immunocompromising conditions would
include diabetes mellitus, alcoholism,
lupus, nephritic syndrome, and some
hematologic cancers. Clostridium and
Escherichia coli are more frequently
associated with crepitant cellulitis and
tissue necrosis. Pasteurella multocida
cellulitis is most frequently associated with
animal bites, especially cat bites.
C. Herpes gladiatorum. The most
common infection transmitted person-toperson in wrestlers is herpes gladiatorum
caused by the herpes simplex virus.
Molluscum contagiosum causes
keratinized plugs. Human papillomavirus
causes warts. Tinea corporis is ringworm,
which is manifested by round to oval
raised areas with central clearing. Mat
burn is an abrasion.

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You are evaluating a 45-year-old male


construction worker with regard to his
skin and sun exposure history. Which one
of the following lesions should be
considered premalignant? (check one)
A. Sebaceous hyperplasia
B. Actinic keratosis
C. Seborrheic keratosis
D. A de Morgan spot
E. A halo nevus

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B. Actinic keratosis. Family physicians


should advise patients of the dangers of
sun exposure especially those with a fair
complexion who work outdoors. Although
malignant melanoma is the most serious
condition of those listed, actinic keratosis
may lead to squamous cell carcinoma with
significant morbidity.

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

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D. celiac sprue. Celiac sprue is an


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

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Which one of the following is an absolute


contraindication to electroconvulsive
therapy (ECT)? (check one)
A. Age >80 years
B. A cardiac pacemaker
C. An implantable cardioverterdefibrillator
D. Pregnancy
E. There are no absolute contraindications
to ECT

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E. There are no absolute contraindications


to ECT. There are no absolute
contraindications to electroconvulsive
therapy (ECT), but factors that have been
associated with reduced efficacy include a
prolonged episode, lack of response to
medication, and coexisting psychiatric
diagnoses such as a personality disorder.
Persons who may be at increased risk for
complications include those with unstable
cardiac disease such as ischemia or
arrhythmias, cerebrovascular disease such
as recent cerebral hemorrhage or stroke,
or increased intracranial pressure. ECT
can be used safely in elderly patients and
in persons with cardiac pacemakers or
implantable cardioverter-defibrillators.
ECT also can be used safely during
pregnancy, with proper precautions and in
consultation with an obstetrician.

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A 55-year-old female presents to an


urgent-care facility with a complaint of
weakness of several weeks' duration. She
has no other symptoms. She has been
healthy except for a history of
hypertension that has been difficult to
control despite the use of
hydrochlorothiazide, 25 mg daily; lisinopril
(Prinivil, Zestril), 40 mg daily; amlodipine
(Norvasc), 10 mg daily; and doxazosin
(Cardura), 8 mg daily.
On examination her blood pressure is
164/102 mm Hg, with the optic fundi
showing grade 2 changes. She has normal
pulses, a normal cardiac examination, and
no abdominal bruits. A CBC is normal
and a blood chemistry panel is also normal
except for a serum potassium level of 3.1
mmol/L (N 3.5-5.5).
Which one of the following would be best
for confirming the most likely diagnosis in
this patient? (check one)

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E. A plasma aldosterone/renin ratio.


Difficult-to-control hypertension has many
possible causes, including nonadherence
or the use of alcohol, NSAIDs, certain
antidepressants, or sympathomimetics.
Secondary hypertension can be caused by
relatively common problems such as
chronic kidney disease, obstructive sleep
apnea, or primary hyperaldosteronism, as
in the case described here.
As many as 20% of patients referred to
specialists for poorly controlled
hypertension have primary
hyperaldosteronism. It is more common in
women and often is asymptomatic. A
significant number of these individuals will
not be hypokalemic. Screening can be
done with a morning plasma
aldosterone/renin ratio. If the ratio is 20 or
more and the aldosterone level is >15
ng/dL, then primary hyperaldosteronism is
likely and referral for confirmatory testing
should be considered.

A. Magnetic resonance angiography of the


renal arteries
B. A renal biopsy
C. 24-hour urine for metanephrines
D. Early morning fasting cortisol
E. A plasma aldosterone/renin ratio

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A 15-month-old male is brought to your


office 3 hours after the onset of an
increased respiratory rate and wheezing.
He has an occasional cough and no
rhinorrhea. His immunizations are up to
date and he attends day care regularly. His
temperature is 38.2C (100.8F),
respiratory rate 42/min, and pulse rate
118 beats/min.

E. Oral high-dose amoxicillin (90


mg/kg/day), with close outpatient followup. The diagnosis of community-acquired
pneumonia is mostly based on the history
and physical examination. Pneumonia
should be suspected in any child with
fever, cyanosis, and any abnormal
respiratory finding in the history or
physical examination. Children under 2
years of age who are in day care are at
The child is sitting quietly on his mother's
higher risk for developing communitylap. His oxygen saturation is 94% on room acquired pneumonia. Laboratory tests are
air. On examination you note inspiratory
rarely helpful in differentiating viral versus
crackles in the left lower lung field. The
bacterial etiologies and should not be
child appears to be well hydrated and the
routinely performed. Outpatient antibiotics
remainder of the examination, including an are appropriate if the child does not have
HEENT examination, is normal. Nebulized a toxic appearance, hypoxemia, signs of
albuterol (AccuNeb) is administered and
respiratory distress, or dehydration.
no improvement is noted.
Streptococcus pneumoniae is one of the
most common etiologies in this age group,
Which one of the following would be most and high-dose amoxicillin is the drug of
appropriate in the management of this
choice.
patient? (check one)
A. Laboratory evaluation
B. Inpatient monitoring, with no antibiotics
at this time
C. Hospitalization and intravenous
ceftriaxone (Rocephin)
D. Close outpatient follow-up, with no
antibiotics at this time
E. Oral high-dose amoxicillin (90
mg/kg/day), with close outpatient followup

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For normal term infants, current practice is


to introduce solid foods into the diet at
what age? (check one)
A. 2-4 weeks
B. 2-3 months
C. 4-6 months
D. 7-9 months
E. 1 year

A 28-year-old male recreational runner


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

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C. 4-6 months. In normal term infants,


there is little evidence that solid foods
contribute to well-being before the age of
4-6 months. In addition, the extrusion
reflex (pushing foreign material out of the
mouth with the tongue) makes feeding of
solids difficult and often forced. This reflex
disappears around the age of 4 months,
making feeding easier. The introduction of
solids at this age helps supply calories,
iron, and vitamins, and may prepare the
infant for later dietary diversity and healthy
dietary habits.
D. An air stirrup leg brace (Aircast).
Midshaft posteromedial tibial stress
fractures are common and are considered
low risk. Management consists of relative
rest from running and avoiding other
activities that cause pain. Once usual daily
activities are pain free, low-impact
exercise can be initiated and followed by a
gradual return to previous levels of
running. A pneumatic stirrup leg brace has
been found to be helpful during treatment
(SOR C). Non-weight bearing is not
necessary, as this patient can walk without
pain. Casting is not recommended.
Ultrasonic pulse therapy has helped
fracture healing in some instances, but has
not been shown to be beneficial in stress
fractures.

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A 59-year-old male reports decreases in


sexual desire and spontaneous erections,
as well as reduced beard growth. The
most appropriate test to screen for lateonset male hypogonadism is: (check one)
A. free testosterone
B. total testosterone
C. sex hormone-binding globulin
D. LH
E. FSH
A 68-year-old African-American female
with primary hypothyroidism is taking
levothyroxine (Synthroid), 125 g/day.
Her TSH level is 0.2U/mL (N 0.5-5.0).
She has no symptoms of either
hypothyroidism or hyperthyroidism.
Which one of the following would be most
appropriate at this point? (check one)
A. Continuing levothyroxine at the same
dosage
B. Increasing the levothyroxine dosage
C. Decreasing the levothyroxine dosage
D. Discontinuing levothyroxine
E. Ordering a free T 4

A 40-year-old female comes to your


office with a 1-month history of right heel
pain that she describes as sharp, searing,
and severe. The pain is worst when she
first bears weight on the foot after
prolonged sitting and when she gets out of
bed in the morning. It gets better with
continued walking, but worsens at the end
of the day. She does not exercise except
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B. total testosterone. A serum total


testosterone level is recommended as the
initial screening test for late-onset male
hypogonadism. Due to its high cost, a free
testosterone level is recommended only if
the total testosterone level is borderline
and abnormalities in sex hormone-binding
globulin are suspected. Follow-up LH and
FSH levels help to distinguish primary
from secondary hypogonadism.
C. Decreasing the levothyroxine dosage.
Because of the precise relationship
between circulating thyroid hormone and
pituitary TSH secretion, measurement of
serum TSH is essential in the management
of patients receiving levothyroxine therapy.
Immunoassays can reliably distinguish
between normal and suppressed
concentrations of TSH. In a patient
receiving levothyroxine, a low TSH level
usually indicates overreplacement. If this
occurs, the dosage should be reduced
slightly and the TSH level repeated in 2-3
months' time. There is no need to
discontinue therapy in this situation, and
repeating the TSH level in 2 weeks would
not be helpful. A free T4 level would also
be unnecessary, since it is not as sensitive
as a TSH level for detecting mild states of
excess thyroid hormone.
B. Over-the-counter heel inserts. Plantar
fasciitis is a common cause of heel pain. It
may be unilateral or bilateral, and the
etiology is unknown, although it is thought
to be due to cumulative overload stress.
While it may be associated with obesity or
overuse, it may also occur in active or
inactive patients of all ages. Typically the
pain is located in the plantar surface of the
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for being on her feet all day in the hospital


where she works as a floor nurse. She
denies any history of trauma. An
examination reveals point tenderness to
palpation on the plantar surface of the heel
at the medial calcaneal tuberosity.
Which one of the following should you
recommend as first-line treatment? (check
one)
A. Taping/strapping
B. Over-the-counter heel inserts
C. Extracorporeal shock wave therapy
D. A corticosteroid injection
E. A fiberglass walking cast

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heel and is worst when the patient first


stands up when getting out of bed in the
morning (first step phenomenon) or after
prolonged sitting. The pain may then
improve after the patient walks around,
only to worsen after prolonged walking.
The diagnosis is made by history and
physical examination. Typical findings
include point tenderness to palpation on
the plantar surface of the heel at the medial
calcaneal tuberosity where the calcaneal
aponeurosis inserts. Radiographs are not
necessary unless there is a history of
trauma or if the diagnosis is unclear.
The condition may last for months or
years, and resolves in most patients over
time with or without specific therapy. One
long-term follow-up study showed that
80% of patients had complete resolution
of their pain after 4 years. Treatments with
limited (level 2) evidence of effectiveness
include off-the-shelf insoles, custom-made
insoles, stretching of the plantar fascia,
corticosteroid iontophoresis, custommade night splints, and surgery (for those
who have failed conservative therapy).
NSAIDs and ice, although not
independently studied for plantar fasciitis,
are included in most studies of other
treatments, and are reasonable adjuncts to
first-line therapy. Magnetic insoles and
extracorporeal shockwave therapy are
ineffective in treating plantar fasciitis.
Due to their expense, custom-made
insoles, custom-made night splints, and
corticosteroid iontophoresis should be
reserved as second-line treatments for
patients who fail first-line treatment.
Surgery may be offered if more

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conservative therapies fail. Corticosteroid


injection may have a short-term benefit at
1 month, but is no better than other
treatments at 6 months and carries a risk
of plantar fascia rupture.

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


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

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D. Acyclovir (Zovirax) suspension. The


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

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

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B. Lachman. Anterior cruciate ligament


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

Which one of the following tests is most


likely to be abnormal in this patient?
(check one)
A. Anterior drawer
B. Lachman
C. McMurray
D. Pivot shift
One of your patients has been diagnosed
with monoclonal gammopathy of
undetermined significance (MGUS).
Which one of the following is used to
determine whether his condition has
progressed to multiple myeloma? (check
one)
A. The length of time since the diagnosis
of MGUS was made
B. The level of M protein
C. The percentage of plasma cells in bone
marrow
D. Evidence of end-organ damage
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D. Evidence of end-organ damage. The


diagnosis of multiple myeloma is based on
evidence of myeloma-related end-organ
impairment in the presence of M protein,
monoclonal plasma cells, or both. This
evidence may include hypercalcemia, renal
failure, anemia, or skeletal lesions.
Monoclonal gammopathy of undetermined
significance does not progress steadily to
multiple myeloma. There is a stable 1%
annual risk of progression.

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A 60-year-old African-American male


who has a 15-year history of diabetes
mellitus reports a 1-week history of
weakness of the lower left leg, giving way
of the knee, and discomfort in the anterior
thigh. He has no history of recent trauma.
A physical examination reveals decreased
sensation to pinprick and light touch over
the left anterior thigh, and reduced motor
strength on hip flexion and knee extension.
The straight leg raising test is normal.
The most likely cause of this condition is:
(check one)
A. femoral neuropathy
B. diabetic polyneuropathy
C. meralgia paresthetica
D. spinal stenosis
E. iliofemoral atherosclerosis

Women who use low-dose estrogen oral


contraceptives have a 50% lower risk of
cancer of the: (check one)
A. breast
B. cervix
C. head and neck
D. lung
E. ovary

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A. femoral neuropathy. These findings are


typical of femoral neuropathy, a
mononeuropathy commonly associated
with diabetes mellitus, although it has been
found to be secondary to a number of
conditions that are common in diabetics
and not to the diabetes itself. Diabetic
polyneuropathy is characterized by
symmetric and distal limb sensory and
motor deficits. Meralgia paresthetica, or
lateral femoral cutaneous neuropathy, may
be secondary to diabetes mellitus, but is
manifested by numbness and paresthesia
over the anterolateral thigh with no motor
dysfunction. Spinal stenosis causes pain in
the legs, but is not associated with the
neurologic signs seen in this patient, nor
with knee problems. Iliofemoral
atherosclerosis, a relatively common
complication of diabetes mellitus, may
produce intermittent claudication involving
one or both calf muscles but would not
produce the motor weakness noted in this
patient.
E. ovary. Women who use low-dose
estrogen oral contraceptives have at least
a 50% lower risk of subsequent epithelial
ovarian cancer than women who have
never used them. Epidemiologic data also
suggests other potential long-term benefits
of oral contraceptives, including a reduced
risk of postmenopausal fractures, as well
as reductions in the risk of endometrial
and colorectal cancers. Oral
contraceptives do not reduce the risk of
carcinoma of the breast, cervix, lung, or
head and neck.

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Which one of the following is most typical


of polymyalgia rheumatica? (check one)
A. Headache and neck pain
B. A normal erythrocyte sedimentation
rate
C. A dramatic response to corticosteroids
D. A lack of systemic symptoms and signs

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C. A dramatic response to
corticosteroids. Polymyalgia rheumatica is
an inflammatory disorder that occurs in
persons over the age of 50. White women
of European ancestry are most commonly
affected. The clinical hallmarks of
polymyalgia rheumatica are pain and
stiffness in the shoulder and pelvic girdle.
One review found that 4%-13% of
patients with clinical polymyalgia
rheumatica have a normal erythrocyte
sedimentation rate (ESR). As many as 5%
of patients initially have a normal ESR that
later rises.
Polymyalgia rheumatica can have a variety
of systemic symptoms. Fever is common,
with temperatures as high as 39C
(102F) along with night sweats.
Additional symptoms include depression,
fatigue, malaise, anorexia, and weight loss.
Corticosteroids are the mainstay of
therapy for polymyalgia rheumatica.
Typically, a dramatic response is seen
within 48-72 hours.

A 53-year-old male presents for a routine


well-care visit. He has no health
complaints. His wife has accompanied
him, however, and is quite concerned
about changes she has noticed over the
last 1-2 years. She says that he has
become quite apathetic and seems to have
lost interest in his job and his hobbies. He
has been accused of making sexually
harassing comments and inappropriate
touching at work, and he no longer helps
with household chores at home. He often
has difficulty expressing himself and his
speech can lack meaning. The physical
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C. frontotemporal dementia. This patient


meets the criteria for frontotemporal
dementia (FTD), a common cause of
dementia in patients younger than 65, with
an insidious onset. Unlike with Alzheimer's
disease, memory is often relatively
preserved, even though insight is
commonly impaired.
There are three subtypes of
frontotemporal dementia: behavioral
variant FTD, semantic dementia, and
progressive nonfluent aphasia. This patient
would be diagnosed with the behavioral
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examination is normal.
Based on the history provided by the wife,
you should suspect a diagnosis of : (check
one)
A. Alzheimer's disease
B. major depressive disorder
C. frontotemporal dementia
D. dementia with Lewy bodies
E. schizophrenia

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variant due to his loss of executive


functioning leading to personality change
(apathy) and inappropriate behavior (SOR
C). Speech output is often distorted in
frontotemporal dementia, although the
particular changes differ between the three
variants.
Patients with FTD often are mistakenly
thought to have major depressive disorder
due to their apathy and diminished interest
in activities. However, patients with
depression do not usually exhibit
inappropriate behavior and lack of
restraint. Dementia with Lewy bodies and
Alzheimer's dementia are both
characterized predominantly by memory
loss. Alzheimer's dementia is most
common after age 65, whereas FTD
occurs most often at a younger age. Lewy
body dementia is associated with
parkinsonian motor features. Patients
diagnosed with schizophrenia exhibit
apathy and personality changes such as
those seen in FTD. However, the age of
onset is much earlier, usually in the teens
and twenties in men and the twenties and
thirties in women.

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An 88-year-old male has been


hospitalized for the past 3 days after being
found on the floor of his home by a
neighbor and transported to the hospital
by ambulance. He was cachectic and
dehydrated at the time of admission, with
a serum albumin level of 1.9 g/dL (N 3.54.7). He has received intravenous fluids
and is now euvolemic. He began
nasogastric tube feeding 2 days ago and
has now developed nausea, vomiting,
hypotension and delirium.
Which one of the following is the most
classic electrolyte abnormality with this
condition? (check one)

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D. Hypophosphatemia. Refeeding
syndrome can be defined as the potentially
fatal shifts in fluids and electrolytes that
may occur in malnourished patients
receiving artificial refeeding (whether
enterally or parenterally). These shifts
result from hormonal and metabolic
changes and may cause serious clinical
complications. The hallmark biochemical
feature of refeeding syndrome is
hypophosphatemia. However, the
syndrome is complex and may also include
abnormal sodium and fluid balance;
changes in glucose, protein, and fat
metabolism; thiamine deficiency;
hypokalemia; and hypomagnesemia.

A. Hypocalcemia
B. Hypercalcemia
C. Hyperkalemia
D. Hypophosphatemia
E. Hyperphosphatemia
When prescribing an inhaled
corticosteroid for control of asthma, the
risk of oral candidiasis can be decreased
by: (check one)
A. using a valved holding chamber
B. limiting use of the inhaled corticosteroid
to once daily
C. adding nasal fluticasone propionate
(Flonase)
D. adding montelukast (Singulair)
E. adding salmeterol (Serevent)

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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 metered-dose inhaler can
minimize the risk of oral candidiasis.

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A 45-year-old female presents with a 3month history of hoarseness that is not


improving. She works as a high-school
teacher. The most appropriate
management at this time would be: (check
one)
A. voice therapy
B. azithromycin (Zithromax)
C. a trial of inhaled corticosteroids
D. a trial of a proton pump inhibitor
E. laryngoscopy

In adults, the most common cause of right


heart failure is: (check one)
A. myocarditis
B. left heart failure
C. pulmonic stenosis
D. ventricular septal defect
============================
===========================
Random Board Review Questions 03
============================
===========================
As the medical review officer for a local
business, you are required to interpret
urine drug tests. Assuming the sample was
properly collected and handled, which one
of the following test results is consistent
with the history provided and should be
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E. laryngoscopy. Hoarseness most


commonly affects teachers and older
adults. The cause is usually benign, but
extended symptoms or certain risk factors
should prompt evaluation; specifically,
laryngoscopy is recommended when
hoarseness does not resolve within 3
months or when a serious underlying cause
is suspected (SOR C). The American
Academy of Otolaryngology/Head and
Neck Surgery Foundation guidelines state
that antireflux medications should not be
prescribed for patients with hoarseness
without reflux symptoms (SOR C).
Antibiotics should not be used, as the
condition is usually caused by acute
laryngitis or an upper respiratory infection,
and these are most likely to be viral.
Inhaled corticosteroids are a common
cause of hoarseness. Voice therapy should
be reserved for patients who have
undergone laryngoscopy first (SOR A).
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.

C. Morphine identified in an employee


taking a prescribed cough medicine
containing codeine. Results of urine drug
test panels obtained in the workplace are
reported by a Medical Review Officer
(MRO) as positive, negative, dilute,
refusal to test, or test canceled; the
drug/metabolite for which the test is
positive or the reason for refusal (e.g., the
presence of an adulterant) or cancellation
is also included in the final report. The
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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)

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MRO interpretation is based on


consideration of many factors, including
the confirmed patient medical history,
specimen collection process, acceptability
of the specimen submitted, and qualified
laboratory measurement of drugs or
metabolites in excess of the accepted
thresholds. These thresholds are set to
preclude the possibility that secondary
contact with smoke, ingestion of poppy
seeds, or similar exposures will result in an
undeserved positive urine drug screen
report. Other findings, such as the
presence of behavioral or physical
evidence of unauthorized use of opiates,
may also factor into the final report.
When a properly collected, acceptable
specimen is found to contain drugs or
metabolites that would be expected based
on a review of confirmed prescribed use
of medications, the test is reported as
negative. Morphine is a metabolite of
codeine that may be found in the urine of
someone taking a codeine-containing
medication; morphine is not a metabolite
of methadone. Oxazepam is a metabolite
of diazepam but the reverse is not true.
Tetrahydrocannabinol would not be found
in the urine as a result of tramadol use.

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)
A. A corticosteroid
B. An antihistamine
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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,
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C. An antiviral agent
D. Strict bed rest
E. Avoidance of contact sports

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including hydration, NSAIDs, and throat


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

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A 65-year-old Hispanic male with known


metastatic lung cancer is hospitalized
because of decreased appetite, lethargy,
and confusion of 2 weeks' duration.
Laboratory evaluation reveals the
following:
Serum calcium......................... 15.8
mg/dL (N 8.4-10.0)
Serum phosphorus...................... 3.9
mg/dL (N 2.6-4.2)
Serum creatinine. ...................... 1.1
mg/dL (N 0.7-1.3)
Total serum protein..................... 5.0
g/dL (N 6.0-8.0)
Albumin.............................. 3.1 g/dL (N
3.7-4.8)
Which one of the following is the most
appropriate INITIAL management?
(check one)

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C. Normal saline intravenously. The initial


management of hypercalcemia of
malignancy includes fluid replacement with
normal saline to correct the volume
depletion that is invariably present and to
enhance renal calcium excretion. The use
of loop diuretics such as furosemide
should be restricted to patients in danger
of fluid overload, since these drugs can
aggravate volume depletion and are not
very effective alone in promoting renal
calcium excretion. Although intravenous
pamidronate has become the mainstay of
treatment for the hypercalcemia of
malignancy, it is considered only after the
hypercalcemic patient has been rendered
euvolemic by saline repletion. The same is
true for the other calcium-lowering agents
listed.

A. Calcitonin-salmon (Miacalcin)
subcutaneously
B. Pamidronate disodium (Aredia) by
intravenous infusion
C. Normal saline intravenously
D. Furosemide intravenously

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A 35-year-old African-American female


with symptomatic uterine fibroids that are
unresponsive to medical management
prefers to avoid a hysterectomy. Which
one of the following would be a reason for
preferring myomectomy over fibroid
embolization? (check one)
A. A desire for future pregnancy
B. Medical problems that increase general
anesthesia risk
C. Religious objections to blood
transfusion
D. The likelihood of a shorter hospital stay
and recovery time
E. The minimal risk of fibroid recurrence
A 70-year-old African-American male
undergoes routine sigmoidoscopy. He has
a long history of constipation,
hypertension, and diet-controlled type 2
diabetes mellitus. The examination reveals
brown to black leopard spotting of the
colonic mucosa.

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A. A desire for future pregnancy. In the


symptomatic patient with uterine fibroids
unresponsive to medical therapy,
myomectomy is recommended over
fibroid embolization for patients who wish
to become pregnant in the future. Uterine
fibroid embolization requires a shorter
hospitalization and less time off work.
General anesthesia is not required, and a
blood transfusion is unlikely to be needed.
Uterine fibroids can recur or develop after
either myomectomy or embolization.

B. review his medications. This patient has


melanosis coli, which is a benign condition
resulting from abuse of anthraquinone
laxatives such as cascara, senna, or aloe.
The condition resolves with
discontinuation of the medication.

You would now: (check one)


A. perform a metastatic workup
B. review his medications
C. prescribe oral corticosteroids
D. prescribe antibiotics and a proton
pump inhibitor
E. check his stool for Clostridium difficile

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The Valsalva maneuver will typically cause


the intensity of a systolic murmur to
increase in patients with which one of the
following conditions? (check one)
A. Aortic stenosis
B. Rheumatic mitral insufficiency
C. Valvular pulmonic stenosis
D. Hypertrophic obstructive
cardiomyopathy
A 12-year-old male presents with left hip
pain. He is overweight and recently started
playing tennis to lose weight. He says the
pain started gradually after his last tennis
game, but he does not recall any injury.
He is walking with a limp. On examination
he is afebrile and has limited internal
rotation of the left hip.
What is the most likely cause of the hip
pain? (check one)
A. Septic arthritis
B. Juvenile rheumatoid arthritis
C. Transient synovitis
D. Slipped capital femoral epiphysis
E. Legg-Calv-Perthes disease

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D. Hypertrophic obstructive
cardiomyopathy. The Valsalva maneuver
decreases venous return to the heart,
thereby decreasing cardiac output. This
causes most murmurs to decrease in length
and intensity. The murmur of hypertrophic
obstructive cardiomyopathy, however,
increases in loudness. The murmur of
mitral valve prolapse becomes longer, and
may also become louder.
D. Slipped capital femoral epiphysis.
Slipped capital femoral epiphysis is the
most common hip disorder in this patient's
age group. It usually occurs between the
ages of 8 and 15 and is more common in
boys and overweight or obese children. It
presents with limping and pain, and limited
internal rotation of the hip is noted on
physical examination.
Septic arthritis would typically present
with a fever. Juvenile rheumatoid arthritis,
transient synovitis, and Legg-CalvPerthes disease are more common in
younger children.

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Which one of the following is associated


with the use of percutaneous endoscopic
gastrostomy (PEG) tubes? (check one)
A. A reduced risk of aspiration pneumonia
in patients with dysphagia
B. Increased use of restraints
C. Improved nutritional status in nursinghome residents with dementia
D. Improved quality of life for patients
with dementia

A 58-year-old white male comes to your


office for follow-up after a recent bout of
acute bronchitis. He reports having a
productive cough for several months. He
gets breathless with exertion and notes
that every time he gets a cold it "goes into
my chest and lingers for months." He has
been smoking for 30 years. A physical
examination is negative except for
scattered rhonchi. A chest radiograph
done 4 months ago at an urgent care visit
was negative except for hyperinflation and
flattened diaphragms.
Which one of the following would be best
for making the diagnosis? (check one)

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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).
D. Spirometry. It is important to
distinguish between COPD and asthma
because of the differences in treatment.
Patients with COPD are usually in their
sixties when the diagnosis is made.
Symptoms of chronic cough (sometimes
for months or years), dyspnea, or sputum
production are often not reported because
the patient may attribute them to smoking,
aging, or poor physical condition.
Spirometry is the best test for the
diagnosis of COPD. The pressure of
outflow obstruction that is not fully
reversible is demonstrated by
postbronchodilator spirometry showing an
FEV /FVC ratio of 70% or less.

A. A chest radiograph
B. CT of the chest
C. Peak flow measurement
D. Spirometry
E. A BNP level

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A 50-year-old female presents with right


eye pain. On examination, you find no
redness, but when you test her extraocular
muscles she reports marked pain with eye
movement.
This finding suggests that her eye pain is
caused by: (check one)

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D. an orbital problem. Pain with eye


movement suggests an orbital condition.
Orbital inflammation, infection, or tumor
invasion can lead to such eye pain. Other
findings suggestive of an orbital cause of
eye pain include diplopia or proptosis. If
an orbital lesion is suspected, imaging
studies should be performed.

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

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C. at age 40 and then every 5 years if


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

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A 64-year-old African-American male


presents with persistent pleuritic pain. The
patient does not feel well in general and
has had a low-grade fever of around
100F (38C). His medications include
simvastatin (Zocor), lisinopril (Prinivil,
Zestril), low-dose aspirin, spironolactone
(Aldactone), furosemide (Lasix),
isosorbide mononitrate (Imdur),
hydralazine, carvedilol (Coreg), and
nitroglycerin as needed.

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A. Hydralazine. Drug-induced pleuritis is


one cause of pleurisy. Several drugs are
associated with drug-induced pleural
disease or drug-induced lupus pleuritis.
Drugs that may cause lupus pleuritis
include hydralazine, procainamide, and
quinidine. Other drugs known to cause
pleural disease include amiodarone,
bleomycin, bromocriptine,
cyclophosphamide, methotrexate,
minoxidil, and mitomycin.

A chest radiograph is normal and does not


demonstrate a pneumothorax. Further
evaluation rules out pulmonary embolus,
pneumonia, and myocardial infarction. A
diagnosis of pleurisy is made.
Which one of the patient's medications
could be related to this condition? (check
one)
A. Hydralazine
B. Simvastatin
C. Lisinopril
D. Spironolactone
E. Carvedilol

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A 30-year-old male presents to the


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

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C. Procainamide. Adenosine, digoxin, and


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

Which one of the following would be the


treatment of choice? (check one)
A. Verapamil (Calan)
B. Adenosine (Adenocard)
C. Procainamide
D. Digoxin
Which one of the following is
contraindicated in the second and third
trimesters of pregnancy? (check one)
A. Amoxicillin
B. Azithromycin (Zithromax)
C. Ceftriaxone (Rocephin)
D. Ciprofloxacin (Cipro)
E. Doxycycline

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E. Doxycycline. Doxycycline is
contraindicated in the second and third
trimesters of pregnancy due to the risk of
permanent discoloration of tooth enamel in
the fetus. Cephalosporins such as
ceftriaxone are usually considered safe to
use during pregnancy. The use of
ciprofloxacin during pregnancy does not
appear to increase the risk of major
congenital malformation, nor does the use
of amoxicillin. Animal studies using rats
and mice treated with daily doses of
azithromycin up to maternally toxic levels
revealed no impairment of fertility or harm
to the fetus.

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A 25-year-old medical student reads


about the benefits of moderate alcohol
consumption on lipid levels and begins to
drink 5 ounces of red wine a day, adding
100 calories to his diet. Assuming that his
diet and exercise levels stay the same,
what effect will the additional 3000
calories a month have on his body weight
over the next 10 years? (check one)
A. They will have essentially no effect
B. His weight will increase by about 25 kg
C. His weight will increase slightly then
stabilize
D. His normal caloric expenditure will
decrease
You have just diagnosed mild persistent
asthma in a 13-year-old African-American
female. Along with patient education, your
initial medical management should be:
(check one)
A. a short-acting inhaled -agonist to be
used only as needed
B. a long-acting inhaled -agonist daily
C. a low-dose inhaled corticosteroid daily,
along with a short-acting inhaled -agonist
as needed
D. a low-dose inhaled corticosteroid daily,
along with a long-acting inhaled -agonist
daily
E. montelukast (Singulair) daily

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C. His weight will increase slightly then


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

C. a low-dose inhaled corticosteroid daily,


along with a short-acting inhaled -agonist
as needed. Inhaled corticosteroids
improve asthma control in adults and
children more effectively than any other
single long-term controller medication, and
all patients should also receive a
prescription for a short-acting -agonist
(SOR A).

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Patients with rheumatoid arthritis should


be screened for tuberculosis before
starting which one of the following
medications? (check one)
A. Gold
B. Hydroxychloroquine (Plaquenil)
C. Infliximab (Remicade)
D. Methotrexate (Rheumatrex)
E. Sulfasalazine (Azulfidine)

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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 42-year-old male with a history of


intravenous drug use asks to be tested for
hepatitis C. The hepatitis C virus (HCV)
antibody enzyme immunoassay and
recombinant immunoblot assay are both
reported as positive. The quantitative
HCV RNA polymerase chain reaction test
is negative. These test results are most
consistent with: (check one)
A. very early HCV infection
B. current active HCV infection
C. a false-positive antibody test
D. past infection with HCV that is now
resolved

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D. past infection with HCV that is now


resolved. The most widely used initial
assay for detecting hepatitis C virus
(HCV) antibody is the enzyme
immunoassay. A positive enzyme
immunoassay should be followed by a
confirmatory test such as the recombinant
immunoblot assay. If negative, it indicates
a false-positive antibody test. If positive,
the quantitative HCV RNA polymerase
chain reaction is used to measure the
amount of virus in the blood to distinguish
active from resolved HCV infection. In
this case, the results of the test indicate
that the patient had a past infection with
HCV that is now resolved.

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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 nursing-home
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
Metformin (Glucophage) should be
stopped prior to which one of the
following, and withheld until 48 hours after
completion of the test? (check one)
A. An upper GI series
B. Abdominal ultrasonography
C. CT angiography
D. MRI of the brain
E. Colonoscopy

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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.

C. CT angiography. Since even a


temporary reduction in renal function, such
as occurs after pyelography or
angiography, can cause lactic acidosis in
patients taking metformin, the drug should
be discontinued 48 hours before such
procedures (SOR C) and restarted 48
hours after the procedure if renal function
is normal. The other procedures listed are
not indications for stopping metformin.

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============================
===========================
Random Board Review Questions 05
============================
===========================
Which one of the following is most
consistent with obsessive-compulsive
disorder in adults? (check one)
A. Impulses related to excessive worry
about real-life problems
B. A belief by the patient that obsessions
are not produced by his or her own mind,
but are "inserted" thoughts
C. Recognition by the patient that the
obsessions or compulsions are excessive
or unreasonable
D. Compulsions that bring relief to the
patient rather than causing distress
E. Full remission with treatment

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C. Recognition by the patient that the


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

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An 82-year-old resident of a local nursing


home is brought to your clinic with fever,
difficulty breathing, and a cough
productive of purulent sputum. The patient
is found to have an oxygen saturation of
86% on room air and a chest radiograph
shows a new infiltrate. A decision is made
to hospitalize the patient.
Which one of the following intravenous
antibiotic regimens would be most
appropriate for this patient? (check one)
A. Levofloxacin (Levaquin)
B. Ceftriaxone (Rocephin) and
azithromycin (Zithromax)
C. Ceftazidime (Fortaz, Tazicef) and
levofloxacin
D. Ceftazidime and vancomycin
E. Ceftazidime, levofloxacin, and
vancomycin

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E. Ceftazidime, levofloxacin, and


vancomycin. Nursing home-acquired
pneumonia should be suspected in patients
with a new infiltrate on a chest radiograph
if it is associated with a fever,
leukocytosis, purulent sputum, or hypoxia.
Nursing-home patients who are
hospitalized for pneumonia should be
started on intravenous antimicrobial
therapy, with empiric coverage for
methicillin-resistant Staphylococcus aureus
(MRSA) and Pseudomonas aeruginosa.
The 2005 American Thoracic
Society/Infectious Diseases Society of
America guideline recommends
combination therapy consisting of an
antipseudomonal cephalosporin such as
cefepime or ceftazidime, an
antipseudomonal carbapenem such as
imipenem or meropenem, or an extendedspectrum -lactam/-lactamase inhibitor
such as piperacillin/tazobactam, PLUS an
antipseudomonal fluoroquinolone such as
levofloxacin or ciprofloxacin, or an
aminoglycoside such as gentamicin,
tobramycin, or amikacin, PLUS an antiMRSA agent (vancomycin or linezolid).
Ceftriaxone and azithromycin or
levofloxacin alone would be reasonable
treatment options for a patient with nursing
home-acquired pneumonia who does not
require hospitalization.

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Which one of the following has the best


evidence that it is safe for use in
pregnancy? (check one)
A. Alprazolam (Xanax)
B. Lithium
C. Bupropion (Wellbutrin)
D. Fluoxetine (Prozac)
E. Paroxetine (Paxil)

You examine an 11-month-old male who


has had several paroxysms of abdominal
pain in the last 2 hours. The episodes last
1-2 minutes; the infant screams, turns pale,
and doubles up. Afterward, he seems
normal. A physical examination is normal
except for a possible fullness in the right
upper quadrant of the abdomen.
The most likely diagnosis is: (check one)
A. pyloric stenosis
B. choledochal cyst
C. Meckel's diverticulum
D. intussusception
E. intestinal malrotation

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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.
D. intussusception. This is a classic
presentation for intussusception, which
usually occurs in children under the age of
2 years and is characterized by paroxysms
of colicky abdominal pain. A mass is
palpable in about two-thirds of patients.
Pyloric stenosis presents with a palpable
mass, but usually develops between 4 and
6 weeks of age. A choledochal cyst
presents with the classic triad of right
upper quadrant pain, jaundice, and a
palpable mass. Meckel's diverticulum
usually presents in this age group with
painless lower gastrointestinal bleeding.
Intestinal malrotation usually presents
within the first 4 weeks of life and is
characterized by bilious vomiting.

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A 62-year-old male with a history of


prostate cancer and well-controlled
hypertension presents with severe
osteoporosis. At 55 years of age he
received prostate brachytherapy and
androgen deprivation for his prostate
cancer and has been disease-free since.
He presently takes lisinopril (Prinivil,
Zestril), 5 mg daily; alendronate
(Fosamax), 70 mg weekly; calcium, 1000
mg daily; and vitamin D, 1200 units daily.
He has never smoked, exercises five times
a week, and maintains a healthy lifestyle.
In spite of his lifestyle and the medications
he takes, he continues to have severe
osteoporosis on his yearly bone density
tests.
In addition to recommending fall
precautions, which one of the following
would you consider next to treat his
osteoporosis? (check one)
A. Testosterone
B. Calcitonin
C. Teriparatide (Forteo)
D. Raloxifene (Evista)
E. Zoledronic acid (Reclast)

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C. Teriparatide (Forteo). Teriparatide is


indicated for the treatment of severe
osteoporosis, for patients with multiple
osteoporosis risk factors, or for patients
with failure of bisphosphonate therapy
(SOR B). Therapy with teriparatide is
currently limited to 2 years and is
contraindicated in patients with a history of
bone malignancy, Paget disease,
hypercalcemia, or previous treatment with
skeletal radiation. Its route of
administration (subcutaneous) and high
cost should be considered when
prescribing teriparatide therapy.
Testosterone therapy is contraindicated in
patients with a history of prostate cancer.
Zoledronic acid is a parenterally
administered bisphosphonate and would
not be appropriate in a patient who has
already failed bisphosphonate therapy.
Likewise, raloxifene and calcitonin are not
indicated in patients with severe
osteoporosis who have failed
bisphosphonate therapy.

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A 20-year-old white female presents with


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

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B. Chlamydia trachomatis. Women who


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

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A previously healthy 82-year-old male is


brought to your office by his daughter after
a recent fall while getting up to go to the
bathroom in the middle of the night. The
patient denies any history of dizziness,
chest pain, palpitations, or current injury.
He has a history of bilateral dense
cataracts. On examination, he is found to
have an increased stance width and walks
carefully and cautiously with his arms and
legs abducted. A timed up-and-go test is
performed, wherein the patient is asked to
rise from a chair without using his arms,
walk 3 meters, turn, return to his chair,
and sit down. It takes the patient 25
seconds and he is noted to have an "en
bloc" turn.
Which one of the following is the most
likely cause of this patient's gait and
balance disorder? (check one)
A. Visual impairment
B. Cerebellar degeneration
C. Frontal lobe degeneration
D. Parkinson's disease
E. Motor neuropathy

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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.

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5/17/2014

A 17-year-old white female has a history


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

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A. Family-based treatment. Family-based


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

Which one of the following interventions is


most likely to be successful? (check one)
A. Family-based treatment
B. Adolescent-focused individual therapy
C. Fluoxetine (Prozac)
D. Phenelzine (Nardil)
E. Desipramine (Norpramin)
A 42-year-old male with well-controlled
type 2 diabetes mellitus presents with a
24-hour history of influenza-like
symptoms, including the sudden onset of
headache, fever, myalgias, sore throat,
and cough. It is December, and there have
been a few documented cases of influenza
recently in the community.
The CDC recommends initiating treatment
in this situation: (check one)
A. on the basis of clinical symptoms alone
B. only if rapid influenza testing is positive
C. only if the diagnosis is confirmed by
immunoassay testing
D. only if the diagnosis is confirmed by
reverse transcriptase polymerase chain
reaction (PCR) assay

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A. on the basis of clinical symptoms alone.


Influenza is a highly contagious viral illness
spread by airborne droplets. This patient's
symptoms are highly suggestive of typical
influenza: a sudden onset of malaise,
myalgia, headache, fever, rhinitis, sore
throat, and cough. While influenza is
typically uncomplicated and self-limited, it
can result in severe complications,
including encephalitis, pneumonia,
respiratory failure, and death.
The effectiveness of treatment for influenza
is dependent on how early in the course of
the illness it is given. Because of the recent
global H1N1 influenza outbreak that
resulted in demand potentially outstripping
the supply of antiviral medication, the
Centers for Disease Control and
Prevention has modified its
recommendation as follows:
Antiviral treatment is recommended as
soon as possible for patients with
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confirmed or suspected influenza who


have severe, complicated, or progressive
illness or who require hospitalization.
Antiviral treatment is recommended as
soon as possible for outpatients with
confirmed or suspected influenza who are
at higher risk for influenza complications
based on their age or underlying medical
conditions. Clinical judgment should be an
important component of outpatient
treatment decisions.
Antiviral treatment also may be considered
on the basis of clinical judgment for any
outpatient with confirmed or suspected
influenza who does not have known risk
factors for severe illness, if treatment can
be initiated within 48 hours of illness onset.
Many rapid influenza tests produce falsenegative results, and more accurate assays
can take more than 24 hours. Thus,
treatment of patients with a clinical picture
suggesting influenza is recommended, even
if a rapid test is negative. Delaying
treatment until further test results are
available is not recommended.

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113/870

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A 52-year-old male has had a chronic


course of multiple vague and exaggerated
symptoms for which no cause has been
found despite extensive testing. Which one
of the following is the most effective
management approach for this patient?
(check one)
A. Reassure the patient that his symptoms
are not real
B. Schedule the patient for regular
appointments every 2-4 weeks
C. Prescribe opioids for the pain
D. Order additional diagnostic tests
E. Advise the patient to go to the
emergency department if the symptoms
occur after office hours

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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.

============================
===========================
Random Board Review Questions 06
============================
===========================
Which one of the following patients should
be advised to take aspirin, 81 mg daily,
for the primary prevention of stroke?
(check one)
A. A 42-year-old male with a history of
hypertension
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B. A 72-year-old female with no chronic


medical conditions. The U.S. Preventive
Services Task Force (USPSTF) has
summarized the evidence for the use of
aspirin in the primary prevention of
cardiovascular disease as follows:
The USPSTF recommends the use of
aspirin for men 45-79 years of age when
the potential benefit from a reduction in
myocardial infarctions outweighs the
potential harm from an increase in
gastrointestinal hemorrhage (Grade A
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B. A 72-year-old female with no chronic


medical conditions
C. An 80-year-old male with a history of
depression
D. An 87-year-old female with a history
of peptic ulcer disease

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recommendation)
The USPSTF recommends the use of
aspirin for women 55-79 years of age
when the potential benefit of a reduction in
ischemic strokes outweighs the potential
harm of an increase in gastrointestinal
hemorrhage (Grade A recommendation)
The USPSTF concludes that the current
evidence is insufficient to assess the
balance of benefits and harms of aspirin
for cardiovascular disease prevention in
men and women 80 years of age or older
(Grade I statement)
The USPSTF recommends against the use
of aspirin for stroke prevention in women
younger than 55 and for myocardial
infarction prevention in men younger than
45 (Grade D recommendation)
In summary, consistent evidence from
randomized clinical trials indicates that
aspirin use reduces the risk for
cardiovascular disease events in adults
without a history of cardiovascular
disease. It reduces the risk for myocardial
infarction in men, and ischemic stroke in
women. Consistent evidence shows that
aspirin use increases the risk for
gastrointestinal bleeding, and limited
evidence shows that aspirin use increases
the risk for hemorrhagic strokes. The
overall benefit in the reduction of
cardiovascular disease events with aspirin
use depends on baseline risk and the risk
for gastrointestinal bleeding.

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A 12-month-old white female whom you


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

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D. prescribe oral iron. Iron deficiency is


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

Of the following, the most appropriate


next step would be to: (check one)
A. order tests for serum iron and total
iron-binding capacity
B. order a serum ferritin level
C. order hemoglobin electrophoresis
D. prescribe oral iron
E. perform stool guaiac testing
Because of safety concerns, which one of
the following asthma medications should
be used only as additive therapy and not
as monotherapy? (check one)
A. Inhaled corticosteroids
B. Leukotriene-receptor antagonists
C. Short-acting 2-agonists
D. Long-acting 2-agonists
E. Mast cell stabilizers

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D. Long-acting 2-agonists. Because of


the risk of asthma exacerbation or asthmarelated death, the FDA has added a
warning against the use of long-acting 2agonists as monotherapy. Inhaled
corticosteroids, leukotriene-receptor
antagonists, short-acting 2-agonists, and
mast-cell stabilizers are approved and
accepted for both monotherapy and
combination therapy in the management of
asthma (SOR A).

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The mother of a 16-year-old male brings


him to your office stating that she wants to
find out if he has Crohn's disease. She
says that both she and the child's aunt
were diagnosed with this condition by
another physician with "blood tests." The
son tells you that for the past several years
his stool is intermittently loose and he has
up to three bowel movements in a day. He
says he does not have fever, pain,
hematochezia, weight loss, or any
extraintestinal symptoms. A physical
examination is normal.
Which one of the following would be the
most appropriate preliminary testing?
(check one)
A. A plain radiograph of the abdomen
B. CT of the abdomen and pelvis
C. An inflammatory bowel disease
serologic panel
D. Colonoscopy with a biopsy
E. A CBC, serum chemistry panel, and
erythrocyte sedimentation rate

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E. A CBC, serum chemistry panel, and


erythrocyte sedimentation rate. The
diagnosis of inflammatory bowel disease
(IBD) can be elusive but relies primarily
on the patient history, laboratory findings,
and endoscopy (or double-contrast
radiographs if endoscopy is not available).
Endoscopy is usually reserved for patients
with more severe symptoms or in whom
preliminary testing shows the potential for
significant inflammation. It is
recommended that this preliminary
evaluation include a WBC count, platelet
count, potassium level, and erythrocyte
sedimentation rate.
Patients who have minimal symptoms and
normal preliminary testing likely do not
have a significant case of IBD. Plain
radiographs and CT of the abdomen may
help rule out other etiologies but are not
considered adequate to diagnose or
exclude IBD. Panels of serologic blood
tests have recently been developed and
are being assessed as to their place in
evaluating patients who may have IBD.
However, this testing is expensive, lacks
sufficient predictive value, and has yet to
prove its utility compared to standard
testing.

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A 3-day-old female developed a rash 1


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

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D. Erythema toxicum neonatorum. This


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

Which one of the following is the most


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

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A 52-year-old Hispanic female with


diabetes mellitus and stage 3 chronic
kidney disease sees you for follow-up
after tests show an estimated glomerular
filtration rate of 56 mL/min. Which one of
the following medications should she avoid
to prevent further deterioration in renal
function? (check one)
A. Lisinopril (Prinivil, Zestril)
B. Folic acid
C. Low-dose aspirin
D. Candesartan (Atacand)
E. Ibuprofen

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E. Ibuprofen. Patients with chronic kidney


disease (CKD) and those at risk for CKD
because of conditions such as
hypertension and diabetes have an
increased risk of deterioration in renal
function from NSAID use. NSAIDs
induce renal injury by acutely reducing
renal blood flow and, in some patients, by
causing interstitial nephritis. Because many
of these drugs are available over the
counter, patients often assume they are
safe for anyone. Physicians should counsel
all patients with CKD, as well as those at
increased risk for CKD, to avoid
NSAIDs.
ACE inhibitors and angiotensin II receptor
blockers are renoprotective and their use
is recommended in all diabetics. The use
of low-dose aspirin and folic acid is
recommended in all patients with diabetes,
due to the vasculoprotective properties of
these drugs. High-dose aspirin should be
avoided because it acts as an NSAID.

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The best drug treatment for symptomatic


mitral valve prolapse is: (check one)
A. quinidine
B. propranolol (Inderal)
C. digoxin
D. procainamide
E. phenytoin (Dilantin)

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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.

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5/17/2014

A 52-year-old male with stable coronary


artery disease and controlled hypertension
sees you for a routine visit and asks for
advice regarding prevention of altitude
illness for his upcoming trip to Bhutan to
celebrate his anniversary. His medical
chart indicates that he had a reaction to a
sulfa drug in the past.
Which one of the following would be most
appropriate? (check one)
A. Advise the patient to not make the trip
B. Recommend ginkgo biloba
C. Prescribe acetazolamide
D. Prescribe dexamethasone

Which one of the following is most


commonly implicated in interstitial
nephritis? (check one)
A. NSAIDs
B. ACE inhibitors
C. Diuretics
D. Corticosteroids
E. Antibiotics

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D. Prescribe dexamethasone. Altitude


illness is common, affecting 25%-85% of
travelers to high altitudes. The most
common manifestation is acute mountain
sickness, heralded by malaise and
headache. Risk factors include young age,
residence at a low altitude, rapid ascent,
strenuous physical exertion, and a
previous history of altitude illness.
However, activity restriction is not
necessary for patients with coronary artery
disease who are traveling to high altitudes
(SOR C).
Ginkgo biloba has been evaluated for both
prevention and treatment of acute
mountain sickness and high-altitude
cerebral edema, and it is not
recommended. Acetazolamide is an
effective prophylactic agent (SOR B), but
is contraindicated in patients with a sulfa
allergy. If used, it should be started a
minimum of one day before ascent and
continued until the patient acclimatizes at
the highest planned elevation.
Dexamethasone is an effective
prophylactic and treatment agent (SOR
B), and it is not contraindicated for those
with a sulfa allergy. It would be the best
option for this patient.
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.

121/870

5/17/2014

Which one of the following has been


shown to be effective for improving
symptoms of varicose veins? (check one)
A. Horse chestnut seed extract
B. Vitamin B12
C. Ephedra
D. Milk thistle
E. St. John's wort

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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 life-threatening 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.

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

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D. Herpes simplex viral lesions on the


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

What is the most common cause of


erythema multiforme, accounting for more
than 50% of cases? (check one)
A. Candida albicans
B. Herpes simplex virus
C. Mycoplasma pneumoniae
D. Penicillin therapy
E. Sulfonamide therapy

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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.

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5/17/2014

A 25-year-old male presents to your


office for evaluation of pain in the right
index finger that has been present for the
past 4 days. The pain has been getting
progressively worse. On examination the
finger is swollen and held in a flexed
position. The pain increases with passive
extension of the finger, and there is
tenderness to palpation from the tip of the
finger into the palm.
Which one of the following is the most
appropriate management of this patient?
(check one)
A. Surgical drainage and antibiotics
B. Antiviral medication
C. Oral antibiotics and splinting
D. Needle aspiration
E. Corticosteroid injection
An 81-year-old male with type 2 diabetes
mellitus has a hemoglobin A 1c of 10.9%.
He is already on the maximum dosage of
glipizide (Glucotrol). His other medical
problems include mild renal insufficiency
and moderate ischemic cardiomyopathy.
Which one of the following would be the
most appropriate change in this patient's
diabetes regimen? (check one)
A. Add metformin (Glucophage)
B. Add sitagliptin (Januvia)
C. Add pioglitazone (Actos)
D. Initiate insulin therapy

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A. Surgical drainage and antibiotics. This


patient has pyogenic tenosynovitis. When
early tenosynovitis (within 48 hours of
onset) is suspected, treatment with
antibiotics and splinting may prevent the
spread of the infection. However, this
patient's infection is no longer in the early
stages and is more severe, so it requires
surgical drainage and antibiotics. A delay
in treatment of these infections can lead to
ischemia of the tendons and damage to the
flexor tendon and sheath. This can lead to
impaired function of the finger. Needle
aspiration would not adequately drain the
infection. Antiviral medication would not
be appropriate, as this is a bacterial
infection. Corticosteroid injections are
contraindicated in the presence of
infection.
D. Initiate insulin therapy. This geriatric
diabetic patient should be treated with
insulin. Metformin is contraindicated in
patients with renal insufficiency. Sitagliptin
should not be added to a sulfonylurea drug
initially, the dosage should be lowered in
patients with renal insufficiency, and given
alone it would probably not result in
reasonable diabetic control. Pioglitazone
can cause fluid retention and therefore
would not be a good choice for a patient
with cardiomyopathy.

124/870

5/17/2014

Which one of the following seafood


poisonings requires more than just
supportive treatment? (check one)
A. Ciguatera
B. Neurotoxic shellfish
C. Paralytic shellfish
D. Scombroid fish

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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.
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 mahimahi, 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.

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5/17/2014

A 22-year-old white female comes to


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

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C. Postural orthostatic tachycardia


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

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Which one of the following is the greatest


risk factor for abdominal aortic aneurysm
(AAA)? (check one)
A. Cigarette smoking
B. Diabetes mellitus
C. Hypertension
D. African-American race
E. Female gender

An asymptomatic 35-year-old female asks


about having a thyroid test performed
because hypothyroidism runs in her family.
You order the tests, which show a TSH
level of 7.6U/mL (N 0.4-5.1) and a free
T4 level within the normal range.
Which one of the following is most likely in
this patient? (check one)
A. A euthyroid state
B. Primary hyperthyroidism
C. Secondary hyperthyroidism
D. Subclinical hypothyroidism
E. Overt hypothyroidism

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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).
D. Subclinical hypothyroidism. Subclinical
hypothyroidism is defined as slightly
elevated TSH (approximately 5-10
mIU/L) and normal levels of thyroid
hormone (free T4 or free T3 ) in an
asymptomatic patient. There is a low rate
of progression to overt hypothyroidism
manifested by symptoms, TSH levels >10
mIU/L, or reduced levels of thyroid
hormone.
Recent studies have shown that there is an
increased risk for cardiovascular morbidity
and mortality in those with subclinical
hypothyroidism. However, treatment with
thyroid replacement hormone did not
seem to affect this risk. The decision about
whether to recommend thyroid
replacement therapy to patients like the
one described here should be
individualized. An alternative to treating
the patient with medication at this time
would be to retest her TSH annually, or
sooner if she becomes symptomatic.

127/870

5/17/2014

Which one of the following tinea infections


in children always requires systemic
antifungal therapy? (check one)
A. Tinea cruris
B. Tinea corporis
C. Tinea capitis
D. Tinea pedis
E. Tinea versicolor

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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.

128/870

5/17/2014

A 26-year-old female calls your office to


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

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C. repeat the Pap test in 12 months. The


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

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

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D. A dipyridamole-thallium scan. Family


physicians are often asked to perform a
preoperative evaluation prior to
noncardiac surgery. This requires an
assessment of the perioperative
cardiovascular risk of the procedure
involved, the functional status of the
patient, and clinical factors that can
increase the risk, such as diabetes mellitus,
stroke, renal insufficiency, compensated or
prior heart failure, mild angina, or previous
myocardial infarction.
This patient is not undergoing emergency
surgery, nor does she have an active
cardiac condition; however, she is
undergoing a high-risk procedure (>5%
risk of perioperative myocardial infarction)
with vascular surgery. As she cannot climb
a flight of stairs or do heavy housework,
her functional status is <4 METs, and she
should be considered for further
evaluation. The patient's diabetes is an
additional clinical risk factor.
With vascular surgery being planned,
appropriate recommendations include
proceeding with the surgery with heart rate
control, or performing noninvasive testing
if it will change the management of the
patient. Coronary angiography is indicated
if the noninvasive testing is abnormal.
Pulmonary function studies are most useful
in patients with underlying lung disease or
those undergoing pulmonary resection.
Hemoglobin A1c is a measure of longterm diabetic control and is not particularly
useful perioperatively. Carotid
angiography is not indicated in
asymptomatic patients being considered
for lower-extremity vascular procedures.

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5/17/2014

A 62-year-old male has been taking


omeprazole (Prilosec) for over a year for
gastroesophageal reflux disease. He is
asymptomatic and has had no problems
tolerating the drug, but asks you about
potential side effects, as well as the
benefits of continuing therapy.
It would be most accurate to tell him that
omeprazole therapy is associated with
which one of the following? (check one)
A. A decreased rate of hip fracture
B. Decreased vitamin B12 absorption
C. A reduced likelihood of pneumonia
D. A reduced likelihood of Clostridium
difficile colitis
E. An increased likelihood of iron
deficiency anemia

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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 community-acquired
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.

131/870

5/17/2014

A 48-year-old white female comes to see


you because of abnormal vaginal bleeding.
Her periods are lasting 3-5 days longer
than usual, bleeding is heavier, and she has
experienced some intermenstrual bleeding.
Her physical examination is unremarkable,
except for a parous cervix with dark
blood at the os and in the vagina. She has
no orthostatic hypotension, and her
hemoglobin level is 11.5 g/dL. A
pregnancy test is negative.
Which one of the following is the most
important next step in management?
(check one)

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B. An endometrial biopsy. A patient over


the age of 35 who experiences abnormal
vaginal bleeding must have an endometrial
assessment to exclude endometrial
hyperplasia or cancer. An endometrial
biopsy is currently the preferred method
for identifying endometrial disease. A
laboratory evaluation for thyroid
dysfunction or hemorrhagic diathesis is
appropriate if no cancer is present on an
endometrial biopsy and medical therapy
fails to halt the bleeding. The other options
listed can be used as medical therapy to
control the bleeding once the
histopathologic diagnosis has been made.

A. Laboratory tests to rule out thyroid


dysfunction
B. An endometrial biopsy
C. Oral contraceptives, 4 times a day for
5-7 days
D. Cyclic combination therapy with
conjugated estrogens (Premarin) and
medroxy-progesterone (Provera) each
month
E. Administration of a gonadotropinreleasing hormone analog such as
leuprolide acetate (Eligard Lupron Depot)

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132/870

5/17/2014

A 75-year-old African-American male


with no previous history of cardiac
problems complains of shortness of breath
and a feeling of general weakness. His
symptoms have developed over the past
24 hours. On physical examination you
find a regular pulse with a rate of 160
beats/min. You note rales to the base of
the scapula bilaterally, moderate jugular
venous distention, and hepatojugular
reflux. His blood pressure is 90/55 mm
Hg; when he sits up he becomes weak
and diaphoretic and complains of
precordial pressure. An EKG reveals
atrial flutter with 2:1 block.

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D. electrical cardioversion. Atrial flutter is


not ordinarily a serious arrhythmia, but this
patient has heart failure manifested by
rales, jugular venous distention,
hepatojugular reflux, hypotension, and
angina. Electrical cardioversion should be
performed immediately. This is generally a
very easy rhythm to convert. Digoxin and
verapamil are appropriate in
hemodynamically stable patients. A
pacemaker for rapid atrial pacing may be
beneficial if digitalis intoxication is the
cause of atrial flutter, but this is unlikely in
a patient with no previous history of
cardiac problems. Amiodarone is not
indicated in this clinical situation.

Management at this time should include:


(check one)
A. intravenous digoxin
B. intravenous verapamil (Calan, Isoptin)
C. amiodarone (Cordarone)
D. electrical cardioversion
E. insertion of a pacemaker

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133/870

5/17/2014

A 60-year-old male is referred to you by


his employer for management of his
hypertension. He has been without
primary care for several years due to a
lapse in insurance coverage. During a
recent employee health evaluation, he was
noted to have a blood pressure of 170/95
mm Hg. He has a 20-year history of
hypertension and suffered a small lacunar
stroke 10 years ago. He has no other
health problems and does not smoke or
drink alcohol. A review of systems is
negative except for minor residual
weakness in his right upper extremity
resulting from his remote stroke. His blood
pressure is 168/98 mm Hg when initially
measured by your nurse, and you obtain a
similar reading during your examination.

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D. A thiazide diuretic/ACE inhibitor


combination. This patient has stage 2
hypertension, and his history of stroke is a
compelling indication to use specific
classes of antihypertensives. For patients
with a history of previous stroke, JNC-7
recommends using combination therapy
with a diuretic and an ACE inhibitor to
treat the hypertension, as this combination
has been clinically shown to reduce the
risk of recurrent stroke. Other classes of
drugs have not been shown to be of
benefit for secondary stroke prevention.
Although blood pressure should not be
lowered quickly in the setting of acute
ischemic stroke, this patient is not having
an acute stroke, so treatment of his
hypertension is warranted.

In addition to counseling him regarding


lifestyle modifications, which one of the
following is the most appropriate treatment
for his hypertension? (check one)
A. An angiotensin receptor blocker
B. A -blocker
C. A calcium channel blocker
D. A thiazide diuretic/ACE inhibitor
combination
E. No medication

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134/870

5/17/2014

With regard to the cardiovascular system,


activation of the sympathetic branch of the
autonomic nervous system will cause a
decrease in which one of the following?
(check one)
A. Heart rate
B. Coronary flow rate
C. Metabolic demand
D. Contractility of cardiac myocytes
E. The P-R interval
A 40-year-old female with chronic plaque
psoriasis requests topical treatment.
Which one of the following topical
therapies would be most effective and
have the fewest adverse effects? (check
one)
A. High-potency corticosteroids
B. Tazarotene (Tazorac)
C. Coal tar polytherapy
D. Anthralin

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E. The P-R interval. The sympathetic


nervous system acts as a positive
chronotropic (increases heart rate) and
inotropic (increases contractility) agent.
This additional work by the heart will
increase metabolic demand and coronary
flow rate. The increased heart rate will
decrease the time intervals between
electrical events shown on an EKG.

A. High-potency corticosteroids. Chronic


plaque psoriasis is the most common type
of psoriasis and is characterized by
redness, thickness, and scaling. A variety
of treatments were found to be more
effective than placebo, but the best results
were produced by topical vitamin D
analogues and topical corticosteroids.
Vitamin D and high-potency
corticosteroids were equally effective
when compared head to head, but the
corticosteroids produced fewer local
reactions (SOR A).

135/870

5/17/2014

You have been treating a 43-year-old


male for unipolar depression for 4 years.
He has developed treatment-resistant
depression, and despite having a good
initial response to an SSRI, his symptoms
are worsening. He has failed to improve
despite escalated doses of multiple SSRIs
and SNRIs. He is currently taking
citalopram (Celexa), 60 mg daily.
Of the following, the most effective
adjunctive therapy would be augmentation
with: (check one)
A. lithium bicarbonate
B. high-dose triiodothyronine
C. an atypical antipsychotic, such as
olanzapine (Zyprexa)
D. an anticonvulsant, such as gabapentin
(Neurontin)

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A. lithium bicarbonate. Up to one-third of


patients with unipolar depression will fail
to respond to treatment with a single
antidepressant, despite adequate dosing
and an appropriate treatment interval.
Lithium, triiodothyronine (T3 ), and
atypical antipsychotics can all provide
clinical improvement when used in
conjunction with the ineffective
antidepressant. The American Psychiatric
Association and the Institute for Clinical
Systems Improvement both recommend a
trial of lithium or low-dose T 3 for patients
who have an incomplete response to
antidepressant therapy. A meta-analysis
showed that a serum lithium level 0.5
mEq/L and a treatment duration of 2
weeks or greater resulted in a good
response (SOR A).
While thyroid supplementation as
adjunctive therapy is effective, the
recommended dosage is no higher than 50
g/day (SOR B). Atypical antipsychotics
can be used as add-on therapy, but are
not as effective as lithium or T3 (SOR B).
Anticonvulsant medications such as
gabapentin have been shown to be
effective in the management of bipolar
affective disorder, but not as adjunctive
therapy in the treatment of unipolar
depression resistant to single-agent
antidepressants.

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A 4-year-old is brought to the emergency


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

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B. A spot first morning urine


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

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A 25-year-old male presents to your


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

============================
===========================
Random Board Review Questions 09
============================
===========================
A 21-year-old African-American female
has been confused and delirious for 2
days. She has no significant past medical
history, and she is taking no medications.
She recently returned from a missionary
trip to Southeast Asia. During your initial
examination in the emergency department,
she has several convulsions and rapidly
becomes comatose. Her temperature is
37.9C (100.3F) and her blood pressure
is 80/50 mm Hg. A neurologic
examination shows no signs of meningeal
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A. NSAIDs for pain relief. Patients who


present with acute cervical radiculopathy
and normal radiographs can be treated
conservatively. The vast majority of
patients with cervical radiculopathy
improve without surgery. Of the
interventions listed, NSAIDs are the initial
treatment of choice. Tricyclic
antidepressants, as well as tramadol and
venlafaxine, have been shown to help with
chronic neuropathic pain. Cervical MRI is
not indicated unless there are progressive
neurologic defects or red flags such as
fever or myelopathy. Likewise, referral to
a subspecialist should be reserved for
patients who have persistent pain after 6-8
weeks of conservative management and
for those with signs of instability. Cervical
corticosteroid injections have been found
to be helpful in the management of cervical
radiculopathy, but should not be
administered before MRI is performed
(SOR C).
B. malaria. Clinical clues to the diagnosis
of malaria in this case include an
appropriately targeted recent travel
history, a prodrome of delirium or erratic
behavior, unarousable coma following a
generalized convulsion, fever, and a lack
of focal neurologic signs in the presence of
a diffuse, symmetric encephalopathy. The
peripheral blood smear shows
normochromic, normocytic anemia with
Plasmodium falciparum trophozoites and
schizonts involving erythrocytes, diagnostic
of cerebral malaria. Treatment of this true
medical emergency is intravenous
quinidine gluconate.
Vitamin B 12 deficiency is a
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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.

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predominantly peripheral neuropathy seen


in older adults. Ehrlichiosis causes
thrombocytopenia but not hemolytic
anemia. Sickle cell disease presents with
painful vaso-occlusive crises in multiple
organs. Coma is rare.

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

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While evaluating a stroke patient, you ask


him to stick out his tongue. At first he is
unable to do this, but a few moments later
he performs this movement spontaneously.
This defect is known as: (check one)
A. apraxia
B. agnosia
C. expressive (Broca's) aphasia
D. astereognosis

When an interpreter is needed for a


patient with limited English proficiency,
which one of the following should be
AVOIDED when possible? (check one)
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

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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.
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.

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A primigravida at 38 weeks gestation is


concerned that her fetus is getting too
large and wants to know what
interventions could prevent complications
from a large baby. On examination her
uterine fundus measures 41 cm from the
pubic symphysis. Ultrasonography is
performed and an estimated fetal weight of
4000 g (8 lb 13 oz) is reported.
Which one of the following management
options is supported by the best evidence?
(check one)
A. Induction of labor
B. Cesarean section
C. Awaiting spontaneous labor
D. Weekly ultrasonography to follow fetal
growth

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.

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A 65-year-old female who is morbidly


obese presents to your office with
intertrigo in the axilla. On examination you
detect small, reddish-brown macules that
are coalescing into larger patches with
sharp borders. You suspect cutaneous
erythrasma complicating the intertrigo.
What would be the most appropriate
topical treatment for this condition? (check
one)
A. Cornstarch
B. A mild corticosteroid lotion
C. A high-potency corticosteroid lotion
D. Erythromycin
The CAGE-AID questionnaire is a tool
for screening for: (check one)
A. depression
B. bipolar illness
C. substance abuse risk
D. psychosis
E. compatibility

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D. Erythromycin. Intertrigo is inflammation


of skinfolds caused by skin-on-skin
friction and is common on opposing
cutaneous or mucocutaneous surfaces.
Secondary cutaneous bacterial and fungal
infections are common complications.
Cutaneous erythrasma may complicate
intertrigo of interweb areas, intergluteal
and crural folds, axillae, or inframammary
regions. Erythrasma is caused by
Corynebacterium minutissimum and
presents as small reddish-brown macules
that may coalesce into larger patches with
sharp borders. Intertrigo complicated by
erythrasma is treated with topical or oral
erythromycin.
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:
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?

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You see a 6-year-old male for the third


time in 3 months with a persistently painful
hand condition. He has been treated with
oral amoxicillin, followed by oral
trimethoprim/ sulfamethoxazole (Bactrim,
Septra), with no improvement. A physical
examination reveals retraction of the
proximal nail fold, absence of the cuticle,
and erythema and tenderness around the
nail fold area. The thumb and second and
third fingers are affected on both hands.
The patient is otherwise healthy.
First-line treatment for this condition
includes: (check one)
A. warm soaks three times a day
B. avoidance of emollient lotions
C. a topical corticosteroid cream
D. an oral antifungal agent

You see a 90-year-old male with a 5-year


history of progressive hearing loss. The
most common type of hearing loss at this
age affects: (check one)
A. predominantly high frequencies
B. predominantly mid frequencies
C. predominantly low frequencies
D. all frequencies roughly the same

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C. a topical corticosteroid cream. This


patient has symptoms and signs consistent
with chronic paronychia. This condition is
often associated with chronic immersion in
water, contact with soaps or detergents,
use of certain systemic drugs
(antiretrovirals, retinoids) and, as is most
likely in a 6-year-old child, finger sucking.
Findings on examination are similar to
those of acute paronychia, with
tenderness, erythema, swelling, and
retraction of the proximal nail fold. Often
the adjacent cuticle is absent. Chronic
paronychia has usually been persistent for
at least 6 weeks by the time of diagnosis.
In addition to medication, basic treatment
principles for the condition include
avoidance of contact irritants, avoiding
immersion of the hands in water, and use
of an emollient. Topical corticosteroids
have higher efficacy for treating chronic
paronychia compared to oral antifungals
(SOR B), particularly given the young age
of the patient. A topical antifungal can also
be tried in conjunction with the
corticosteroid.
A. predominantly high frequencies. In the
geriatric population, presbycusis is the
most common cause of hearing loss.
Patients typically have the most difficulty
hearing higher-frequency sounds such as
consonants. Lower-frequency sounds
such as vowels are preserved.

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A 44-year-old female who suffers from


obstructive sleep apnea complains of
gradual swelling in her legs over the last
several weeks. Her vital signs include a
BMI of 44.1 kg/m2 , a respiratory rate of
12/min, a blood pressure of 120/78 mm
Hg, and an O 2 saturation of 86% on
room air. An EKG and a chest radiograph
are normal. Pulmonary function testing
shows a restrictive pattern with no signs of
abnormal diffusion. Abnormal blood tests
include only a significantly elevated
bicarbonate level.
Which one of the following treatments is
most likely to reduce this patient's
mortality rate? (check one)
A. ACE inhibitors
B. Routine use of nebulized albuterol
(AccuNeb)
C. High-dose diuretic therapy
D. Continuous oxygen therapy
E. Continuous or bilevel positive airway
pressure (CPAP or Bi-PAP)

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E. Continuous or bilevel positive airway


pressure (CPAP or Bi-PAP). This patient
has obesity-hypoventilation syndrome,
often referred to as Pickwickian
syndrome. These patients are obese (BMI
>30 kg/m 2 ), have sleep apnea, and
suffer from chronic daytime hypoxia
andcarbon dioxide retention. They are at
increased risk for significant respiratory
failure and death compared to patients
with otherwise similar demographics.
Treatment consists of nighttime positive
airway pressure in the form of continuous
(CPAP) or bi-level (BiPAP) devices, as
indicated by sleep testing. The more hours
per day that patients can use this therapy,
the less carbon dioxide retention and less
daytime hypoxia will ensue. Several small
studies suggest that the increased mortality
risk from obesity-hypoventilation
syndrome can be decreased by adhering
to this therapy. The use of daytime oxygen
can improve oxygenation, but is not
considered adequate to restore the
chronic low respiratory drive that is
characteristic of this condition.

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A 38-year-old day-care worker consults


you for "a cold that won't go away." It
began with a runny nose, malaise, and a
slight temperature elevation up to 100F
(37.8C). She notes that after 2 weeks
she is now experiencing "coughing fits,"
which are sometimes so severe that she
vomits. She has had no immunizations
since her freshman year in college and
does not smoke. On examination you note
excessive lacrimation and conjunctival
injection. Her lungs are clear.
Which one of the following is the most
likely diagnosis? (check one)
A. Pertussis
B. Rhinovirus infection
C. Nonasthmatic eosinophilic bronchitis
D. Cough-variant asthma
E. Gastroesophageal reflux

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A. Pertussis. Pertussis, once a common


disease in infants, declined to around 1000
cases in 1976 as a result of widespread
vaccination. The incidence began to rise
again in the 1980s, possibly because the
immunity from vaccination rarely lasts
more than 12 years.
The disease is characterized by a
prodromal phase that lasts 1-2 weeks and
is indistinguishable from a viral upper
respiratory infection. It progresses to a
more severe cough after the second week.
The cough is paroxysmal and may be
severe enough to cause vomiting or
fracture ribs. Patients are rarely febrile, but
may have increased lacrimation and
conjunctival injection. The incubation
period is long compared to a viral
infection, usually 7-10 days.
Nonasthmatic eosinophilic bronchitis,
cough-variant asthma, and
gastroesophageal reflux disease cause a
severe cough not associated with a
catarrhal phase. A rhinovirus infection
would probably be resolving within 2-3
weeks.

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============================
===========================
Random Board Review Questions 10
============================
===========================
A painful thrombosed external hemorrhoid
diagnosed within the first 24 hours after
occurrence is ideally treated by: (check
one)
A. appropriate antibiotics
B. office banding
C. office cryotherapy
D. thrombectomy under local anesthesia
E. total hemorrhoidectomy
Which one of the following is most
characteristic of patellofemoral pain
syndrome in adolescent females? (check
one)
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

A 52-year-old patient is concerned about


a biopsy result from a recent screening
colonoscopy. Which one of the following
types of colon polyp is most likely to
become malignant? (check one)
A. Hyperplastic polyp
B. Hamartomatous polyp
C. Tubular adenoma
D. Villous adenoma
E. Tubulovillous adenoma

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D. thrombectomy under local anesthesia.


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

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.
D. Villous adenoma. Hamartomatous (or
juvenile) polyps and hyperplastic polyps
are benign lesions and are not considered
to be premalignant. Adenomas, on the
other hand, have the potential to become
malignant. Sessile adenomas and lesions
>1.0 cm have a higher risk for becoming
malignant. Of the three types of adenomas
(tubular, tubulovillous, and villous), villous
adenomas are the most likely to develop
into an adenocarcinoma.

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Which one of the following treatments for


diabetes mellitus reduces insulin
resistance? (check one)
A. Acarbose (Precose)
B. Sitagliptin (Januvia)
C. Repaglinide (Prandin)
D. Exenatide (Byetta)
E. Pioglitazone (Actos)

Which one of the following has been


shown to be most effective for smokeless
tobacco cessation? (check one)
A. Behavioral interventions
B. Mint snuff as a smokeless tobacco
substitute
C. Bupropion (Wellbutrin)
D. The nicotine patch
E. Nicotine gum

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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 PPARY, a receptor that affects several insulinresponsive 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.
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.

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An 81-year-old African-American female


complains of increasing fatigue over the
past several months. She has also noticed
that her skin and hair feel dry and that she
often feels cold. She also complains of
intermittent swallowing difficulties. Her
past medical history is significant for longstanding coronary artery disease, for
which she takes metoprolol (Lopressor).
Her physical examination is normal except
for a resting pulse rate of 56 beats/min,
dry skin, brittle hair, and a slow relaxation
phase of the deep tendon reflexes. Her
serum TSH level is 63.2 U/mL (N 0.55.0).
Which one of the following should you do
now? (check one)
A. Stop the metoprolol
B. Start levothyroxine (Synthroid)
C. Start liothyronine (Cytomel)
D. Start propylthiouracil
E. Refer for radioactive iodine ablation

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B. Start levothyroxine (Synthroid).


Autoimmune hypothyroidism is common in
elderly women. Symptoms often include
fatigue, bradycardia, dry skin, brittle hair,
and a prolonged relaxation phase of the
deep tendon reflexes. While replacement
therapy with levothyroxine is indicated,
care must be taken in the elderly,
particularly in those with coronary artery
disease, to replace the deficit slowly.
Levothyroxine replacement should begin
at 25g daily for 6 weeks, with the
dosage increased in 25-g increments as
needed, based on TSH levels.
Rapid replacement of thyroid hormone
can increase the metabolic rate, and
therefore myocardial oxygen demand, too
quickly. This can precipitate complications
of coronary artery disease such as atrial
fibrillation, angina, and myocardial
infarction. Stopping a -blocker in this
setting is likely to increase the risk.
Radioactive iodine ablation is indicated for
some cases of hyperthyroidism.

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Which one of the following is associated


with vacuum-assisted delivery? (check
one)
A. Lower fetal risk than with forceps
delivery
B. More maternal soft-tissue trauma than
forceps delivery
C. A reduced likelihood of severe perineal
laceration compared to spontaneous
delivery
D. An increased incidence of shoulder
dystocia

A 21-year-old sexually active female


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

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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 vacuumassisted delivery without episiotomy, and
the odds are even higher in vacuumassisted 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.
B. Transvaginal ultrasonography. The best
initial imaging study for acute pelvic pain in
women is transvaginal ultrasonography
(SOR C). This provides the greatest level
of detail regarding the uterus and adnexae,
superior to transcutaneous
ultrasonography. CT of the
abdomen/pelvis and
hysterosalpingography may be indicated
eventually in some patients with pelvic
pain, but they are not the initial studies of
choice. Hysteroscopy is not routinely used
in the evaluation of pelvic pain.

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A 27-year-old female presents to the


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

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C. Monitor her renal function. Escherichia


coli O:157 is an increasingly common
cause of serious gastrointestinal illness.
The usual source is undercooked beef.
The child is at risk, since at least 20% of
cases result from secondary spread.
Transmission is frequent in children's daycare facilities and nurseries. Some cases
are asymptomatic, but the great majority
are symptomatic, and patients present with
bloody diarrhea. Levofloxacin is not useful
for prophylaxis in contacts. This patient
has a 10%-15% risk of developing
hemolytic uremic syndrome secondary to
her E. coli O:157 infection, making close
monitoring of renal function essential.

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A 21-year-old female complains of


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

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C. LMWH subcutaneously for at least 5


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

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

B. mirtazapine (Remeron). Trazodone


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

The most appropriate medication for his


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

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A 55-year-old female who has


hypertension, hyperlipidemia, and
osteoarthritis of the knees develops acute
gout and is found to have hyperuricemia.
Discontinuation of which one of the
following medications may improve her
hyperuricemia? (check one)

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A. Hydrochlorothiazide. Diuretics such as


hydrochlorothiazide are known to increase
serum uric acid levels, but losartan has
been shown to decrease uric acid.
Metoprolol, simvastatin, and
acetaminophen have no specific effect on
serum uric acid levels.

A. Hydrochlorothiazide
B. Losartan (Cozaar)
C. Metoprolol (Lopressor)
D. Simvastatin (Zocor)
E. Acetaminophen
A patient with chronic kidney disease
presents with chronic normocytic anemia
with a hemoglobin level of 7.8 g/dL. The
best outcome is predicted if you raise the
hemoglobin level to: (check one)
A. 8-10 g/dL
B. 10-12 g/dL
C. 12-14 g/dL
D. >14 g/dL

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).

A 25-year-old female sees you in the


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

B. vocal cord dysfunction. Vocal cord


dysfunction is an idiopathic disorder
commonly seen in patients in their twenties
and thirties in which the vocal cords
partially collapse or close on inspiration. It
mimics, and is commonly mistaken for,
asthma. Symptoms include episodic
tightness of the throat, a choking
sensation, shortness of breath, and
coughing. A careful history and
examination reveal that the symptoms are

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symptoms. She is asymptomatic today.


Spirometry shows a normal FEV1 , a
normal FVC and FEV1 /FVC ratio, and a
flattened inspiratory loop.
The most likely diagnosis is: (check one)
A. globus hystericus
B. vocal cord dysfunction
C. asthma
D. anaphylaxis
E. COPD

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worse with inspiration than with


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

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In a patient with a sudden onset of


dyspnea, which one of the following
makes a pulmonary embolus more likely?
(check one)
A. Fever >38.0C (100.4F)
B. Chest pain
C. Orthopnea
D. Wheezes
E. Rhonchi

A 2-year-old child stumbles, but his


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

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

A. dislocation of the ulna


B. dislocation of the olecranon epiphysis
C. subluxation of the head of the radius
D. subluxation of the head of the ulna
E. anterior dislocation of the humeral head

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You treat a 65-year-old white female for a


clean minor laceration. Her chart reveals
that she has received two previous doses
of tetanus toxoid. The last dose was 12
years ago.
Which one of the following is the preferred
treatment? (check one)
A. Reassurance that her tetanus immune
status is adequate
B. Tetanus immune globulin (TIG) and
tetanus toxoid (TT)
C. Tetanus toxoid only
D. Tdap
E. DTaP

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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.

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A 45-year-old male has diabetes mellitus


B. ACE inhibitors. The target blood
and hypertension. He has no other medical pressure in patients with diabetes mellitus
problems.
is <130/80 mm Hg (SOR A). ACE
inhibitors and angiotensin receptor
Which one of the following classes of
blockers (ARBs) are the preferred firstmedications is the preferred first-line
line agents for the management of patients
therapy for the treatment of hypertension
with hypertension and diabetes mellitus
in this patient? (check one)
(SOR A). If the target blood pressure is
not achieved with an ACE inhibitor or
A. Potassium-sparing diuretics
ARB, the addition of a thiazide diuretic is
B. ACE inhibitors
the preferred second-line therapy for most
C. -Receptor blockers
patients; potassium-sparing and loop
D. Calcium channel blockers
diuretics are not recommended (SOR B).
E. -Blockers
-Blockers are recommended for patients
with diabetes mellitus who also have a
history of myocardial infarction, heart
failure, coronary artery disease, or stable
angina (SOR A). Calcium channel
blockers should be reserved for patients
with diabetes mellitus who cannot tolerate
preferred antihypertensive agents, or for
those who need additional agents to
achieve their target blood pressure (SOR
A).

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A 73-year-old white female with a long


history of rheumatoid arthritis has a
normocytic normochromic anemia. Her
hemoglobin level is 9.8 g/dL (N 12.016.0) with decreased serum iron,
decreased total iron-binding capacity, and
increased serum ferritin.
Which one of the following is the most
appropriate treatment for this patient?
(check one)
A. Oral iron
B. Intramuscular iron dextran
(DexFerrum, InFeD)
C. Treatment of the rheumatoid arthritis
D. Transfusion
E. Folic acid

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C. Treatment of the rheumatoid arthritis.


This patient has anemia of chronic disease
secondary to her rheumatoid arthritis. This
anemia is usually mild, with hemoglobin
levels of 9.0-11.0 g/dL, and is usually
normocytic-normochromic, although it can
be microcytic. Characteristically, serum
iron and total iron-binding capacity are
decreased and ferritin is increased. The
best treatment of this anemia is to treat the
underlying systemic disease. Neither iron
nor folic acid is effective. Since the anemia
is usually mild, transfusion is not
necessary.

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Which one of the following would suggest


that the sudden and unexpected death of a
healthy infant resulted from deliberate
suffocation rather than sudden infant death
syndrome? (check one)
A. No previous history of apneic episodes
B. An age of 9 months
C. Mottled skin
D. Clenched fists
E. Blood-tinged froth in the mouth

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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.

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============================
===========================
Random Board Review Questions 12
============================
===========================
The most appropriate advice for a 50year-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

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E. take potassium citrate with meals.


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

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A 22-year-old female presents with lower


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

A 23-year-old white male is brought to


the emergency department with slurred
speech, confusion, and ataxia. He works
as an auto mechanic and has been known
to consume alcohol heavily in the past, but
denies recent alcohol intake. He appears
intoxicated, but no odor of alcohol is
noted on his breath. Abnormalities on the
metabolic profile include a carbon dioxide
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A. Plain radiographs. The findings in this


patient are consistent with a stress
fracture. Plain radiographs should be the
initial imaging modality because of
availability and low cost (SOR C). These
are usually negative initially, but are more
likely to be positive over time. If the initial
films are negative and the diagnosis is not
urgently needed, a second plain
radiograph can be performed in 2-3
weeks.
Although CT is useful for evaluation of
bone pathology, it is not commonly used
as even second-line imaging for stress
fractures, due to lower sensitivity and
higher radiation exposure than other
modalities. Triple-phase bone scintigraphy
has a high sensitivity and was previously
used as a second-line modality; however,
MRI has equal or better sensitivity than
scintigraphy and higher specificity. MRI is
now recommended as the second-line
imaging modality when plain radiographs
are negative and clinical suspicion of stress
fracture persists (SOR C).
Musculoskeletal ultrasonography has the
advantage of low cost with no radiation
exposure, but additional studies are
needed before it can be recommended as
a standard imaging modality.
D. Fomepizole (Antizol). Ethylene glycol
poisoning should be suspected in patients
with metabolic acidosis of unknown cause
and subsequent renal failure, as rapid
diagnosis and treatment will limit the
toxicity and decrease both morbidity and
mortality. This diagnosis should be
considered in a patient who appears
intoxicated but does not have an odor of
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content of 10 mmol/L (N 20-30). His


blood alcohol level is <10 mg/dL
(0.01%). A urinalysis shows calcium
oxalate crystals and an RBC count of 1020/hpf. Woods lamp examination of the
urine shows fluorescence. His arterial pH
is 7.25.
Which one of the following would be most
appropriate at this point? (check one)
A. Immediate hemodialysis
B. Gastric lavage
C. Administration of activated charcoal
D. Fomepizole (Antizol)

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alcohol, and has anion gap acidosis,


hypocalcemia, urinary crystals, and
nontoxic blood alcohol levels. Ethylene
glycol is found in products such as engine
coolant, de-icing solution, and carpet and
fabric cleaners. Ingestion of 100 mL of
ethylene glycol by an adult can result in
toxicity.
The American Academy of Clinical
Toxicology criteria for treatment of
ethylene glycol poisoning with an antidote
include a plasma ethylene glycol
concentration >20 mg/dL, a history of
ingesting toxic amounts of ethylene glycol
in the past few hours with an osmolal gap
>10 mOsm/kg H O2 (N 5-10), and
strong clinical suspicion of ethylene glycol
poisoning, plus at least two of the
following: arterial pH <7.3, serum
bicarbonate <20 mmol/L, or urinary
oxalate crystals.
Until recently, ethylene glycol poisoning
was treated with sodium bicarbonate,
ethanol, and hemodialysis. Treatment with
fomepizole (Antizol) has this specific
indication, however, and should be
initiated immediately when ethylene glycol
poisoning is suspected. If ethylene glycol
poisoning is treated early, hemodialysis
may be avoided, but once severe acidosis
and renal failure have occurred
hemodialysis is necessary. Ethylene glycol
is rapidly absorbed, and use of ipecac or
gastric lavage is therefore not effective.
Large amounts of activated charcoal will
only bind to relatively small amounts of
ethylene glycol, and the therapeutic
window for accomplishing this is less than
1 hour.

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A 67-year-old white male with


hypertension and chronic kidney disease
presents with the recent onset of excessive
thirst, frequent urination, and blurred
vision. Laboratory testing reveals a fasting
blood glucose level of 270 mg/dL, a
hemoglobin A 1c of 8.5%, a BUN level of
32 mg/dL, and a serum creatinine level of
2.3 mg/dL. His calculated glomerular
filtration rate is 28 mL/min.
Which one of the following medications
should you start at this time? (check one)

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A. Glipizide (Glucotrol). It is
recommended that metformin be avoided
in patients with a creatinine level >1.5
mg/dL for men or >1.4 mg/dL for women.
Glyburide has an active metabolite that is
eliminated renally. This metabolite can
accumulate in patients with chronic kidney
disease, resulting in prolonged
hypoglycemia. Acarbose should be
avoided in patients with chronic kidney
disease, as it has not been evaluated in
these patients. Glipizide does not have an
active metabolite, and is safe in patients
with chronic renal disease.

A. Glipizide (Glucotrol)
B. Metformin (Glucophage)
C. Glyburide (DiaBeta)
D. Acarbose (Precose)
A 60-year-old male has a drug-eluting
stent placed in his right coronary artery.
He will require treatment to prevent stent
thrombosis, and once his initial treatment
period is completed he will be placed on
aspirin, 75-165 mg/day indefinitely.
Which one of the following is the preferred
initial regimen for preventing stent
thrombosis in this situation? (check one)
A. Aspirin/dipyridamole (Aggrenox) for 3
months
B. Aspirin, 162-325 mg/day for 3 months
C. Aspirin, 162-325 mg/day, plus
clopidogrel (Plavix), both for 3 months
D. Aspirin, 162-325 mg/day, plus
clopidogrel, both for 12 months
E. Warfarin (Coumadin) for 3 months

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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 sirolimuseluting stent, and 6 months for other drugeluting stents.

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A 57-year-old male executive sees you


because of "shaky hands." His tremor is
most noticeable when he is holding
something or writing, and is more
prominent in his hand than in his shoulder.
He has noticed that it seems better "after a
beer or two" at social gatherings. He has
no other health problems. On examination
you note a very definite tremor when he
unbuttons his shirt. His gait is normal and
there is no resting tremor. He has a
previous history of intolerance to A 57year-old male executive sees you because
of "shaky hands." His tremor is most
noticeable when he is holding something or
writing, and is more prominent in his hand
than in his shoulder. He has noticed that it
seems better "after a beer or two" at social
gatherings. He has no other health
problems. On examination you note a very
definite tremor when he unbuttons his shirt.
His gait is normal and there is no resting
tremor. He has a previous history of
intolerance to -blockers.

C. Primidone (Mysoline). Parkinson's


disease and essential tremor are the
primary concerns in a person of this age
who presents with a new tremor. A
coarse, resting, pill-rolling tremor is
characteristic of Parkinson's disease.
Essential tremor is primarily an action
tremor and is a common movement
disorder, occurring in members of the
same family with a high degree of
frequency. Alcohol intake will temporarily
cause marked reduction in the tremor. Adrenergic blockers have been the
mainstay of treatment for these tremors,
but this patient is intolerant to these drugs.
Primidone has been effective in the
treatment of essential tremor, and in headto-head studies with propranolol has been
shown to be superior after 1 year.
Levodopa in combination with carbidopa
is useful in the treatment of parkinsonian
tremor but not essential tremor.

Of the following, which medication would


be the best choice for this patient? (check
one)
A. Levodopa/carbidopa (Sinemet)
B. Amantadine (Symmetrel)
C. Primidone (Mysoline)
D. Lithium carbonate

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Which one of the following is true


regarding medical errors? (check one)
A. Malpractice litigation is more common
when physicians disclose errors to patients
B. The use of the word "error" should be
avoided when disclosing mistakes to
patients
C. Physicians in private practice are more
likely to disclose errors to patients than
physicians employed by institutions or
health care organizations
D. Patients prefer to receive apologies and
explanations when an error has been made
E. It is ethically defensible to only disclose
an error if the patient is aware there is a
problem

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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.

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A 60-year-old female presents with a 1year history of episodes of urinary


incontinence. She tells you that she will
suddenly feel the need to urinate and can
barely make it to the bathroom. She
occasionally loses urine before reaching
the toilet. Her only medication is
hydrochlorothiazide, which she has been
taking for many years for hypertension.
On examination, her vaginal mucosa is
pale and somewhat dry. Minimal prolapse
of her vaginal and urethral areas is noted.

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D. Oral anticholinergic therapy. First-line


therapies for urge urinary incontinence
include behavioral therapy, such as pelvic
muscle contractions, and anticholinergic
therapy. Oral estrogen is not indicated.
Noninvasive treatments should be tried
initially. Urodynamic testing is indicated
preoperatively. Stopping the
hydrochlorothiazide would not be helpful,
as it would not address the issue of
detrusor instability.

Which one of the following would be most


appropriate at this point? (check one)
A. Urodynamic testing
B. Referral for surgical evaluation
C. Oral estrogen
D. Oral anticholinergic therapy
E. Stopping the hydrochlorothiazide

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A 42-year-old female brings you the


results of a comprehensive metabolic
profile obtained through a health screening
program offered by her employer. She
fasted for 8 hours prior to the test, and her
blood glucose level was reported as 110
mg/dL. Her lipid values and her blood
pressure were normal, but her BMI is
30.5 kg/m 2 .
She currently views herself as relatively
healthy and reports no symptoms
consistent with diabetes mellitus during
your review of systems. Additional testing
reveals a hemoglobin A1c of 6.3%.
Based on this data, which one of the
following is most appropriate at this time?
(check one)
A. Order a C-peptide level
B. Order an islet cell antibody level
C. Recommend lifestyle modifications only
D. Start low-dose glyburide (DiaBeta)
daily
E. Start low-dose insulin glargine (Lantus)
daily

Which one of the following is consistent


with spinal stenosis but not with a
herniated vertebral disk? (check one)
A. Numbness
B. Muscle weakness
C. Pain relieved by sitting
D. Pain relieved by standing

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C. Recommend lifestyle modifications


only. The ADA recommends testing to
detect type 2 diabetes mellitus in
asymptomatic adults with a BMI 25
kg/m 2 and one or more additional risk
factors. Risk factors include physical
inactivity, hypertension, an HDLcholesterol level <35 mg/dL, a triglyceride
level >250 mg/dL, a history of
cardiovascular disease, a hemoglobin A
1c5.7%, a history of gestational diabetes
or delivery of an infant weighing >4 kg (9
lb), and a history of polycystic ovary
syndrome.
Diabetes mellitus can be diagnosed if the
patient's fasting blood glucose level is
126 mg/dL on two separate occasions.
It can also be diagnosed if a random
blood glucose level is 200 mg/dL if
classic symptoms of diabetes are present.
A fasting blood glucose level of 100-125
mg/dL, a glucose level of 140-199 mg/dL
2 hours following a 75-g glucose load, or
a hemoglobin A 1c of 5.7%-6.9% signifies
impaired glucose tolerance. Patients
meeting these criteria have a significantly
higher risk of progression to diabetes and
should be counseled about lifestyle
modifications such as weight loss and
exercise.
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.

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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)

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

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

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C. The baby should be given 400 IU of


supplemental vitamin D daily. In 2008, the
American Academy of Pediatrics
increased its recommended daily intake of
vitamin D in infants, children, and
adolescents to 400 IU/day (SOR C).
Breastfeeding does not provide adequate
levels of vitamin D. Exclusive formula
feeding probably provides adequate levels
of vitamin D, but infants who consume less
than 1 liter of formula per day need
supplementation with 400 IU of vitamin D
daily. Vitamin D supplementation should
be started within the first 2 months of
birth.

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A 60-year-old male is recovering from a


non-Q-wave myocardial infarction. He
has a 40-pack-year smoking history,
currently smokes a pack of cigarettes per
day, and has a strong family history of
coronary artery disease. Studies ordered
by the cardiologist showed no indication
for any coronary artery procedures. His
BMI is 27.5 kg/m 2 and his blood
pressure is 130/70 mm Hg. Laboratory
tests reveal a fasting blood glucose level of
85 mg/dL, a total cholesterol level of 195
mg/dL, and an LDL-cholesterol level of
95 mg/dL.

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A. A weight reduction diet. Although


dietary management may be appropriate,
a weight reduction diet is not likely to
improve this patient's cardiovascular
outcome. In fact, even if this person were
obese, there is insufficient evidence that
weight reduction would decrease his
cardiovascular mortality (SOR C). There
is good evidence that the other options,
even -blockers in a patient with normal
blood pressure, are indicated. All of these
measures have evidence to support their
usefulness for secondary prevention of
coronary artery disease (SOR A).

Which one of the following secondary


prevention measures would be LEAST
likely to improve this patient's
cardiovascular outcome? (check one)
A. A weight reduction diet
B. A -blocker
C. A statin
D. An antiplatelet agent
E. Smoking cessation

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You have just diagnosed post-traumatic


stress disorder in a 32-year-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)

You volunteer some of your time to


provide services to athletes at a small
liberal arts college that has several NCAA
Division II teams. When screening these
athletes for health problems, you would
advise that students with uncontrolled
stage 2 hypertension should not participate
in: (check one)
A. rowing
B. soccer
C. tennis
D. fencing
E. baseball

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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.
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.

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A 36-year-old male presents to the


emergency department with disorientation,
tachycardia, diaphoresis, and
hypertension. According to his family, he
has been consuming up to a fifth of vodka
daily but abruptly discontinued alcohol
consumption 2 days ago. There is no
history of additional substance abuse and
a urine drug screen is negative.
Which one of the following is most
indicated in the management of this
patient? (check one)
A. An anticonvulsant
B. A typical antipsychotic
C. A benzodiazepine
D. A centrally-acting 2-agonist
E. Baclofen

A 54-year-old female has pain and


swelling of the right knee. Examination of
the synovial fluid reveals a leukocyte count
of 5000/mm3 , and crystals that appear as
short, blunt rods, rhomboids, and cuboids
when viewed under polarized light.
The most likely diagnosis is: (check one)
A. gonococcal arthritis
B. tuberculous arthritis
C. rheumatoid arthritis
D. pseudogout
E. gout

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C. A benzodiazepine. Psychomotor
agitation is experienced by most patients
during alcohol withdrawal.
Benzodiazepines are clearly the drug class
of choice. Providing medication on an asneeded basis rather than on a fixed
schedule is generally preferred.
Antipsychotics and butyrophenones
(including haloperidol) lower the seizure
threshold and should not be used. For
short-term management of status
epilepticus, anticonvulsants may be used in
conjunction with benzodiazepines. The
vast majority of seizures from withdrawal
are self-limited and do not require
anticonvulsant treatment. Clonidine and
other 2-agonists do reduce minor
symptoms of withdrawal, but have not
been shown to prevent seizures. The
effectiveness of baclofen in acute alcohol
withdrawal is unknown.
D. pseudogout. Microscopic examination
of synovial fluid in a patient suffering an
acute attack of pseudogout shows large
numbers of polymorphonuclear
leukocytes. Calcium pyrophosphate
dihydrate crystals are frequently found
extracellularly and in polymorphonuclear
leukocytes. When viewed with polarized
light, the crystals appear as short, blunt
rods, rhomboids, and cuboids. The
diagnosis is made by finding typical
crystals under compensated polarized light
and is supported by radiographic evidence
of chondrocalcinosis.

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A 66-year-old male with type 2 diabetes


mellitus is seen for a follow-up visit and
has a hemoglobin A1c of 6.7%. He is
currently taking metformin (Glucophage),
1000 mg twice daily. He has no history of
coronary artery disease or heart failure.
Which one of the following would be most
appropriate? (check one)

A. Continuing his current regimen.


According to the American Diabetes
Association, the goal for patients with type
2 diabetes mellitus is to achieve a
hemoglobin A1c of <7.0% (SOR C). This
patient has achieved this goal, and there is
no indication for changes in his
management.

A. Continuing his current regimen


B. Increasing the metformin dosage
C. Adding a sulfonylurea
D. Adding a thiazolidinedione
E. Adding daily long-acting insulin
Which one of the following would most
likely be found in a patient with giardiasis?
(check one)
A. Fecal leukocytosis
B. Mucus in the stool
C. Eosinophilia
D. Hematochezia
E. Foul-smelling flatus

A 12-year-old male is brought to your


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


erythema measuring approximately 3 cm in
diameter.

Porphyromonas, Prevotella,
Propionibacterium and
Peptostreptococcus.

Which one of the following is the most


likely infectious agent in this situation?
(check one)

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.

A. Candida albicans
B. Capnocytophaga canimorsus
C. Methicillin-resistant Staphylococcus
aureus (MRSA)
D. Pasteurella multocida
E. Streptococcus pneumoniae

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.

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

E. group A Streptococcus pyogenes. The


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

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

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A 35-year-old male consults you about


vague chest pain he developed while
sitting at his desk earlier in the day. The
pain is right-sided and was sharp for a
brief time when it began, but it rapidly
subsided. There was no hemoptysis and
the pain does not seem pleuritic. His
physical examination, EKG, and oxygen
saturation are unremarkable. A chest film
shows a 10% right pneumothorax.
Which one of the following should you do
next? (check one)
A. Admit the patient to the hospital for
observation
B. Admit the patient to the hospital for
chest tube placement
C. Obtain a repeat chest radiograph in
24-48 hours
D. Obtain an expiratory chest radiograph

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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.

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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

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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 casecontrol 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.

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A 46-year-old white female complains of


a 3-month history of hoarseness and
nocturnal wheezing. On further
questioning, she tells you that she has to
clear her throat repeatedly and feels like
she has something stuck in her throat.

B. gastroesophageal reflux disease. Acid


laryngitis is a group of respiratory
symptoms related to gastroesophageal
reflux disease. The symptoms of
hoarseness (especially in the morning), a
repeated need to clear the throat, and
nocturnal or early morning wheezing may
These symptoms are most likely related to: occur singly or in varying combinations,
(check one)
and are believed to be caused by gastric
contents irritating the larynx and
A. thyroid disease
hypopharynx. Thyroid disease, sinusitis,
B. gastroesophageal reflux disease
and tracheal stenosis can produce one or
C. sinusitis
more of the symptoms described, but not
D. tracheal stenosis
all of them.
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.
Which one of the following foods is most
likely to provoke an allergic response in
this patient? (check one)
A. Avocados
B. Walnuts
C. Shellfish
D. Strawberries
E. Wheat
Which cardiac arrhythmia has been
reported with high-dose methadone use?
(check one)

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.

D. Torsades de pointes. The cardiac


toxicity of methadone is primarily related
to QT prolongation and torsades de
pointes.

A. Atrial fibrillation
B. Paroxysmal supraventricular
tachycardia
C. Third degree heart block
D. Torsades de pointes
E. Multifocal atrial tachycardia

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A 17-year-old white female at 20 weeks


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

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D. Viral polymerase chain reaction (PCR)


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

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Outbreaks of dermatitis and folliculitis


associated with swimming pools and hot
tubs are often caused by which one of the
following? (check one)

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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
A 40-year-old female presents with a
complaint of fatigue. She says she is also
concerned because she has gained about
10 lb over the last several months.
Physical examination reveals no
enlargement or other abnormalities of the
thyroid gland. Laboratory testing reveals a
TSH level of 0.03 U/mL (N 0.4-4.0)
and a free T4 level of 1.0 g/dL (N 1.55.5).
Which one of the following is the most
likely cause of her problem? (check one)
A. Malnutrition
B. Graves' disease
C. Goiter
D. Hashimoto's thyroiditis
E. Pituitary failure

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E. Pituitary failure. This patient's


symptoms and laboratory findings suggest
a significant lack of TSH despite low
levels of circulating thyroid hormone. This
is diagnostic of secondary hypothyroidism.
Such findings should prompt a workup for
a pituitary or hypothalamic deficiency that
is causing a lack of TSH production.
Primary hypothyroidism, such as
Hashimoto's thyroiditis, would be
evidenced by an elevated TSH and low
(or normal) T4 . Graves' disease is a
cause of hyperthyroidism, which would be
expected to increase T4 levels, although
low TSH with a normal T4 level may be
present. Some nonthyroid conditions such
as malnutrition may suppress T4 . In such
cases the TSH would be elevated or
normal. This patient has gained weight,
which does not coincide with malnutrition.
The patient does not have the thyroid
gland enlargement seen with goiter.

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A 45-year-old male sees you for a routine


annual visit and is found to have atrial
fibrillation, with a ventricular rate of 70-75
beats/min. He is otherwise healthy, and a
laboratory workup and echocardiogram
are normal.
Which one of the following would be the
most appropriate management? (check
one)
A. Aspirin, 325 mg daily
B. Warfarin (Coumadin), with a target
INR of 2.0-3.0
C. Clopidogrel (Plavix), 75 mg daily
D. Amiodarone (Cordarone), 200 mg
daily
E. Observation only

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A. Aspirin, 325 mg daily. Atrial fibrillation


is the most common arrhythmia, and its
prevalence increases with age. The major
risk with atrial fibrillation is stroke, and a
patient's risk can be determined by the
CHADS 2 score. CHADS stands for
Congestive heart failure, Hypertension,
Age >75, Diabetes mellitus, and previous
Stroke or transient ischemic attack. Each
of these is worth 1 point except for stroke,
which is worth 2 points. A patient with 4
or more points is at high risk, and 2-3
points indicates moderate risk. Having 1
point indicates low risk, and this patient
has 0 points.
Low-risk patients should be treated with
aspirin, 81-325 mg daily (SOR B).
Moderate-or high-risk patients should be
treated with warfarin. Amiodarone is used
for rate control, and clopidogrel is used
for vascular events not related to atrial
fibrillation.

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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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A. Constipation. Constipation is one


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

In this situation, it should be kept in mind


that which one of the following adverse
effects of opioids does NOT diminish over
time? (check one)
A. Constipation
B. Nausea
C. Mental status changes
D. Pruritus
E. Sedation
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

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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.

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A 28-year-old female consults you


because of fatigue, arthralgias that are
worse in the morning, and painful, swollen
finger joints. She is a high-school teacher.
Her erythrocyte sedimentation rate is 60
mm/hr and a test for rheumatoid factor is
strongly positive.
The best choice for initial therapy would
be: (check one)
A. prednisone
B. aspirin
C. naproxen (Naprosyn)
D. rituximab (Rituxan)
E. methotrexate (Rheumatrex)
Which one of the following treatments is
most appropriate for a patient with
uncomplicated acute bronchitis? (check
one)
A. Amoxicillin
B. Amoxicillin/clavulanate (Augmentin)
C. Azithromycin (Zithromax)
D. Doxycycline
E. Supportive care only

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E. methotrexate (Rheumatrex). Aspirin


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

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A 60-year-old male presents with


profound weakness after 3 days of
watery, frequent diarrhea. He has had no
fever, bloody stool, or vomiting. His
appetite has been poor. He has a history
of hypertension treated with
chlorthalidone, 25 mg daily, and potassium
chloride, 20 mEq twice daily. Laboratory
testing reveals a serum creatinine level of
2.0 mg/dL (N 0.6-1.5), a potassium level
of 6.5 mmol/L (N 3.4-4.8), and a BUN of
50 mg/dL (N 8-25). Baseline values were
normal.

A. Regular insulin plus dextrose


intravenously. Insulin and glucose
intravenously will provide the fastest and
most consistent early lowering of serum
potassium (SOR C). Calcium is important
for arrhythmia prevention, but does not
lower the potassium level. Sodium
polystyrene sulfonate given orally or
rectally will only lower potassium in a
delayed fashion.

Which one of the following is most likely


to lower the serum potassium within 1
hour? (check one)
A. Regular insulin plus dextrose
intravenously
B. Calcium chloride, 10% solution
intravenously
C. Sodium polystyrene sulfonate
(Kalexate) orally
D. Sodium polystyrene sulfonate rectally

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A 40-year-old male with HIV infection


presents to the emergency department
with a 5-day history of progressive cough
and dyspnea on exertion. A chest
radiograph shows bilateral diffuse
interstitial infiltrates. Arterial blood gas
levels show an increased alveolar-arterial
gradient and a pO2 of 60 mm Hg. His
CBC is normal but his CD4 count is
150/mm3 .
In addition to
trimethoprim/sulfamethoxazole (Bactrim,
Septra), which one of the following
medications should be prescribed? (check
one)

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E. Corticosteroids.
Trimethoprim/sulfamethoxazole is the
treatment of choice for acute
Pneumocystis pneumonia. Adjunctive
corticosteroids should also be started in
any patient whose initial pO2 on room air
is <70 mm Hg. Three prospective trials
have shown that there is a decrease in
mortality and frequency of respiratory
failure when corticosteroids are used in
addition to antibiotics. All of the other
medications listed are effective therapy for
Pneumocystis pneumonia, but they do not
need to be given with
trimethoprim/sulfamethoxazole.

A. Pentamidine (Pentam)
B. Dapsone
C. Atovaquone (Mepron)
D. Clindamycin (Cleocin) and primaquine
E. Corticosteroids

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You have been asked to see a 75-yearold female who has just had hip surgery to
correct a fractured femoral neck. She has
a 2-year history of diabetes mellitus
treated with pioglitazone (Actos), 30 mg
daily, and metformin (Glucophage), 1000
mg twice daily. She is now fully alert and
has been able to eat her evening meal. A
physical examination is normal except for
her being mildly overweight and having a
bandage on her left hip. A CBC and
chemistry profile done earlier today were
normal except for a serum glucose level of
200 mg/dL. Her hemoglobin A1c at an
office visit 2 weeks ago was 6.8%.
Which one of the following would be the
best management of this patient's diabetes
at this time? (check one)
A. Stop her usual medications and begin a
sliding-scale insulin regimen
B. Stop the metformin only
C. Initiate an insulin drip to maintain
glucose levels of 80-120 mg/dL
D. Decrease the dosage of pioglitazone
E. Continue with her usual medication
regimen

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E. Continue with her usual medication


regimen. Current evidence indicates that
traditional sliding-scale insulin as the only
means of controlling glucose in
hospitalized patients is inadequate. For
patients in a surgical intensive-care unit,
using an insulin drip to maintain tight
glucose control decreases the risk of
sepsis but has no mortality benefit.
Metformin should be stopped if the serum
creatinine level is 1.5 mg/dL in men or
1.4 mg/dL in women, or if an imaging
procedure requiring contrast is needed. In
patients who have not had their
hemoglobin A 1c measured in the past 30
days, this could be done to provide a
better indication of glucose control. If
adequate control has been demonstrated
and no contraindications are noted, the
patient's usual medication regimen should
be continued (SOR B).

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A 28-year-old white male comes to your


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

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E. A thumb spica cast. Fracture of the


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

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You are caring for an 88-year-old female


nursing-home resident with multiple
comorbidities and advanced Alzheimer's
disease. The patient has never completed
advance directives and no longer has the
ability to make decisions. The family
inquires about hospice services for this
patient.
Which one of the following is true
regarding this patient and hospice? (check
one)
A. Nursing-home residents are not eligible
for hospice
B. The decision to enter hospice care is
reversible
C. End-stage Alzheimer's disease is not a
qualifying diagnosis for hospice
D. Failure to complete advance directives
by this patient prevents participation in
hospice
E. The patient must have a life expectancy
of less than 4 months to qualify for hospice
services

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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.

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A 28-year-old male presents with the


recent onset of intermittent urethral
discharge accompanied by dysuria. He is
heterosexual, has no prior history of a
sexually transmitted infection, and
acquired a new sexual partner a month
ago. He has no regional lymphadenopathy
or ulcers, and gentle milking of the urethra
produces no discharge. Evaluation of a
first-void urine specimen, however,
reveals 15 WBCs/hpf. You treat him with
oral azithromycin (Zithromax), 1 g in a
single dose, and ceftriaxone (Rocephin),
125 mg intramuscularly. Test results for
gonorrhea, Chlamydia, syphilis, HIV, and
hepatitis B are negative.

A. Metronidazole (Flagyl). According to


CDC guidelines, the initial workup for
urethritis in men includes gonorrhea and
Chlamydia testing of the penile discharge
or urine, urinalysis with microscopy if no
discharge is present, VDRL or RPR
testing for syphilis, and HIV and hepatitis
B testing. Empiric treatment for men with a
purulent urethral discharge or a positive
urine test (positive leukocyte esterase or
10 WBCs/hpf in the first-void urine
sediment) includes azithromycin, 1 g orally
as a single dose, OR doxycycline, 100 mg
orally twice a day for 7 days, PLUS
ceftriaxone, 125 mg intramuscularly, OR
cefixime, 400 mg orally as a single dose.

He returns 2 months later because his


urethral discharge has persisted. He
reports no relationships with a different
sexual partner, and is confident that his
current partner has only had sexual
contact with him. You repeat the previous
tests and again treat him with oral
azithromycin.

If the patient presents with the same


complaint within 3 months, and does not
have a new sexual partner, the tests
obtained at his first visit should be
repeated, and consideration should be
given to obtaining cultures for
Mycoplasma or Ureaplasma and
Trichomonas from the urethra or urine.
Treatment should include azithromycin,
500 mg orally once daily for 5 days, or
doxycycline, 100 mg orally twice daily for
7 days, plus metronidazole, 2 g orally as a
single dose.

According to CDC testing and treatment


guidelines, which one of the following
drugs should be added to his treatment
regimen? (check one)
A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
E. Cefixime (Suprax)

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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
The FDA has imposed a black box
warning on all thiazolidinediones, such as
pioglitazone (Actos). This warning
addresses a contraindication to the
prescription of these drugs in patients with:
(check one)

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B. all children with normal immune status.


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

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.

A. renal insufficiency
B. dementia
C. exposure to radiocontrast media
D. heart failure
E. respiratory failure

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


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

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B. amoxicillin for 10 days. The treatment


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

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A previously healthy gravida 1 para 1 who


is 3 weeks post partum complains of
bilateral nipple pain with breastfeeding.
When she first started breastfeeding she
had some soreness that went away after
repositioning with feeding. The current
pain began gradually 3 days ago. It has
been worsening, inhibiting feeding, and is
present between feedings. Examination of
the breast is notable for erythema and
cracking of the areola.

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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.

The most likely cause is: (check one)


A. engorgement
B. mastitis
C. improper latch-on
D. eczema flare
E. Candida infection
An 8-year-old male presents with cervical
lymphadenitis. He has a kitten at home
and you are concerned about cat-scratch
disease. Which one of the following
antibiotics is most appropriate for
treatment of Bartonella henselae infection?
(check one)
A. Azithromycin (Zithromax)
B. Ceftriaxone (Rocephin)
C. Amoxicillin/clavulanate (Augmentin)
D. Doxycycline
E. Clindamycin (Cleocin)
The parents of a young child 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)

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

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
(USPSTF) is that children over the age of
6 months receive oral fluoride
supplementation if the primary drinking
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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

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water source is deficient in fluoride. The


USPSTF cites "fair" evidence (B
recommendation) that such
supplementation reduces the incidence of
dental caries and concludes 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 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

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supplementation.
An enlarged tongue is associated with
which one of the following? (check one)
A. Pellagra
B. Amyloidosis
C. Pernicious anemia
D. Xerostomia
E. Syphilis

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B. Amyloidosis. An enlarged tongue


(macroglossia) may be part of a syndrome
found in developmental conditions such as
Down syndrome, or may be caused by a
tumor (hemangioma or lymphangioma),
metabolic diseases such as primary
amyloidosis, or endocrine disturbances
such as acromegaly or cretinism. A "bald"
tongue may be associated with
xerostomia, pernicious anemia, iron
deficiency anemia, pellagra, or syphilis.

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A 3-year-old male is brought to your


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

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B. Reassure the parents that this is a


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

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A 36-year-old male complains of clear


rhinorrhea, nasal congestion, and watery,
itchy eyes for several months. Tests in the
past have suggested that he has an allergy
to dust mites.
Which one of the following is most likely
to provide the most relief from his
symptoms? (check one)
A. Oral antihistamines
B. An oral leukotriene-receptor antagonist
C. Intranasal antihistamines
D. Intranasal corticosteroids
E. Furnace filters and mite-proof bedding
covers
A 57-year-old female is noted to have a
serum calcium level of 11.1 mg/dL (N
8.9-10.5) on a chemistry profile obtained
at the time of a routine annual visit. The
remainder of the chemistry profile is
unremarkable, including normal BUN and
creatinine levels. She is otherwise healthy,
and is on no medications. On follow-up
testing her calcium level is unchanged, a
vitamin D level is normal, and her
parathyroid hormone level is elevated.
Which one of the following is the most
likely cause of her hypercalcemia? (check
one)

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D. Intranasal corticosteroids. This patient


has classic symptoms of allergic rhinitis.
Intranasal corticosteroids are considered
the mainstay of treatment for mild to
moderate cases. In multiple studies,
intranasal corticosteroid sprays have
proven to be more efficacious than the
other options listed, even for ocular
symptoms. Air filtration systems and
bedding covers have not been shown to
reduce symptoms.

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.

A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Cancer metastatic to bone
E. Humoral hypercalcemia of malignancy

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

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E. Perform no further evaluation of the


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

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A 23-month-old child is brought to your


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

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E. Supportive care only. This child has


typical findings of bronchiolitis. The initial
infection usually occurs by the age of 2
years. It is caused by respiratory syncytial
virus (RSV). Bronchodilator treatment
may be tried once and discontinued if
there is no improvement. Treatment
usually consists of supportive care only,
including oxygen and intravenous fluids if
indicated (SOR B). Corticosteroids,
antibiotics, and decongestants are of no
benefit. RSV infection may recur, since an
infection does not provide immunity. Up to
10% of infected children will have
wheezing past age 5, and bronchiolitis may
predispose them to asthma.
D. Current pelvic inflammatory disease.
Contraindications to insertion of the
levonorgestrel intrauterine system (LNGIUS) include uterine anomalies,
postpartum endometritis, untreated
cervicitis, and current pelvic inflammatory
disease. Nulliparity may increase
discomfort during insertion but is not a
contraindication. Levonorgestrel is a
synthetic progestin and is not associated
with an increased risk of deep vein
thrombosis. It also is not associated with
any adverse effect on quantity or quality of
milk in breastfeeding women, and has no
adverse effects on the infant. The LNGIUS is not contraindicated in patients with
endometriosis, and there is some evidence
that it may improve symptom scores in
these women.

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The best management of localized, welldifferentiated prostate cancer in men older


than 65 is: (check one)
A. radiation implants
B. external beam radiation therapy
C. watchful waiting
D. primary androgen deprivation therapy
E. robot-assisted prostatectomy
A 67-year-old Hispanic male comes to
your office with severe periumbilical
abdominal pain, vomiting, and diarrhea,
which began suddenly several hours ago.
His temperature is 37.0C (98.6F),
blood pressure 110/76 mm Hg, and
respirations 28/min. His abdomen is
slightly distended, soft, and diffusely
tender; bowel sounds are normal. Other
findings include clear lungs, a rapid and
irregularly irregular heartbeat, and a pale
left forearm and hand with no palpable left
brachial pulse. Right arm and lower
extremity pulses are normal. Testing
reveals the presence of blood in both his
stool and his urine. His hemoglobin level is
16.4 g/dL (N 13.0-18.0) and his WBC
count is 25,300/mm3 (N 4300-10,800).
The diagnostic imaging procedure most
likely to produce a specific diagnosis of
the abdominal pain is: (check one)
A. intravenous pyelography (IVP)
B. sonography of the abdominal aorta
C. a barium enema
D. celiac and mesenteric arteriography
E. contrast venography

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C. watchful waiting. For men older than


65 years of age with small-volume, lowgrade disease and a 10- to 15-year 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).
D. celiac and mesenteric arteriography.
The sudden onset of severe abdominal
pain, vomiting, and diarrhea in a patient
with a cardiac source of emboli and
evidence of a separate embolic event
makes superior mesenteric artery
embolization likely. In this case, evidence
of a brachial artery embolus and a cardiac
rhythm indicating atrial fibrillation suggest
the diagnosis. Some patients may have a
surprisingly normal abdominal examination
in spite of severe pain. Microscopic
hematuria and blood in the stool may both
occur with embolization, and severe
leukocytosis is present in more than twothirds of patients with this problem.
Diagnostic confirmation by angiography is
recommended. Immediate embolectomy
with removal of the propagated clot can
then be accomplished and a decision
made regarding whether or not the
intestine should be resected. A second
procedure may be scheduled to reevaluate
intestinal viability.

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Which one of the following platelet counts


is the threshold for prophylactic platelet
transfusion in most patients? (check one)
A. 10,000/L
B. 25,000/L
C. 40,000/L
D. 50,000/L
E. 100,000/L
Which one of the following medications
has the best evidence for preventing hip
fracture? (check one)
A. Ibandronate (Boniva)
B. Raloxifene (Evista)
C. Denosumab (Prolia)
D. Etidronate (Didronel)
E. Alendronate (Fosamax)
The sensitivity of a test is defined as:
(check one)
A. the probability of disease before a test
is performed
B. the probability of disease after a test is
performed
C. the percentage of patients with a
positive test result who are confirmed to
have the disease
D. the percentage of patients with the
disease who have a positive test result
E. the percentage of patients without the
disease who have a negative test result

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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.
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.
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.

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A 28-year-old female sees you with a


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

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B. Metformin (Glucophage). First-line


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

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5/17/2014

The FDA issued a boxed warning


describing an increased risk of
tendinopathy and tendon rupture
associated with the use of which class of
antibiotics? (check one)
A. Macrolides
B. Aminoglycosides
C. Fluoroquinolones
D. Tetracyclines
E. Polypeptides
============================
===========================
Random Board Review Questions 18
============================
===========================
When added to compression therapy,
which one of the following has been
shown to be an effective adjunctive
treatment for venous ulcers? (check one)

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C. Fluoroquinolones. Fluoroquinolones
are associated with an increased risk of
tendinopathy and tendon rupture. About
1/6000 prescriptions will cause an Achilles
tendon rupture. The risk is higher in those
also taking corticosteroids or over the age
of 60.

D. Pentoxifylline (Trental). Pentoxifylline is


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

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

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5/17/2014

A 75-year-old white male suffers an


anteroseptal myocardial infarction. Four
hours after admission to the hospital his
blood pressure is 65/40 mm Hg. A SwanGanz catheter is inserted into the
pulmonary artery, and the pulmonary
capillary wedge pressure is found to be 8
mm Hg.

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C. infusion of normal saline. A pulmonary


capillary wedge pressure of 8 mm Hg
suggests hypovolemia. Normal saline
should be given because 5% dextrose is
not a reliable volume expander.

The best therapy in this instance is: (check


one)
A. infusion of dopamine
B. infusion of 5% dextrose
C. infusion of normal saline
D. digoxin
E. furosemide (Lasix)
A 72-year-old male with COPD presents
to the emergency department with an
acute exacerbation marked by increased
sputum production and shortness of
breath. His oxygen saturation is 88% on
room air and he has diffuse inspiratory and
expiratory wheezes bilaterally.
In addition to oxygen and bronchodilators,
which one of the following is most
appropriate for this patient? (check one)

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.

A. No additional treatments
B. Systemic corticosteroids only
C. Inhaled corticosteroids only
D. Systemic corticosteroids and antibiotics
E. Inhaled corticosteroids and antibiotics

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5/17/2014

A 42-year-old female with a history of


alcoholism and binge drinking presents
with a 3-hour history of severe epigastric
pain associated with nausea and vomiting.
Her pain radiates to her back and into her
lower abdomen. The patient appears to be
in moderate distress due to pain. She is
afebrile with a pulse rate of 110 beats/min
and a blood pressure of 98/66 mm Hg.
Her abdominal examination is remarkable
for epigastric tenderness, guarding, and
mild abdominal distention. Laboratory
evaluation reveals a serum lipase level of
562 U/L (N 22-51) and a serum amylase
level of 317 U/L (N 36-128).
You admit the patient to the hospital. Your
treatment plan includes volume repletion,
pain control, and close monitoring of her
hemodynamic status. After 48 hours of
treatment, she is hemodynamically stable.
Her serum lipase level is now 168 U/L.
She is awake and alert and in no distress,
but still requires parenteral pain
medication.

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D. Intravenous total parenteral nutrition.


Although intravenous dextrose in normal
saline can initially be used for aggressive
rehydration, it does not meet the nutritional
needs of patients with acute pancreatitis.
Total enteral nutrition is superior to total
parenteral nutrition in stable patients with
acute pancreatitis, in both mild and severe
cases (SOR A). When compared to total
parenteral nutrition in these patients,
enteral nutrition is associated with reduced
rates of mortality, multiple organ failure,
systemic infection, and operative
interventions (SOR A). Enteral nutrition
likely contributes to better outcomes by
inhibiting bacterial translocation from the
gut, thereby preventing the development of
infected necrosis. This patient is awake
and alert and presumably able to protect
her airway, so nasogastric tube feeding is
unnecessary to provide enteral nutrition.

Which one of the following is most


appropriate for meeting her fluid and
caloric needs at this time? (check one)
A. D5 normal saline intravenously at a
maintenance rate
B. Enteral feedings via nasogastric feeding
tube
C. A low-fat diet orally and oral fluids ad
libitum
D. Intravenous total parenteral nutrition

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5/17/2014

Which one of the following is effective for


single-dose prophylaxis against Lyme
disease after an Ixodes scapularis tick
bite? (check one)

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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
A 63-year-old white male sees you for an
initial visit and is accompanied by his
daughter, who is a patient of yours and
scheduled the visit. The father recently
relocated to be near the daughter after his
wife died. He has well-controlled type 2
diabetes mellitus, but is otherwise healthy.
Referring to the copy of the medical
records they brought with them, the
daughter notes that her father has received
influenza vaccine in 3 of the past 5 years,
but she can find no documentation that he
ever had "the pneumonia vaccine." She
asks if he should receive it at this visit.
You advise them that he should receive
pneumococcal vaccine: (check one)

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.

A. annually, along with influenza vaccine


B. now and a repeat dose every 5 years
C. every 5 years starting at age 65
D. now and a repeat dose once at age 68
E. only once, at age 65

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5/17/2014

A 50-year-old Hispanic male has a


solitary 5-mm pulmonary nodule on a
chest radiograph. His only medical
problem is severe osteoarthritis. He quit
smoking 10 years ago.
Which one of the following would be the
most appropriate follow-up for the
pulmonary nodule? (check one)
A. Positron emission tomography (PET)
B. Chest CT
C. A repeat chest radiograph in 6 weeks
D. A repeat chest radiograph in 6 months
E. Referral for a biopsy

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B. Chest CT. Solitary pulmonary nodules


are common radiologic findings, and the
differential diagnosis includes both benign
and malignant causes. The American
College of Chest Physicians guidelines for
evaluation of pulmonary nodules are based
on size and patient risk factors for cancer.
Lesions 8 mm in diameter with a
"ground-glass" appearance, an irregular
border, and a doubling time of 1 month to
1 year suggest malignancy, but smaller
lesions should also be evaluated,
especially in a patient with a history of
smoking.
CT is the imaging modality of choice to
reevaluate pulmonary nodules seen on a
radiograph (SOR C). PET is an
appropriate next step when the cancer
pretest probability and imaging results are
discordant (SOR C). Patients with notable
nodule growth during follow-up should
undergo a biopsy (SOR C).

Early palliative care in patients with a


terminal disease, including symptom
management, psychosocial support, and
assistance with decision making, has been
shown to: (check one)
A. shorten the time to death
B. increase aggressive end-of-life care
C. increase health care costs
D. decrease depressive symptoms
E. reduce the need for hospice

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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-oflife 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).
205/870

5/17/2014

Which one of the following community


health programs best fits the definition of
secondary prevention? (check one)
A. An antismoking education program at a
local middle school
B. Blood pressure screening at a local
church
C. A condom distribution program
D. Screening diabetic patients for
microalbuminuria

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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 postmyocardial infarction prophylaxis with blockers and aspirin).

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A 4-month-old white male in respiratory


distress is brought to the emergency
department. On examination, heart sounds
include a grade 4/6 pansystolic murmur,
best heard at the lower left sternal border.
He is acyanotic. A chest radiograph
shows an enlarged heart and increased
pulmonary vascular markings, and an
EKG shows combined ventricular
hypertrophy.

C. ventricular septal defect. Ventricular


septal defect causes overload of both
ventricles, since the blood is shunted left to
right. The murmur is harsh and
holosystolic, generally heard best at the
lower left sternal border. As the volume of
the shunting increases, cardiac
enlargement and increased pulmonary
vascular markings can be seen on a chest
radiograph.

Of the following, the most likely diagnosis


is: (check one)

Hypoplastic left heart syndrome would be


manifested by near-obliteration of the left
ventricle on the EKG and chest
radiograph, and the infant would be
cyanotic. Transposition of the great
vessels would cause AV conduction
defects and single-sided hypertrophy on
the EKG. The chest radiograph would
show a straight shoulder on the left heart
border where the aorta was directed to
the right. Tetralogy of Fallot causes
cyanosis and right ventricular enlargement.
The murmur of patent ductus arteriosus is
continuous, best heard below the left
clavicle. The EKG shows left atrial and
ventricular enlargement.

A. hypoplastic left heart syndrome (aortic


valve atresia)
B. transposition of the great vessels
C. ventricular septal defect
D. tetralogy of Fallot
E. patent ductus arteriosus

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

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E. Metabolic syndrome. Non-alcoholic


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

Which one of the following is the most


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

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5/17/2014

A 67-year-old female is admitted to the


hospital with severe community-acquired
pneumonia. Her urine should be tested for
which one of the following antigens?
(check one)
A. Chlamydia
B. Mycoplasma
C. Legionella
D. Haemophilus influenzae
E. Pseudomonas
A 22-year-old male presents to your
office with a 2-hour history of a painful
right scrotal mass. The physical
examination raises concerns that the
patient may have testicular torsion. The
imaging study of choice would be (check
one)
A. a plain film
B. color duplex Doppler ultrasonography
C. CT
D. MRI
E. a nuclear scan

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C. Legionella. In patients with severe


pneumonia, the urine should be tested for
antigens to Legionella and pneumococcus.
Two blood cultures should also be drawn,
but these are positive in only 10%-20% of
all patients with community-acquired
pneumonia.

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

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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.
A 22-year-old male has acute low back
pain without paresthesias or other
neurologic signs. There is no lower
extremity weakness.
Which treatment has been shown to be of
most benefit initially? (check one)
A. Complete bed rest for 2 weeks
B. Bed rest plus local injection of
corticosteroids
C. A low-back strengthening program
D. Resumption of physical activity as
tolerated

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D. Resumption of physical activity as


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

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A 68-year-old female is being monitored


in the hospital after elective surgery. On
her third postoperative day she suddenly
develops hypoxia, fever, tachycardia, and
hypotension. You institute high-rate
intravenous fluids and empiric antibiotics.
However, approximately 2 hours into this
therapy, her blood pressure remains at 80
mm Hg systolic with sluggish urine output.
Which one of the following hormones
should be assessed at this time? (check
one)
A. Aldosterone
B. Catecholamines
C. Cortisol
D. Renin
E. TSH

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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.

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In order to be eligible for Medicare


hospice benefits, a patient must be entitled
to Medicare Part A and: (check one)
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

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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-notresuscitate orders are not specifically
related to eligibility requirements for this
benefit.

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A 7-year-old female with a history of


asthma is brought to your office for a
routine follow-up visit. She has a history of
exercise-induced asthma, but also has had
exacerbations in the past that were
unrelated to exercise. In the past month,
she has premedicated herself with
albuterol (Proventil, Ventolin) with a
spacer before recess 5 days/week as
usual. She has also needed her albuterol to
treat symptoms (wheezing and/or
shortness of breath) once or twice per
week and had one exacerbation requiring
medical treatment in the past year. She has
had no nighttime symptoms. Albuterol as
needed is her only medication.
After reinforcing asthma education, which
one of the following would be most
appropriate? (check one)
A. Referral to an asthma specialist
B. Addition of a low-dose inhaled
corticosteroid
C. Addition of a long-acting -agonist
D. Elimination of premedication with
albuterol, restricting use to an as-needed
basis
E. No changes to her regimen
A young woman in labor at term develops
frank eclampsia. What is the best choice
of anticonvulsant to treat her condition?
(check one)
A. Phenytoin (Dilantin)
B. Diazepam (Valium)
C. Topiramate (Topamax)
D. Lamotrigine (Lamictal)
E. Magnesium sulfate

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E. No changes to her regimen. This


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

E. Magnesium sulfate. Intravenous


magnesium sulfate reduces the risk of
subsequent seizures in women with
eclampsia compared with placebo, and
with fewer adverse effects for the mother
and baby compared with phenytoin or
diazepam. The newer oral agents have no
role in this emergency.

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Which one of the following is associated


with a history of sexual abuse in females?
(check one)
A. Lifelong functional gastrointestinal
disorders
B. Lifelong headache disorders
C. Obesity
D. Recurrent syncope
Of the following, the greatest risk for
developing colon cancer is associated with
a personal history of: (check one)
A. tobacco use
B. ulcerative colitis
C. villous adenoma
D. familial adenomatous polyposis
E. colon cancer in a first degree relative

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A. Lifelong functional gastrointestinal


disorders. A comprehensive, systematic
literature review found an association of
sexual abuse with a lifelong history of
functional gastrointestinal disorders,
irrespective of the age of the victim at the
time of abuse. There was no statistically
significant association with obesity,
headache, or syncope.
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

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

A. The lidocaine patch (Lidoderm).


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

Which one of the following analgesic


medications would have the least potential
for adverse side effects? (check one)
A. The lidocaine patch (Lidoderm)
B. Hydrocodone/acetaminophen
C. Nortriptyline (Pamelor)
D. Duloxetine (Cymbalta)
E. Celecoxib (Celebrex)

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Which one of the following is


recommended for routine prenatal care?
(check one)
A. Hepatitis C antibody testing
B. Parvovirus antibody testing
C. Cystic fibrosis carrier testing
D. HIV screening
E. Examination of a vaginal smear for clue
cells
At the 18-month visit, which one of the
following is the most specific sign of
autism? (check one)
A. Delayed or odd use of language
B. Repetitive behaviors
C. Stereotypic movements
D. Delayed attainment of social skill
milestones
E. Self-injurious behaviors

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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.
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, new-onset 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.

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A 55-year-old male presents with a 2year history of persistent, worsening neck


stiffness. Over the past month, the stiffness
has been associated with left thumb
tingling.
After completing a thorough history and
physical examination, which one of the
following studies would be the most
appropriate next step in further evaluating
the patient's complaints? (check one)
A. Lateral neck radiography
B. A cervical spine series
C. Neck MRI
D. CT myelography
E. Diskography
You are initiating treatment for a patient
being admitted to the hospital with a new
diagnosis of pulmonary embolus. Low
molecular weight heparin and warfarin
(Coumadin) are started immediately.
When can the low molecular weight
heparin be stopped? (check one)
A. When the INR is 2.0
B. When the INR is 2.0 for 24 hours
C. After 4 days, if the INR is 2.0
D. After 4 days, if the INR has been 2.0
for 24 hours
E. After 5 days, if the INR has been 2.0
for 24 hours

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B. A cervical spine series. Based on the


American College of Radiology's
Appropriateness Criteria for chronic neck
pain, a complete cervical spine series that
includes five views is the correct study in a
patient of any age with chronic neck pain
and no history of trauma, malignancy, or
surgery. If the radiographs are normal and
the patient has neurologic signs or
symptoms, the next step would be MRI. If
MRI is contraindicated, CT myelography
should be offered (SOR B). A single
lateral radiograph is not sufficient.
Diskography is not recommended in
patients with chronic neck pain (SOR C).

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.

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A 70-year-old retired engineer who is an


avid runner asks you about his slow,
progressive decrease in exercise
performance. He says he realizes he is
getting older, but is in good health and is
curious as to why this is happening.
You tell him that there are multiple
physiologic changes associated with aging
that lower exercise performance, including
a decrease in: (check one)
A. cardiac output
B. systolic blood pressure
C. pulse pressure
D. residual lung volume
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
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

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A. cardiac output. Cardiovascular changes


associated with aging include decreased
cardiac output, maximum heart rate, and
stroke volume, as well as increased
systolic and diastolic blood pressure.
Respiratory changes include an increase in
residual lung volume and a decrease in
vital capacity. Other changes include
decreases in nerve conduction,
proprioception and balance, maximum O2
uptake, bone mass, muscle strength, and
flexibility. Most of these changes,
however, can be reduced in degree by a
regular aerobic and resistance training
program.
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.
Large, well-designed studies have found

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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.

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An 8-year-old male is brought to your


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

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D. Propranolol (Inderal). This patient most


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

A. Sumatriptan (Imitrex)
B. Ibuprofen
C. Carbamazepine (Tegretol)
D. Propranolol (Inderal)
E. Amitriptyline
A 12-year-old Hispanic female develops
fever, knee pain with swelling, diffuse
abdominal pain, and a palpable purpuric
rash. A CBC and platelet count are
normal.
Her long-term prognosis depends on the
severity of involvement of the: (check one)
A. gastrointestinal tract
B. heart
C. liver
D. kidneys
E. lungs

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


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

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According to the Beers criteria, a list of


drugs that should be avoided in geriatric
patients, which one of the following
NSAIDs should be avoided in older
patients due to its higher rate of adverse
central nervous system effects? (check
one)

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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.

A. Indomethacin
B. Ibuprofen
C. Diclofenac sodium
D. Etodolac
E. Celecoxib (Celebrex)
============================
===========================
Random Board Review Questions 21
============================
===========================
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)
A 7-year-old female is brought to your
clinic by her mother, who has concerns
about her behavior. For the last 2 months,
the patient has resisted going to school.
Each school morning she complains of not
feeling well and asks to stay home. When
forcibly taken to school she cries and begs
to go home. Once at home she is playful
and engages in normal activities. She also
resists attending her usual swimming
lessons in the evenings. She has frequent
nightmares in which one of her parents
dies.
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A. Exenatide (Byetta). Of the many


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

A. separation anxiety disorder. This


patient suffers from separation anxiety
disorder, which is unique to pediatric
patients and is characterized by excessive
anxiety regarding separation from the
home or from people the child is attached
to, such as family members or other
caregivers. The anxiety is beyond what is
developmentally appropriate for the child's
age. Patients may even suffer distress from
anticipation of the separation. Other
characteristics include persistent worry
about harm occurring to major attachment
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After a thorough history and physical


examination rule out an underlying medical
condition, you diagnose the patient with:
(check one)
A. separation anxiety disorder
B. generalized anxiety disorder
C. acute stress disorder
D. panic disorder with agoraphobia
E. social phobia

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figures, worry about an event that may


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

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In patients with pes anserine bursitis,


tenderness is most likely to be noted:
(check one)
A. over the medial epicondyle
B. over the lateral pelvic/hip region
C. over the medial proximal tibia
D. just posterior to the medial malleolus
E. just distal to the lateral malleolus

The results of a given study are reported


as achieving significance at a p-value of
<0.05 (the 5% level). True statements
about this finding include which one of the
following? (check one)
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%

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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 antiinflammatory agents, physical therapy, and
corticosteroid injection.
A. There is a 5% likelihood of the results
having occurred by chance alone. The pvalue 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 falsenegative rate, or 1 - specificity, and cannot
be calculated from the information given.

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A 23-year-old female comes to your


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

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D. A previous history of depression.


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

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A 40-year-old businessman has recently


been diagnosed with irritable bowel
syndrome after extensive testing by his
gastroenterologist. His predominant
symptoms are diarrhea and pain.
Which one of the following has been
shown to be helpful in controlled trials?
(check one)
A. Probiotics such as yogurt and
buttermilk
B. Insoluble fiber such as wheat bran,
corn bran, and defatted flaxseed
C. Soluble fiber such as psyllium
(ispaghula)
D. Turmeric
E. Peppermint oil
A 32-year-old white female presents with
a 6-week history of increasing headache,
which she now describes as severe. The
only abnormal finding on examination is a
BMI of 32.4 kg/m2 . A neurologic
examination is normal. CT of the head is
normal and a lumbar puncture is
remarkable only for increased
cerebrospinal fluid pressure. There is no
history of trauma or hypercoagulable
disorder.
Management should be directed toward
preventing which one of the following?
(check one)
A. Visual loss
B. Hearing loss
C. Vertigo
D. A cerebrovascular accident
E. Cerebral herniation

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E. Peppermint oil. Studies suggest that in


25% of patients, irritable bowel syndrome
may be caused or aggravated by one or
more dietary components. Restriction of
fermentable, poorly absorbed
carbohydrates is beneficial, including
fructan (found in wheat and onions),
sorbitol, and other such alcohols. Further
studies are needed, however. Despite its
popularity, fiber is marginally beneficial
and insoluble fiber may worsen symptoms
in patients with diarrhea. Probiotics in the
form of foods such as buttermilk and liveculture yogurt have thus far not been
established as useful. Daily use of
peppermint oil has been shown to relieve
symptoms.
A. Visual loss. Loss of vision is a
devastating neurologic deficit that occurs
with idiopathic intracranial hypertension
(pseudotumor cerebri, benign intracranial
hypertension), although it is uncommon.
Sixth cranial nerve palsies may also occur
as a false localizing sign. The typical
presentation is a young, obese woman
with a headache, palpable tinnitus, and
nausea and vomiting. CT is usually normal
or shows small ventricles. The lumbar
puncture shows elevated pressure with
normal fluid examination. CSF protein
levels may be low.
Hearing loss and vertigo are not
characteristic of this disorder. Long tract
signs and facial nerve palsies have been
attributed to idiopathic intracranial
hypertension; they are atypical and should
lead to consideration of other diagnoses.

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The U.S. Preventive Services Task Force


recommends which one of the following
regarding general screening for COPD?
(check one)
A. A routine chest radiograph for
screening patients over 50 with a history
of tobacco use
B. Spirometry for screening patients over
50 with a history of tobacco use
C. Arterial blood gas analysis for patients
over 60 with a history of tobacco use
D. Peak flow measurement for office
screening for COPD
E. No routine screening for COPD with
spirometry
A 27-year-old female presents with 2
weeks of generalized pruritus. She had
previously been in good health except for
a laparoscopic cholecystectomy 3 weeks
earlier. She has had intermittent right
upper quadrant abdominal pain since the
surgery, and has occasionally taken
acetaminophen with hydrocodone for pain
relief. Her examination is remarkable only
for questionable scleral icterus.
The most likely diagnosis is: (check one)

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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.

C. retained common duct stone.


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

A. hydrocodone allergy
B. liver toxicity from acetaminophen
C. retained common duct stone
D. acute hepatitis

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Regular breast self-examinations to screen


for breast cancer: (check one)
A. are performed by most American
women
B. reduce mortality due to breast cancer
C. reduce all-cause mortality in women
D. are recommended by the U.S.
Preventive Services Task Force
E. increase the number of breast biopsies
performed

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

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E. increase the number of breast biopsies


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

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In the elderly, the risk of heat waverelated death is highest in those who:
(check one)
A. have COPD
B. have diabetes and are insulin dependent
C. have a functioning fan, but not air
conditioning
D. are homebound

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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.

Which one of the following is a criterion


for gastric bypass surgery, according to
recommendations of the National Institutes
of Health? (check one)
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

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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 obesityrelated 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.

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A 66-year-old male has hypertension that


has become difficult to manage after
several years of good control on a stable
medical regimen. On evaluation, his BUN
level is 40 mg/dL (N 8-25) and his serum
creatinine level is 2.1 mg/dL (N 0.6-1.5).
Which one of the following tests would be
best to evaluate this patient for
renovascular hypertension? (check one)
A. Duplex Doppler ultrasonography
B. CT angiography
C. Aortography
D. Captopril (Capoten) renography

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A. Duplex Doppler ultrasonography.


Duplex Doppler ultrasonography is the
preferred initial test for renovascular
hypertension in patients with impaired
renal function. Tests involving intravenous
radiographic contrast material may cause
deterioration in renal function. Captopril
renography is not reliable in the setting of
poor renal function. Magnetic resonance
angiography also could be considered, but
the association between the use of
gadolinium contrast agents and
nephrogenic systemic fibrosis in patients
with renal dysfunction would be a
concern.

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5/17/2014

A 24-year-old primigravida has nausea


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

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E. Doxylamine (Unisom) and vitamin B6.


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

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A 45-year-old white male develops


disabling tremulousness, loss of voice, and
a marked sense of forceful and rapid
heartbeat whenever he must speak to a
large group.
Which one of the following drugs is likely
to be of most value in enabling him to give
presentations at sales and stockholders'
meetings? (check one)
A. Desipramine (Norpramin)
B. Propranolol (Inderal)
C. Alprazolam (Xanax)
D. Amantadine (Symmetrel)
E. Buspirone (BuSpar)

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B. Propranolol (Inderal). This patient has


a specific situational anxiety disorder or
social phobia called performance anxiety
or speech phobia, characterized by
marked and sometimes disabling
symptoms of catecholamine excess during
specific performance situations, such as
public speaking. Rates of speech phobia
may exceed 50% in the population, but it
is unclear whether such fear and
avoidance of public speaking warrants a
psychiatric diagnosis.
Specific phobias such as speech phobia
respond moderately well to -blockers
used prior to a performance. These drugs
block peripheral anxiety symptoms such
as tachycardia and tremulousness that can
escalate subjective anxiety and impair
performance. Drugs that are primarily
psychotropics or antiparkinsonian agents
are much less likely to be of value in this
specific anxiety disorder, and may cause
undesirable sedation and dry mouth.

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


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

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D. A serum creatine kinase level. The


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

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An 80-year-old female is being started on


warfarin (Coumadin) for atrial fibrillation.
According to the American College of
Chest Physicians guidelines, the initial dose
in this patient should NOT exceed: (check
one)

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B. 5 mg. The American College of Chest


Physicians recommends a starting warfarin
dosage of 5 mg/day in elderly patients,
or in patients who have conditions such as
heart failure, liver disease, or a history of
recent surgery. The INR should be used
to guide adjustments in the dosage.

A. 2.5 mg
B. 5 mg
C. 7.5 mg
D. 10 mg
E. 12.5 mg

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Over the past year, a 32-year-old white


female has experienced increasing hair
growth on her chin and chest, acne, and
irregular menstrual periods. She takes no
medications.
Which one of the following would be the
most appropriate course of action at this
point? (check one)
A. Empiric treatment with metformin
(Glucophage)
B. CT of the adrenal glands
C. Laboratory testing
D. Brain MRI
E. Pelvic ultrasonography

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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.

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You have diagnosed type 2 diabetes


mellitus in a 64-year-old male. He has no
known coronary heart disease. You
recommend lowering his LDL-cholesterol
to below a threshold of: (check one)
A. 190 mg/dL
B. 160 mg/dL
C. 130 mg/dL
D. 100 mg/dL
E. 70 mg/dL

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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.

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5/17/2014

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

C. Cilostazol (Pletal). The patient


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

Which one of the following would be most


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

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A mother calls for advice regarding her 2year-old son. She found an open container
of immediate-release diltiazem (Cardizem)
on the floor, with some spilled and
partially chewed tablets, and estimates that
her son opened the container about 90
minutes ago. He does not appear to be in
any distress.
Which one of the following would you
advise her to do? (check one)
A. Administer syrup of ipecac at home
and observe
B. Transport the child to the emergency
department for gastric lavage
C. Transport the child to the emergency
department for administration of activated
charcoal
D. Transport the child to the emergency
department for administration of activated
charcoal and a cathartic
E. Transport the child to the hospital for
admission to the pediatric intensive-care
unit for observation

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E. Transport the child to the hospital for


admission to the pediatric intensive-care
unit for observation. More than 9500
cases of calcium channel blocker
intoxication were reported to U.S. poison
control centers in 2005. Substantial
toxicity can occur with one or two tablets,
and all children suspected of ingesting a
calcium channel blocker should be
admitted to a pediatric intensive-care unit
for monitoring and management.
The use of gastric emptying, cathartics, or
adsorptive agents is unlikely to be helpful
and should be considered only in patients
presenting within 1 hour of ingestion, if
then. The American Academy of
Pediatrics has advised that syrup of ipecac
not be kept in the home because of
toxicity and dubious benefit.

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A 55-year-old white male comes to your


office with weakness and a headache. He
also describes an annoying pruritus that
occurs frequently after he takes a hot
shower. The physical examination is
remarkable for the presence of an
enlarged spleen. He has a hemoglobin
level of 21 g/dL (N 12-16) and a
hematocrit of 63% (N 36-48). To confirm
your clinical diagnosis, you obtain
additional studies.
Which one of the following would be most
consistent with the most likely diagnosis in
this patient? (check one)
A. A low serum erythropoietin level
B. A low platelet count
C. A low arterial oxygen concentration
D. An elevated carboxyhemoglobin level

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A. A low serum erythropoietin level. The


patient described in this case has
polycythemia vera. Pruritus after a hot
shower (aquagenic pruritus) and the
presence of splenomegaly helps to
clinically distinguish polycythemia vera
from other causes of erythrocytosis
(hematocrit >55%). Specific criteria for
the diagnosis of polycythemia vera include
an elevated red cell mass, a normal arterial
oxygen saturation (>92%), and the
presence of splenomegaly. In addition,
patients usually exhibit thrombocytosis
(platelet count >400,000/mm3 ),
leukocytosis (WBC>12,000/mm3 ), a low
serum erythropoietin level, and an elevated
leukocyte alkaline phosphatase score.
High carboxyhemoglobin levels are
associated with secondary polycythemia.

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A previously healthy 73-year-old male is


admitted to the intensive-care unit after an
emergency appendectomy. He does well
until the evening, when he suddenly
appears confused. His speech is rambling
and incoherent, and he is disoriented to
person, place, and time. His wife says he
was sleepy but otherwise acting normal 2
hours ago. On examination he has normal
vital signs and no fever. Other than the
cognitive changes and some mild periincisional tenderness the examination is
normal. Serum electrolytes, a CBC,
arterial blood gases, and a routine
chemistry panel are normal.
The most likely cause for his altered
sensorium is
(check one)
A. sepsis
B. acute psychosis
C. dementia with Lewy bodies
D. delirium
E. ischemic stroke

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D. delirium. The syndrome of delirium is


common in the postoperative setting. It is
characterized by disorganized thinking;
rambling, incoherent speech; and a
reduced ability to maintain and shift
attention. In addition, at least two of the
following are typically present: a reduced
level of consciousness with perceptual
disturbances or hallucinations; sleep
disturbances or changes in psychomotor
activity; disorientation to time, place, or
person; and memory impairment. This
syndrome typically begins abruptly and
may fluctuate hourly. There is usually a
specific etiologic factor identified, such as
surgery in this case.
A patient with normal vital signs, no fever,
and normal laboratory studies is unlikely to
be septic. Patients with psychosis typically
maintain orientation to person and place,
as well as attention. Dementia with Lewy
bodies has a more chronic onset, and the
absence of focal neurologic findings makes
stroke unlikely. Alcohol withdrawal is also
a consideration in the differential diagnosis.

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A 75-year-old male develops a mild


Clostridium difficile infection and is treated
with 10 days of metronidazole (Flagyl),
500 mg orally 3 times daily. The diarrhea
recurs 10 days after he completes the
course of treatment.
Which one of the following would be most
appropriate? (check one)
A. Repeat the course of metronidazole
B. Repeat the course of metronidazole
and add vancomycin
C. Administer vancomycin intravenously
D. Prescribe loperamide (Imodium), 4 mg
twice daily as needed
E. Prescribe a probiotic
Which one of the following, when
confirmed with a repeat test, meets the
diagnostic criteria for diabetes mellitus?
(check one)
A. A fasting blood glucose level of 120
mg/dL
B. A 2-hour value of 180 mg/dL on an
oral glucose tolerance test
C. A random glucose level of 180 mg/dL
in a patient with symptoms of diabetes
mellitus
D. A positive urine dipstick for glucose
E. A hemoglobin A1c of 7.0%

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A. Repeat the course of metronidazole.


Clostridium difficile infection is more
common with aging and can be treated
with either metronidazole or vancomycin
daily. For mild recurrent disease, repeating
the course of the original agent is
appropriate (SOR B). Multiple
recurrences or severe disease warrants the
use of both agents. The effectiveness of
probiotics such as Lactobacillus remains
uncertain. Intravenous vancomycin has not
been effective. Antiperistaltic drugs should
be avoided.

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.

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5/17/2014

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

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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.

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5/17/2014

In patients with chronic renal insufficiency


and hypertension, the target blood
pressure should be: (check one)
A. <110/70 mm Hg
B. <120/80 mm Hg
C. <130/80 mm Hg
D. <140/90 mm Hg

A 59-year-old male with known cirrhosis


is beginning to show some lower
abdominal distention. Ultrasonography
confirms your suspicion that he has
developed moderate ascites for the first
time.
Which one of the following is
recommended as the initial treatment of
choice for this condition? (check one)
A. Chlorthalidone
B. Spironolactone (Aldactone)
C. Furosemide (Lasix)
D. Ramipril (Altace)
E. Large-volume paracentesis

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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.
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.

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About a month after returning from the


Middle East, an American soldier
develops a papule on his forearm that
subsequently ulcerates to form a shallow
annular lesion with a raised margin. The
lesion shows no signs of healing 3 months
after it first appeared. He has no systemic
symptoms.

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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.

The most likely diagnosis is: (check one)


A. leishmaniasis
B. schistosomiasis
C. malaria
D. trypanosomiasis
E. syphilis
============================
===========================
Random Board Review Questions 24
============================
===========================
Which one of the following organisms is
NOT killed by alcohol-based hand
disinfectants? (check one)

E. Clostridium difficile. Sporulating


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

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

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A 53-year-old male presents with a 1-day


history of swelling in his upper arm, shown
in Figure 1.
The swelling appeared after a sudden
painful "pop" as he was lifting a heavy box.
A physical examination reveals a soft to
firm, nontender mass in the anterior aspect
of the arm, and weakness of forearm
supination. Shoulder radiographs are
normal.
Which one of the following is the most
likely diagnosis? (check one)
A. Acute anterior shoulder dislocation
B. Lateral epicondylitis
C. Biceps tendinitis
D. Biceps tendon rupture

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D. Biceps tendon rupture. Biceps tendon


rupture is one of the most common
musculotendinous ruptures. Patients
typically present with a visible lump in the
upper arm following an audible, painful
"pop." The injury typically results from
application of an eccentric load to a flexed
elbow. Risk factors for biceps tendon
rupture include age >40, deconditioning,
contralateral biceps tendon rupture, a
history of rotator cuff tear, rheumatoid
arthritis, and cigarette smoking. Weakness
in forearm supination and elbow flexion
may be present. The biceps squeeze test
and the hook test are both sensitive and
specific for diagnosing the condition.
Acute anterior shoulder dislocation is
typically very painful, with restricted
shoulder movements. Lateral epicondylitis
results in pain and tenderness over a
localized area of the proximal lateral
forearm. Biceps tendinitis results in a deep
throbbing pain over the anterior shoulder,
accompanied by bicipital groove
tenderness.

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One week after returning from a


Caribbean vacation, a 43-year-old female
presents to a walk-in clinic with a
complaint of redness and itching on the
sole of her foot, shown in Figure 2.
She recalls experiencing a stinging
sensation in the same area while she was
wading in the surf on the day before she
was to return home, but was unable to see
any sign of injury immediately following the
incident. Since her return the itching has
intensified and the red area has enlarged.
The most likely cause of this condition is a:
(check one)
A. filarial nematode
B. jellyfish
C. hookworm
D. roundworm
E. tapeworm

An 80-year-old white male is admitted to


the hospital with an acute myocardial
infarction. He is given an antiarrhythmic for
ventricular ectopic beats. During
monitoring in the coronary care unit, he
develops the rhythm shown on the EKG in
Figure 3.

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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 self-limited, 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.
...

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This rhythm is best described as: (check


one)
A. ventricular flutter
B. ventricular fibrillation
C. ventricular tachycardia
D. torsades de pointes

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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 antiarrhythmic 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.

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A 7-year-old male complains of left


shoulder pain after a bicycle accident. The
neurovascular evaluation is normal. A
radiograph is shown in Figure 4.

...

The best management for his condition is:


(check one)

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 figureof-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.

A. chest radiography and frequent vital


sign observation
B. internal fixation under general
anesthesia
C. Steinmann's pin fixation under local
anesthesia
D. sending the patient home in a sling and
swathe
E. a modified shoulder spica cast
A 68-year-old white female with a
several-year history of well-controlled
essential hypertension and a history of
acute myocardial infarction 2 years ago is
brought to the emergency department
complaining of sudden, painless, complete
loss of vision in her left eye that began 1
hour ago. Her vital signs are stable, and
her blood pressure is 148/90 mm Hg. Her
corrected visual acuity is: leftabsent,
with no light perception; right20/30.
The external eye examination is entirely
unremarkable. A retinal examination
reveals the findings shown in Figure 5.

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...

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The most likely diagnosis is: (check one)


A. acute narrow-angle glaucoma
B. optic neuritis
C. retinal hemorrhage
D. central retinal artery occlusion
E. central retinal vein occlusion

The pruritic lesions on the arm shown in


Figure 6 are typical of: (check one)
A. poison ivy dermatitis
B. brown recluse spider bites
C. bedbug bites
D. Hymenoptera stings
E. molluscum contagiosum

A 23-year-old female with a history of


systemic lupus erythematosus presents
with a 48-hour history of vague left
precordial pain. Serum markers for acute
cardiac injury are normal. An EKG
performed in the emergency department is
shown in Figure 7.

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D. 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.
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.
...

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Which one of the following would be best


at this point for determining the cause of
the patient's chest pain? (check one)
A. Cardiac angiography
B. Echocardiography
C. An erythrocyte sedimentation rate
D. A CBC
E. An antinuclear antibody titer

A 26-year-old male presents with hand


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

Which one of the following would be the


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

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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.
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.

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A 27-year-old female radiology technician


developed an area of redness over the left
interscapular region while visiting a friend
in Paris last week. The rash has
progressed to include the area shown in
Figure 10 and the patient says it itches.
She recalls feeling somewhat tired and
achy once she arrived in Paris but
attributed this to jet lag. She denies any
other systemic symptoms. Your
examination reveals no significant findings
except for the rash.

...

Of the following, which one is most


consistent with this patient's history and
examination? (check one)

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.

A. Guttate psoriasis
B. Tinea versicolor
C. Radiation dermatitis
D. Cutaneous T-cell lymphoma
E. Pityriasis rosea

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

A. Frozen shoulder. Frozen shoulder is an


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

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

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E. Ventricular tachycardia of torsades de


pointes. A well-known use of intravenous
magnesium is for correcting the uncommon
ventricular tachycardia of torsades de
pointes. Results of a meta-analysis suggest
that 1.2-10.0 g of intravenous magnesium
sulfate also is a safe and effective strategy
for the acute management of rapid atrial
fibrillation.

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Which one of the following is a physiologic


difference between males and females that
can affect the pharmacokinetics of
medications with a narrow therapeutic
index? (check one)
A. A consistently higher glomerular
filtration rate in women
B. The typically higher BMI in women
C. Smaller fat stores in women
D. Greater gastric acid secretion in
women
E. Slower gastrointestinal transit times in
women

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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.

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A 52-year-old female with a 60-packyear history of cigarette smoking and


known COPD presents with a 1-week
history of increasing purulent sputum
production and shortness of breath on
exertion. Which one of the following is
true regarding the management of this
problem? (check one)
A. Antibiotics should be prescribed
B. Intravenous corticosteroids are
superior to oral corticosteroids
C. Inhaled corticosteroids should be
started or the dosage increased
D. Levalbuterol (Xopenex) is superior to
albuterol
E. Acetylcysteine should be given if the
patient is hospitalized
During rounds, you notice a new rash on a
full-term 2-day-old white female. It
consists of 1-mm pustules surrounded by
a flat area of erythema, and is located on
the face, trunk, and upper arms. An
examination is otherwise normal, and she
does not appear ill.
Which one of the following is the most
likely diagnosis?
(check one)

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A. Antibiotics should be prescribed.


Antibiotic use in moderately or severely ill
patients with a COPD exacerbation
reduces the risk of treatment failure or
death, and may also help patients with
mild exacerbations. Brief courses of
systemic corticosteroids shorten hospital
stays and decrease treatment failures.
Studies have not shown a difference
between oral and intravenous
corticosteroids. Inhaled corticosteroids
are not helpful in the management of an
acute exacerbation. Levalbuterol and
albuterol have similar benefits and adverse
effects. Acetylcysteine, a mucolytic agent,
has not been shown to be helpful for
routine treatment of COPD exacerbations.
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.

A. Erythema toxicum neonatorum


B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. Staphylococcus aureus sepsis

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Which one of the following is true


concerning anterior cruciate ligament
(ACL) tears? (check one)
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
Which one of the following is
recommended to reduce the risk of
sudden infant death syndrome (SIDS)?
(check one)
A. The use of home cardiorespiratory
monitors
B. The use of soft bedding materials
C. Having the infant sleep in a prone
position
D. Having the infant sleep in a separate
bed
E. Maintaining a room temperature of
78F-80F when the infant is sleeping

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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.
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.

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A critically ill adult male is admitted to the


intensive-care unit because of sepsis. He
has no history of diabetes mellitus, but his
glucose level on admission is 215 mg/dL
and insulin therapy is ordered.
Which one of the following is the most
appropriate target glucose range for this
patient?
(check one)
A. 80-120 mg/dL
B. 100-140 mg/dL
C. 120-160 mg/dL
D. 140-180 mg/dL
E. 160-200 mg/dL

Which one of the following is the


recommended duration of dual antiplatelet
therapy after placement of a drug-eluting
coronary artery stent? (check one)
A. 1 week
B. 1 month
C. 2 months
D. 3 months
E. 1 year

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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.
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.

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A 21-year-old primigravida at 28 weeks


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

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E. ursodiol (Actigall). This patient's


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

A. triamcinolone (Kenalog) cream


B. cholestyramine (Questran)
C. diphenhydramine (Benadryl)
D. doxylamine succinate
E. ursodiol (Actigall)

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

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D. It reduces the risk of transmission to


others. Antibiotic treatment for pertussis is
effective for eradicating bacterial infection
but not for reducing the duration or
severity of the disease. The eradication of
infection is important for disease control
because it reduces infectivity. Antibiotic
treatment is thought to be most effective if
started early in the course of the illness,
characterized as the catarrhal phase. The
paroxysmal stage follows the catarrhal
phase. The CDC recommends macrolides
for primary treatment of pertussis. The
preferred antimicrobial regimen is
azithromycin for 3-5 days or
clarithromycin for 7 days. These regimens
are as effective as longer therapy with
erythromycin and have fewer side effects.
Children under 1 month of age should be
treated with azithromycin. There is an
association between erythromycin and
hypertrophic pyloric stenosis in young
infants. Trimethoprim/sulfamethoxazole
can be used in patients who are unable to
take macrolides or where macrolide
resistance may be an issue, but should not
be used in children under the age of 2
months. Fluoroquinolones have been
shown to reduce pertussis in vitro but have
not been shown to be
clinically effective (SOR A).

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A 16-year-old female cross-country


runner has pain around both ankles. On
examination, pain is elicited on foot
inversion and there is decreased motion of
the hind foot and peroneal tightness. A
rigid flat foot also is observed.
Which one of the following is the most
likely diagnosis?
(check one)
A. Non-ossification of the os trigonum
B. Sever's apophysitis
C. Plantar fasciitis
D. Navicular stress fracture
E. Tarsal coalition
Which one of the following is true
concerning breast cancer screening?
(check one)
A. It is useful for detecting premalignant
conditions
B. It can predict which of the discovered
cancers are indolent, with a low potential
for harm
C. The decrease in mortality from breast
cancer can be attributed almost entirely to
early detection
D. It has resulted in an increase in the
diagnosis of localized disease
E. It has resulted in a significant decrease
in the incidence of regional and metastatic
disease

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E. Tarsal coalition. Tarsal coalition is the


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

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You make a diagnosis of depression in a


26-year-old female. Her BMI is 32 kg/m
and she has been trying to lose weight.
Which one of the following
antidepressants would be LEAST likely to
cause her to gain weight? (check one)
A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)
Medicare pays for which one of the
following? (check one)
A. Routine dental care
B. Custodial nursing-home care
C. Hearing aids
D. Screening mammography

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C. Bupropion (Wellbutrin). Bupropion is


the antidepressant least likely to cause
weight gain, and may induce modest
weight loss. All of the other choices are
more likely to cause weight gain. Among
SSRIs, paroxetine is associated with the
most weight gain and fluoxetine with the
least. Mirtazapine has been associated
with more weight gain than the SSRIs.

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.

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5/17/2014

A 24-year-old female presents to your


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

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D. Viral infection. The conditions that


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

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A 70-year-old male complains of lowerextremity pain. Increased pain with which


one of the following would be most
consistent with lumbar spinal stenosis?
(check one)
A. Lumbar spine extension
B. Lumbar spine flexion
C. Internal hip rotation
D. Pressure against the lateral hip and
trochanter
E. Walking uphill

Which one of the following is true


concerning the use of short-acting inhaled
-agonists for asthma? (check one)
A. They should be given before any
inhaled corticosteroid to facilitate lung
delivery
B. They are ineffective in patients taking
-blockers
C. They are less effective than oral agonists
D. They are less effective than
anticholinergic bronchodilators when given
with inhaled corticosteroids
E. Their effects begin within 5 minutes and
last 4-6 hours

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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.
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.

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Which one of the following is true


regarding NSAIDs? (check one)
A. They are cardioprotective
B. They should be avoided in persons with
cirrhotic liver disease
C. They are not safe in pregnancy
D. They are not safe in lactating women

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.

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5/17/2014

A 5-year-old female is seen for a


kindergarten physical and is noted to be
below the 3rd percentile for height. A
review of her chart shows that her height
curve has progressively fallen further
below the 3rd percentile over the past
year. She was previously at the 50th
percentile for height. The physical
examination is otherwise normal, but your
workup shows that her bone age is
delayed.
Of the following conditions, which one is
the most likely cause of her short stature?
(check one)

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B. Growth hormone deficiency. This


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

A. Constitutional growth delay


B. Growth hormone deficiency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia
============================
===========================
Random Board Review Questions 27
============================
===========================
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

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D. video-electroencephalography (vEEG)
monitoring. Inpatient videoelectroencephalography (vEEG)
monitoring is the preferred test for the
diagnosis of psychogenic nonepileptic
seizures (PNES), and is considered the
gold standard (SOR B). Video-EEG
monitoring combines extended EEG
monitoring with time-locked video
acquisition that allows for analysis of
clinical and electrographic features during
a captured event. Many other types of
evidence have been used, including the
presence or absence of self-injury and
incontinence, the ability to induce seizures
by suggestion, psychologic tests, and
ambulatory EEG. While useful in some
cases, these alternatives have been found
to be insufficient for the diagnosis of
PNES.
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Elevated postictal prolactin levels (at least


two times the upper limit of normal) have
been used to differentiate generalized and
complex partial seizures from PNES, but
are not reliable (SOR B). While prolactin
levels are often elevated after an epileptic
seizure, they do not always rise, and the
timing of measurement is crucial, making
this a less sensitive test than was
previously believed. Other serum markers
have also been used to help distinguish
PNES from epileptic seizures, including
creatine phosphokinase, cortisol, WBC
counts, lactate dehydrogenase, pCO2 ,
and neuron-specific enolase. These also
are not reliable, as threshold levels for
abnormality, sensitivity, and specificity
have not been determined.
MRI is not reliable because abnormal
brain MRIs have been documented in as
many as one-third of patients with PNES.
In addition, patients with epileptic seizures
often have normal brain MRIs.
A 4-year-old white male is brought to
your office because he has had a lowgrade fever and decreased oral intake
over the past few days. On examination
you note shallow oral ulcerations confined
to the posterior pharynx. Which one of the
following is the most likely diagnosis?
(check one)
A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola infantum
E. Rubella

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A. Herpangina. Herpangina is a febrile


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

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5/17/2014

A 45-year-old female presents with a rash


on the central portion of her face. She
states that she has intermittent flushing and
intense erythema that feels as if her face is
stinging. She has noticed that her
symptoms can be worsened by sun
exposure, emotional stress, alcohol, or
eating spicy foods. She has been in good
health and has taken conjugated estrogens
(Premarin), 0.625 mg daily, since a
hysterectomy for benign reasons. A
general examination is normal except for
erythema of the cheeks and chin. No
pustules or comedone formation is noted
around her eyes, but telangiectasias are
present.
Which one of the following would be
appropriate in the management of this
problem?
(check one)
A. Increasing her estrogen dosage
B. Referral to a rheumatologist
C. Low-potency non-fluorinated topical
corticosteroids
D. Oral prednisone
E. Metronidazole gel (MetroGel)

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E. Metronidazole gel (MetroGel).


Rosacea is a relatively common condition
seen most often in women between the
ages of 30 and 60. Central facial erythema
and telangiectasias are prominent early
features that may progress to a chronic
infiltrate with papules and sometimes
sterile pustules. Facial edema also may
occur. Some patients develop rhinophyma
due to hypertrophy of the subcutaneous
glands of the nose. The usual presenting
symptoms are central facial erythema and
flushing that many patients find socially
embarrassing. Flushing can be triggered by
food, environmental, chemical, or
emotional triggers. Ocular problems occur
in half of patients with rosacea, often in the
form of an intermittent inflammatory
conjunctivitis with or without blepharitis.
Management includes avoidance of
precipitating factors and use of sunscreen.
Oral metronidazole, doxycycline, or
tetracycline also can be used, especially if
there are ocular symptoms. These are
often ineffective for the flushing, so lowdose clonidine or a nonselective -blocker
may be added.
Topical treatments such as metronidazole
and benzoyl peroxide may also be
effective, particularly for mild cases. Other
illnesses to consider include acne,
photodermatitis, systemic lupus
erythematosus, seborrheic dermatitis,
carcinoid syndrome, and mastocytosis.

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266/870

5/17/2014

Which one of the following confirmed


findings in a 3-year-old female is
diagnostic of sexual abuse? (check one)
A. Bacterial vaginosis
B. Genital herpes
C. Gonorrhea
D. Anogenital warts
E. Hepatitis

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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.

267/870

5/17/2014

A 63-year-old male with type 2 diabetes


mellitus is seen in the emergency
department for an acute, superficial,
previously untreated infected great toe.
Along with Staphylococcus aureus, which
one of the following is the most common
pathogen in this situation? (check one)

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B. Streptococcus. The most common


pathogens in previously untreated acute
superficial foot infections in diabetic
patients are aerobic gram-positive
Staphylococcus aureus and -hemolytic
streptococci (groups A, B, and others).
Previously treated and deep infections are
often polymicrobial.

A. Pseudomonas
B. Streptococcus
C. Clostridium
D. Escherichia coli
E. Adenovirus
An obese, hypertensive 53-year-old
physician suffers a cardiac arrest while
making rounds. He is resuscitated after 15
minutes of CPR, but remains comatose.
Which one of the following is associated
with the lowest likelihood of neurologic
recovery in this situation?
(check one)
A. Duration of CPR >10 minutes
B. No pupillary light reflex at 30 minutes
C. No corneal reflex at 2 hours
D. No motor response to pain at 6 hours
E. Myoclonic status epilepticus at 24
hours

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E. Myoclonic status epilepticus at 24


hours. It is difficult to establish a prognosis
in a comatose patient after a cardiac
arrest. The duration of CPR is not a
factor, and the absence of pupillary and
corneal reflexes, as well as motor
responses to pain, are not reliable
predictors before 72 hours. Myoclonic
status epilepticus at 24 hours suggests no
possibility of a recovery.

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5/17/2014

A 61-year-old female is found to have a


serum calcium level of 11.6 mg/dL (N
8.6-10.2) on routine laboratory screening.
To confirm the hypercalcemia you order
an ionized calcium level, which is 1.49
mmol/L (N 1.14-1.32). Additional testing
reveals an intact parathyroid hormone
level of 126 pg/mL (N 15-75) and a urine
calcium excretion of 386 mg/24 hr (N
100-300).
Which one of the following is the most
likely cause of the patient's
hypercalcemia? (check one)
A. Primary hyperparathyroidism
B. Malignancy
C. Familial hypocalciuric hypercalcemia
D. Hypoparathyroidism
E. Hyperthyroidism

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A. Primary hyperparathyroidism. Primary


hyperparathyroidism and malignancy
account for more than 90% of
hypercalcemia cases. These conditions
must be differentiated early to provide the
patient with optimal treatment and an
accurate prognosis. Humoral
hypercalcemia of malignancy implies a
very limited life expectancyoften only a
matter of weeks. On the other hand,
primary hyperparathyroidism has a
relatively benign course. Intact parathyroid
hormone (PTH) will be suppressed in
cases of malignancy-associated
hypercalcemia, except for extremely rare
cases of parathyroid carcinoma.
Thyrotoxicosis-induced bone resorption
elevates serum calcium, which also results
in suppression of PTH.
Patients with familial hypocalciuric
hypercalcemia (FHH) have moderate
hypercalcemia but relatively low urinary
calcium excretion. PTH levels can be
normal or only mildly elevated despite the
hypercalcemia. This mild elevation can
lead to an erroneous diagnosis of primary
hyperparathyroidism. The conditions can
be differentiated by a 24-hour urine
collection for calcium; calcium levels will
be high or normal in patients with
hyperparathyroidism and low in patients
with FHH.

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269/870

5/17/2014

A 40-year-old male who recently


immigrated from central Africa presents to
a public health clinic where you are
working. He was referred by a physician
in the local emergency department, who
made a diagnosis of type 2 diabetes
mellitus. The patient has no history of fever
or night sweats, weight loss, or cough. He
does have a history of receiving bacille
Calmette-Gurin (BCG) vaccine in the
past. Screening tests for HIV and hepatitis
performed in the emergency department
were negative.
Which one of the following is true
regarding screening for latent tuberculosis
infection by in vitro interferon-gamma
release assay (IGRA) compared to
screening by the traditional targeted
tuberculin skin test (TST) in this patient?
(check one)

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C. IGRA differentiates Mycobacterium


tuberculosis from nontuberculous
mycobacteria. In vitro interferon-gamma
release assays (IGRAs) are a new way of
screening for latent tuberculosis infection.
One of the advantages of IGRA is that it
targets antigens specific to Mycobacterium
tuberculosis. These proteins are absent
from the BCG vaccine strains and from
commonly encountered nontuberculous
mycobacteria. Unlike skin testing, the
results of IGRA are objective. It is
unnecessary for IGRA to be done in
tandem with skin testing, and it eliminates
the need for two-step testing in high-risk
patients. IGRAs are labor intensive,
however, and the blood sample must be
received by a qualified laboratory and
incubated with the test antigens within 816 hours of the time it was
drawn,depending upon the brand of
cuurently available IGRAs

A. Both tests require subjective


interpretation
B. BCG interferes with IGRA results
C. IGRA differentiates Mycobacterium
tuberculosis from nontuberculous
mycobacteria
D. IGRA results are valid if the sample is
analyzed within 24 hours
E. IGRA should be done in tandem with
TST

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An 11-year-old female has been


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

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E. Stress reduction and participation in


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

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5/17/2014

Amiodarone (Cordarone) is most useful


for which one of the following? (check
one)
A. Prophylactic perioperative use for
emergency surgery
B. Primary prevention of nonischemic
cardiomyopathy
C. Treatment of atrial flutter
D. Treatment of multi-focal premature
ventricular contractions following acute
myocardial infarction
E. Treatment of sustained ventricular
tachyarrhythmias in patients with poor
hemodynamic stability

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E. Treatment of sustained ventricular


tachyarrhythmias in patients with poor
hemodynamic stability. Amiodarone is one
of the most frequently prescribed
antiarrhythmic medications in the U.S. It is
useful in the acute management of
sustained ventricular tachyarrhythmias,
regardless of hemodynamic stability.
Amiodarone is appropriate first-line
treatment for atrial fibrillation only in
symptomatic patients with left ventricular
dysfunction and heart failure. It has a very
limited role in the treatment of atrial flutter.
The only role for prophylactic amiodarone
is in the perioperative period of cardiac
surgery. The use of prophylactic
antiarrhythmic agents in the face of
"warning dysrhythmias" or after
myocardial infarction is no longer
recommended. Prophylactic amiodarone
is not indicated for primary prevention in
patients with nonischemic
cardiomyopathy.

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============================
===========================
Random Board Review Questions 28
============================
===========================
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)

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B. Markedly decreased activity until the


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

A. Complete bed rest for 2 weeks


B. Markedly decreased activity until the
pain lessens, and follow-up in 1 week
C. Referral for vertebroplasty as soon as
possible
D. NSAIDs and referral for physical
therapy
On his first screening colonoscopy, a 67year-old male is found to have a 0.5-cm
adenomatous polyp with low-grade
dysplasia.
According to current guidelines, when
should this patient have his next
colonoscopy?
(check one)
A. 6 months
B. 1 year
C. 3 years
D. 5 years
E. Screening is no longer necessary

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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 510 years (SOR B).

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A 25-year-old female has been trying to


conceive for over 1 year without success.
Her menstrual periods occur
approximately six times per year.
Laboratory evaluation of her hormone
status has been negative, and her husband
has a normal semen analysis. Her only
other medical problem is hirsutism, which
has not responded to topical treatment.
Pelvic ultrasonography of her uterus and
ovaries is unremarkable.
Of the following, which one would be the
most appropriate treatment for her
infertility? (check one)
A. Metformin (Glucophage)
B. Danazol
C. Medroxyprogesterone (Provera)
D. Spironolactone (Aldactone)
When treating acute adult asthma in the
emergency department, using a metereddose inhaler (MDI) with a spacer has
been shown to result in which one of the
following, compared to use of a nebulizer?
(check one)
A. Higher hospitalization rates
B. Shorter stays in the emergency
department
C. Higher relapse rates
D. Less improvement in peak-flow rates
E. Increases in the total dose of albuterol

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A. Metformin (Glucophage). This patient


fits the criteria for polycystic ovary
syndrome (oligomenorrhea, acne,
hirsutism, hyperandrogenism, infertility).
Symptoms also include insulin resistance.
Evidence of polycystic ovaries is not
required for the diagnosis.
Metformin has the most evidence
supporting its use in this situation, and is
the only treatment listed that is likely to
decrease hirsutism and improve insulin
resistance and menstrual irregularities.
Metformin and clomiphene alone or in
combination are first-line agents for
ovulation induction. Clomiphene does not
improve hirsutism, however. Progesterone
is not indicated for any of this patient's
problems. Spironolactone will improve
hirsutism and menstrual irregularities, but is
not indicated for ovulation induction.
B. Shorter stays in the emergency
department. Compared to nebulizers,
MDIs with spacers have been shown to
lower pulse rates, provide greater
improvement in peak-flow rates, lead to
greater improvement in arterial blood
gases, and decrease required albuterol
doses. They have also been shown to
lower costs, shorten emergency
department stays, and significantly lower
relapse rates at 2 and 3 weeks compared
to nebulizers. There is no difference in
hospital admission rates.

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A 31-year-old female who is a successful


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

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E. Conversion aphonia. This patient has


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

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A 62-year-old diabetic with stage 2 renal


dysfunction is evaluated for knee pain that
has mildly interfered with his usual
activities over the past 3 months. On
examination he is mildly tender over the
medial joint line. A knee radiograph shows
moderate medial joint space narrowing.
In addition to low-impact exercise, which
one of the following would you
recommend initially?
(check one)

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E. Acetaminophen. Intra-articular
injections should not be considered firstline treatment for symptomatic
osteoarthritis of the knee. They are
recommended for short-term pain control,
with the evidence for hyaluronic acid being
somewhat weak. Renal dysfunction is a
contraindication to the use of NSAIDs.
Acetaminophen is the first-line treatment in
this case.

A. Intra-articular hyaluronic acid


B. Intra-articular corticosteroids
C. Celecoxib (Celebrex)
D. Naproxen
E. Acetaminophen
A 24-year-old female presents with pelvic
pain. She says that the pain is present on
most days, but is worse during her
menses. Ibuprofen has helped in the past
but is no longer effective. Her menses are
normal and she has only one sexual
partner. A physical examination is normal.
Which one of the following should be the
next step in the workup of this patient?
(check one)
A. Transvaginal ultrasonography
B. CT of the abdomen and pelvis
C. MRI of the pelvis
D. A CA-125 level
E. Colonoscopy

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A. Transvaginal ultrasonography. The


initial evaluation for chronic pelvic pain
should include a urinalysis and culture,
cervical swabs for gonorrhea and
Chlamydia, a CBC, an erythrocyte
sedimentation rate, a -hCG level, and
pelvic ultrasonography. CT and MRI are
not part of the recommended initial
diagnostic workup, but may be helpful in
further assessing any abnormalities found
on pelvic ultrasonography. Referral for
diagnostic laparoscopy is appropriate if
the initial workup does not reveal a source
of the pain, or if endometriosis or
adhesions are suspected. Colonoscopy
would be indicated if the history or
examination suggests a gastrointestinal
source for the pain after the initial
evaluation.

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


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

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A. Empiric antibiotic treatment for


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

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


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

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B. Flattening of the inspiratory portion of


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

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A 45-year-old female presents to your


office with a 1-month history of pain and
swelling posterior to the medial malleolus.
She does not recall any injury, but reports
that the pain is worse with weight bearing
and with inversion of the foot. Plantar
flexion against resistance elicits pain, and
the patient is unable to perform a singleleg heel raise.
Which one of the following is true
regarding this problem?
(check one)
A. The patient most likely has a medial
ankle sprain
B. NSAIDs will improve the long-term
outcome
C. Injecting a corticosteroid into the
tendon sheath of the involved tendon is
recommended
D. A lateral heel wedge should be
prescribed
E. Immobilization in a cast boot for 3
weeks is indicated

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E. Immobilization in a cast boot for 3


weeks is indicated. The diagnosis of
tendinopathy of the posterior tibial tendon
is important, in that the tendon's function is
to perform plantar flexion of the foot,
invert the foot, and stabilize the medial
longitudinal arch. An injury can, over time,
elongate the midfoot and hindfoot
ligaments, causing a painful flatfoot
deformity.
The patient usually recalls no trauma,
although the injury may occur from
twisting the foot by stepping in a hole. This
is most commonly seen in women over the
age of 40. Without proper treatment,
progressive degeneration of the tendon
can occur, ultimately leading to tendon
rupture.
Pain and swelling of the tendon is often
noted, and is misdiagnosed as a medial
ankle sprain. With the patient standing on
tiptoe, the heel should deviate in a varus
alignment, but this does not occur on the
involved side. A single-leg toe raise should
reproduce the pain, and if the process has
progressed, this maneuver indicates
progression of the problem.
While treatment with acetaminophen or
NSAIDs provides short-term pain relief,
neither affects long-term outcome.
Corticosteroid injection into the synovial
sheath of the posterior tibial tendon is
associated with a high rate of tendon
rupture and is not recommended. The best
initial treatment is immobilization in a cast
boot or short leg cast for 2-3 weeks.

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============================
===========================
Random Board Review Questions 29
============================
===========================
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)

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A. Bilateral renal artery stenosis. Classic


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

A. Bilateral renal artery stenosis


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

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A 58-year-old male presents with a


several-day history of shortness of breath
with exertion, along with pleuritic chest
pain. His symptoms started soon after he
returned from a vacation in South
America. He has a history of deep-vein
thrombosis (DVT) in his right leg after
surgery several years ago, and also has a
previous history of prostate cancer. You
suspect pulmonary embolism (PE.).
Which one of the following is true
regarding the evaluation of this patient?
(check one)
A. CT angiography would reliably either
confirm or rule out PE
B. Compression ultrasonography of the
lower extremities will reveal a DVT in the
majority of patients with PE
C. No further testing is needed if a
ventilation-perfusion lung scan shows a
low probability of PE
D. No further testing is needed if a Ddimer level is normal
E. An elevated D-dimer level would
confirm the diagnosis of PE
A 30-year-old white gravida 2 para 1
who has had no prenatal care presents for
urgent care at 33 weeks gestation. Her
symptoms include vaginal bleeding, uterine
tenderness, uterine pain between
contractions, and fetal distress. Her first
pregnancy was uncomplicated, with a
vaginal delivery at term.
Which one of the following is the most
likely diagnosis? (check one)
A. Uterine rupture
B. Vasa previa
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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 ventilationperfusion 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.

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
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C. Placenta previa
D. Placental abruption
E. Cervical cancer

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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.

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A 43-year-old female complains of a


several-month history of unpleasant
sensations in her legs and an urge to move
her legs. These symptoms only occur at
night and improve when she gets up and
stretches. The sensations often awaken
her, and she feels very tired. She has no
other medical problems and takes no
medication. Laboratory tests reveal a
serum calcium level of 8.9 mg/dL (N 8.510.5), a serum potassium level of 4.1
mmol/L (N 3.5-5.0), a serum ferritin level
of 15 ng/mL (N 10-200), and a serum
magnesium level of 1.5 mEq/L (N 1.42.0).
Which one of the following may improve
her symptoms? (check one)

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A. Iron supplementation. This patient has


restless legs syndrome, which includes
unpleasant sensations in the legs and can
cause sleep disturbances. The symptoms
are relieved by movement.
Recommendations for treatment include
lower-body resistance training and
avoiding or changing medications that may
exacerbate symptoms (e.g., antihistamines,
caffeine, SSRIs, tricyclic antidepressants,
etc.). It is also recommended that patients
with a serum ferritin level below 50 ng/mL
take an iron supplement (SOR C).
Magnesium supplementation does not
improve restless legs syndrome.
Ropinirole may be used if
nonpharmacologic therapies are
ineffective.

A. Iron supplementation
B. Magnesium supplementation
C. Antihistamines
D. Stopping calcium supplementation
E. Amitriptyline

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A 56-year-old female with well-controlled


diabetes mellitus and hypertension
presents with an 18-hour history of
progressive left lower quadrant abdominal
pain, low-grade fever, and nausea. She
has not been able to tolerate oral intake
over the last 6 hours. An abdominal
examination reveals significant tenderness
in the left lower quadrant with slight
guarding but no rebound tenderness.
Bowel sounds are hypoactive. Rectal and
pelvic examinations are unremarkable.
Which one of the following is
recommended as the initial diagnostic
procedure in this situation? (check one)
A. CT of the abdomen and pelvis
B. Abdominal and pelvic ultrasonography
C. A barium enema
D. Colonoscopy
E. Laparoscopy

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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.

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Which one of the following is true


concerning Norwalk virus? (check one)
A. Outbreaks occur mostly in settings with
large numbers of children, such as schools
and day-care centers
B. Viral shedding continues long after the
acute illness
C. The virus does not survive long on
most environmental surfaces
D. An episode of Norwalk gastroenteritis
leads to long-lasting immunity
E. It is a less common cause of diarrhea in
adults than Shigella

Patient-centered medical home is a term


used to describe which one of the
following developments in medical care?
(check one)
A. A federally imposed restriction on
family medicine's role in providing care
B. A physician-led team of care providers
taking responsibility for the quality and
safety of an individual's health
C. A "practice without walls" that provides
primary care services in the homes of
patients
D. A small group of patients paying an
annual fee to have a physician be available
to them at all times
E. Improving the dignity of care for
nursing-home residents

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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.
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 thirdparty payers, including Medicare.

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Which one of the following Mantoux


tuberculin skin test results should be read
as NEGATIVE for latent tuberculosis
infection? (check one)
A. 7 mm induration on an individual having
recent household contact with a
tuberculosis patient
B. 8 mm induration on an HIV-positive
individual who has no documented
previous test result
C. 10 mm induration on a nursing-home
resident
D. 12 mm induration on a homeless
individual
E. 9 mm induration on a hospital-based
nurse who had a test with 2 mm induration
1 year ago

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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 HIVpositive 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.

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The Health Insurance Portability and


Accountability Act (HIPAA) (check one)
A. sets a federal minimum on the
protection of privacy
B. requires that privacy notices be
acknowledged and signed at each office
visit
C. allows the patient to inspect and obtain
a copy of his/her record without exception
D. requires privacy notices prior to giving
emergency care

Estimating the 10-year risk of developing


coronary heart disease with the
Framingham Heart Study Score Sheet
would be most reliable when applied to
which one of the following individuals?
(check one)
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 54-year-old female
with angina
E. A 78-year-old male with a history of
hypertension

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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.
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.

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============================
===========================
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

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C. Finding the underlying pathology


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

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An 82-year-old male nursing-home


resident is sent to the emergency
department with lower abdominal pain and
bloody diarrhea. He has a history of multiinfarct dementia, hypertension, and
hyperlipidemia. On examination he is
afebrile, and a nasogastric aspirate is
negative for evidence of bleeding.

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B. Ischemic colitis. This patient most likely


has ischemic colitis, given the abdominal
pain, bloody diarrhea, and cardiovascular
risks. Peptic ulcer disease is unlikely
because the nasogastric aspirate was
negative. Diverticular bleeding and
angiodysplasia are painless. Infectious
colitis is associated with fever.

Which one of the following is the most


likely cause of this patient's bleeding?
(check one)
A. Peptic ulcer disease
B. Ischemic colitis
C. Diverticular bleeding
D. Angiodysplasia
E. Infectious colitis

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A 62-year-old female undergoes elective


surgery and is discharged on
postoperative day 3. A week later she is
hospitalized again with pneumonia. A
CBC shows that her platelet count has
dropped to 150,000/mm3 (N 150,000300,000) from 350,000 /mm3 a week
ago. She received prophylactic heparin
postoperatively during her first
hospitalization.
The patient is started on intravenous
antibiotics for the pneumonia and
subcutaneous heparin for deep-vein
thrombosis prophylaxis. On hospital day
2, she has an acute onset of severe
dyspnea and hypoxia; CT of the chest
reveals bilateral pulmonary emboli. Her
platelet count is now 80,000/mm3 .
Which one of the following would be most
appropriate at this point? (check one)
A. Continue subcutaneous heparin
B. Discontinue subcutaneous heparin and
start a continuous intravenous heparin drip
C. Discontinue heparin and give a platelet
transfusion
D. Discontinue heparin and start a nonheparin anticoagulant such as argatroban
or desirudin (Iprivask)
E. Discontinue unfractionated heparin and
start a low molecular weight heparin such
as enoxaparin (Lovenox)

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D. Discontinue heparin and start a nonheparin anticoagulant such as argatroban


or desirudin (Iprivask). This patient needs
prompt evaluation and treatment for
probable heparin-induced
thrombocytopenia (HIT). HIT is a
potentially life-threatening syndrome that
usually occurs within 1-2 weeks of heparin
administration and is characterized by the
presence of HIT antibodies in the serum,
associated with an otherwise unexplained
30%-50% decrease in the platelet count,
arterial or venous thrombosis,
anaphylactoid reactions immediately
following heparin administration, or skin
lesions at the site of heparin injections.
Postoperative patients receiving
subcutaneous unfractionated heparin
prophylaxis are at highest risk for HIT.
Because of this patient's high-risk scenario
and the presence of acute thrombosis, it is
advisable to begin immediate empiric
treatment for HIT pending laboratory
confirmation. Management should include
discontinuation of heparin and treatment
with a non-heparin anticoagulant.

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A 64-year-old male presents with a 3month history of difficulty sleeping. A


history and physical examination, followed
by appropriate ancillary testing, leads to a
diagnosis of chronic primary insomnia.
Which one of the following would be most
appropriate for managing this patient's
problem? (check one)
A. An SSRI
B. A small glass of wine 1 hour before
bedtime
C. Cognitive-behavioral therapy
D. Watching television at bedtime, with
the timer set to turn off in 60 minutes
E. Reading in bed with a soft light

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C. Cognitive-behavioral therapy. Chronic


insomnia is defined as difficulty with
initiating or maintaining sleep, or
experiencing nonrestorative sleep, for at
least 1 month, leading to significant
daytime impairment. Primary insomnia is
not caused by another sleep disorder,
underlying psychiatric or medical
condition, or substance abuse disorder.
Cognitive-behavioral therapy is effective
for managing this problem, and should be
used as the initial treatment for chronic
insomnia. It has been shown to produce
sustained improvement at both 12 and 24
months after treatment is begun. One
effective therapy is stimulus control, in
which patients are taught to eliminate
distractions and associate the bedroom
only with sleep and sex. Reading and
television watching should occur in a room
other than the bedroom.
Pharmacotherapy alone does not lead to
sustained benefits. SSRIs can cause
insomnia, as can alcohol.

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Which one of the following would be most


appropriate for stroke prevention in a
patient with hypertension, diabetes
mellitus, and atrial fibrillation? (check one)
A. Clopidogrel (Plavix)
B. Aspirin
C. Dipyridamole (Persantine)
D. Warfarin (Coumadin)
E. Enoxaparin (Lovenox)

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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.

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

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According to the guidelines of the Joint


National Committee on Prevention,
Detection, Evaluation, and Treatment of
High Blood Pressure, for hypertensive
patients who also have diabetes mellitus,
the blood pressure goal is below a
threshold of: (check one)
A. 140/95 mm Hg
B. 135/90 mm Hg
C. 130/80 mm Hg
D. 120/75 mm Hg

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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 evidence-based 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.
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 hospitalized patient is being treated with


vancomycin for an infection due to
methicillin-resistant Staphylococcus aureus
(MRSA). Which one of the following is
most important to monitor? (check one)
A. Hepatic function
B. Trough serum levels
C. Peak serum levels
D. Audiograms

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B. Trough serum levels. The best


predictor of vancomycin efficacy is the
trough serum concentration, which should
be over 10 mg/L to prevent development
of bacterial resistance. Peak serum
concentration is not a predictor of efficacy
or toxicity. Monitoring for ototoxicity is
not currently recommended. Older
vancomycin products had impurities,
which apparently caused the ototoxicity
seen with these early formulations of the
drug.

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A 35-year-old male amateur rugby player


seeks your advice because right hip pain
of several months' duration has progressed
to the point of interfering with his athletic
performance. The pain is accentuated
when he transitions from a seated to a
standing position, and especially when he
pivots on the hip while running, but he
cannot recall any significant trauma to the
area and finds no relief with over-thecounter analgesics. On examination his gait
is stable. The affected hip appears normal
and is neither tender to palpation nor
excessively warm to touch. Although he
has a full range of passive motion, obvious
discomfort is evident with internal rotation
of the flexed and adducted right hip.
Which one of the following is most
strongly suggested by this clinical picture?
(check one)
A. Osteoarthritis
B. Avascular necrosis
C. Bursitis
D. Impingement
E. Pathologic fracture

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D. Impingement. Gradually worsening


anterolateral hip joint pain that is sharply
accentuated when pivoting laterally on the
affected hip or moving from a seated to a
standing position is consistent with
femoroacetabular impingement.
Reproduction of the pain on range-ofmotion examination by manipulating the
hip into a position of flexion, adduction,
and internal rotation (FADIR test) is the
most sensitive physical finding. Special
radiographic imaging of the flexed and
adducted hip can emphasize the anatomic
abnormalities associated with impingement
that may go unnoticed on standard
radiographic series views. Although the
pain associated with avascular necrosis is
similarly insidious and heightened when
bearing weight, tenderness is usually
evident with hip motion in any direction.
Osteoarthritis of the hip generally occurs in
individuals of more advanced age than this
patient, and the pain produced is typically
localized to the groin area and can be
elicited by flexion, abduction, and external
rotation (FABER test) of the affected
hip.Bursitis manifests as soreness after
exercise and tenderness over the affected
bursa.

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A 39-year-old African-American
multigravida at 36 weeks gestation
presents with a temperature of 40.0C
(104.0F), chills, backache, and vomiting.
On physical examination, the uterus is
noted to be nontender, but there is slight
bilateral costovertebral angle tenderness.
A urinalysis reveals many leukocytes,
some in clumps, as well as numerous
bacteria.

E. intravenous ceftriaxone (Rocephin).


Pyelonephritis is the most common
medical complication of pregnancy. The
diagnosis is usually straightforward, as in
this case. Since the patient is quite ill,
treatment is best undertaken in the hospital
with parenteral agents, at least until the
patient is stabilized and cultures are
available. Ampicillin plus gentamicin or a
cephalosporin is typically used.

Of the following, the most appropriate


therapy at this time would be: (check one)

Sulfonamides are contraindicated late in


pregnancy because they may increase the
incidence of kernicterus. Tetracyclines are
contraindicated because administration
late in pregnancy may lead to discoloration
of the child's deciduous teeth.
Nitrofurantoin may induce hemolysis in
patients who are deficient in G-6-PD,
which includes approximately 2% of
African-American women. The safety of
levofloxacin in pregnancy has not been
established, and it should not be used
unless the potential benefit outweighs the
risk.

A. oral trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. oral nitrofurantoin (Macrodantin)
C. oral levofloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceftriaxone (Rocephin)

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

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

A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)
Brain natriuretic peptide (BNP) is a
marker for which one of the following?
(check one)
A. Renal failure
B. Acute adrenal insufficiency
C. Cerebrovascular accident
D. Heart failure
E. Ureteral obstruction

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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.

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An 82-year-old male presents to your


office because his blood pressure has
been "high" when taken by a friend on
several occasions. His blood pressure in
your office is 173/94 mm Hg, which is
similar to the levels his friend recorded.
The history and physical examination are
otherwise unremarkable, and a CBC,
metabolic panel, and urinalysis are normal.

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C. Treatment with a thiazide diuretic will


lower this patient's risk of death. Studies
have shown that the treatment of systolic
and diastolic hypertension, especially with
thiazide diuretics, with or without an ACE
inhibitor, reduces stroke, heart failure, and
death from all causes. Such treatment is
effective in both sexes.

Which one of the following is most


consistent with current evidence?
(check one)
A. This patient's mortality will not be
affected by treatment of his hypertension
B. Treating this patient with an ARB for
hypertension would be ineffective and
dangerous
C. Treatment with a thiazide diuretic will
lower this patient's risk of death
D. In this age group, treatment of
hypertension in males does not reduce
stroke and heart failure as it does in
females
A 68-year-old female presents with a
several-month history of weight loss,
fatigue, decreased appetite, and vague
abdominal pain. The most appropriate
initial test to rule out adrenal insufficiency
is: (check one)
A. morning serum cortisol
B. a cosyntropin (ACTH) stimulation test
C. MRI
D. an insulin tolerance test
E. a metyrapone test

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A. morning serum cortisol. A single


morning serum cortisol level >13g/dL
reliably excludes adrenal insufficiency. If
the morning cortisol level is lower than
this, further evaluation with a 1g ACTH
stimulation test is necessary, although the
test is somewhat difficult. It requires
dilution of the ACTH prior to
administration, and requires multiple blood
draws. The insulin tolerance test and
metyrapone test, although historically
considered to be "gold standards," are not
widely available or commonly used in
clinical practice. MRI does not provide
information about adrenal function.
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A healthy 48-year-old female consults you


about continuing the use of her
estrogen/progestin oral contraceptives.
She has regular menstrual periods, is not
hypertensive or diabetic, and does not
smoke.
What advice would you give her? (check
one)

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E. It is safe to continue the oral


contraceptives. Healthy women may
continue combination birth control pills
into their fifties, and this patient has no
contraindications. Screening for
thrombophilic conditions is not indicated
due to the low yield. FSH levels are not
specific enough to evaluate the effect of
stopping the contraceptive.

A. She should stop the oral contraceptives


B. She should switch to a progestin-only
pill
C. She should discontinue the
contraceptive for 1 month, and if FSH is
then elevated to postmenopausal levels,
the pills should be stopped
D. She can safely continue to take the
contraceptive if screening for
thrombophilic conditions is negative
E. It is safe to continue the oral
contraceptives
Which one of the following is necessary to
make a diagnosis of polymyalgia
rheumatica? (check one)
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

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E. Bilateral shoulder or hip stiffness and


aching. There must be bilateral shoulder or
hip stiffness and aching for at least one
month in order to make the diagnosis of
polymyalgia rheumatica. Joint swelling
occurs occasionally, but neither swelling
nor early morning stiffness is necessary to
make the diagnosis. Polymyalgia
rheumatica does not respond to NSAIDs.
The erythrocyte sedimentation rate should
be 40 mm/hr.

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The Centers for Disease Control and


Prevention currently recommends that all
patients between the ages of 13 and 64
years be screened for: (check one)
A. tuberculosis
B. hepatitis B
C. human papillomavirus infection
D. elevated serum cholesterol levels
E. HIV infection

A 71-year-old female with end-stage lung


cancer was recently extubated and is
awaiting transfer to hospice. She is awake
and confused and has significant
respiratory secretions.

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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.
D. Glycopyrrolate (Robinul).
Glycopyrrolate does not cross the bloodbrain barrier, and is therefore least likely
to cause central nervous system effects
such as sedation. The other medications
listed do cross the blood-brain barrier.

Which one of the following medications


used for reducing respiratory secretions is
LEAST likely to cause central nervous
system effects such as sedation? (check
one)
A. Atropine
B. Transdermal scopolamine (Transderm
Scop)
C. Hyoscyamine (Levsin)
D. Glycopyrrolate (Robinul)

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A 25-year-old female comes to your


office requesting a referral to an
otolaryngologist for surgery on her nose.
She states that her nose is too large and
that "something must be done." She has
already seen multiple family physicians, as
well as several otolaryngologists. She is
168 cm (66 in) tall and weighs 64 kg (141
lb). A physical examination is normal, and
even though she initially resists a nasal
examination, it also is normal. The size of
her nose is normal.
Which one of the following is the most
likely cause of this patient's concern about
her nose? (check one)

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D. Body dysmorphic disorder. Body


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

A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder

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A 78-year-old male presents for a routine


follow-up 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)
A. Amiodarone (Cordarone) for
suppression of PVCs
B. Flecainide (Tambocor) for suppression
of PVCs
C. Evaluation for underlying coronary
artery disease
D. No further evaluation or treatment

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C. Evaluation for underlying coronary


artery disease. In patients with no known
coronary artery disease (CAD), the
presence of frequent premature ventricular
contractions (PVCs) is linked to acute
myocardial infarction and sudden death.
The Framingham Heart Study defines
frequent as >30 PVCs per hour. The
American College of Cardiology and the
American Heart Association recommend
evaluation for CAD in patients who have
frequent PVCs and cardiac risk factors,
such as hypertension and smoking (SOR
C). Evaluation for CAD may include
stress testing, echocardiography, and
ambulatory rhythm monitoring (SOR C).
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).

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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)

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D. a posterior splint and a repeat


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

A. a long arm cast for 2 weeks, followed


by use of a brace
B. mobilization of the elbow beginning 3
weeks after the injury
C. a posterior splint for 6 weeks
D. a posterior splint and a repeat
radiograph in 1-2 weeks
The best available evidence supports
which one of the following statements
regarding the cardiovascular effects of
hypoglycemic agents? (check one)
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

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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.

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A 46-year-old female presents to your


office for follow-up of elevated blood
pressure on a pre-employment
examination. She is asymptomatic, and her
physical examination is normal with the
exception of a blood pressure of 160/100
mm Hg. Screening blood work reveals a
potassium level of 3.1 mEq/L (N 3.7-5.2).
You consider screening for primary
hyperaldosteronism. (check one)
A. 24-hour urine aldosterone levels
B. An ACTH infusion test
C. Adrenal venous sampling
D. CT of the abdomen
E. A serum aldosterone-to-renin ratio

Pay-for-performance (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

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E. A serum aldosterone-to-renin ratio.


Primary hyperaldosteronism is relatively
common in patients with stage 2
hypertension (160/100 mm Hg or higher)
or treatment-resistant hypertension. It has
been estimated that 20% of patients
referred to a hypertension specialist suffer
from this condition. Experts recommend
screening for this condition using a ratio of
morning plasma aldosterone to plasma
renin. A ratio >20:1 with an aldosterone
level >15 ng/dL suggests the diagnosis.
The level of these two values is affected
by several factors, including medications
(especially most blood pressure
medicines), time of day, position of the
patient, and age.
Patients who are identified as possibly
having this condition should be referred to
an endocrinologist for further confirmatory
testing.
E. Taking patient compliance into account
when performing the evaluation. Pay-forperformance 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
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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) physicianpatient 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.

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A 45-year-old male presents with a 4month history of low back pain that he
says is not alleviated with either ibuprofen
or acetaminophen. On examination he has
no evidence of weakness or focal
tenderness. Laboratory studies, including a
CBC, erythrocyte sedimentation rate, Creactive protein, and complete metabolic
profile, are all normal. MRI of the
lumbosacral region shows mild bulging of
the L4-L5 disc without impingement on
the thecal sac.
Which one of the following has been
shown to be beneficial in this situation?
(check one)
A. Traction
B. Ultrasound
C. Epidural corticosteroid injection
D. A back brace
E. Acupuncture

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E. Acupuncture. Most chronic back pain


(up to 70%) is nonspecific or idiopathic in
origin. Treatment options that have the
best evidence for effectiveness include
analgesics (acetaminophen, tramadol,
NSAIDs), multidisciplinary rehabilitation,
and acupuncture (all SOR A).
Other treatments likely to be beneficial
include herbal medications, tricyclics,
antidepressants, exercise therapy,
behavior therapy, massage, spinal therapy,
opioids, and short-term muscle relaxants
(all SOR B). There is conflicting data
regarding the effectiveness of back school,
low-level laser therapy, lumbar supports,
viniyoga, antiepileptic medications,
prolotherapy, short-wave diathermy,
traction, transcutaneous electrical nerve
stimulation, ultrasound, and epidural
corticosteroid injections (all SOR C).

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A 45-year-old white female with elevated


cholesterol and coronary artery disease
comes in for a periodic fasting lipid panel
and liver enzyme levels. She began statin
therapy about 2 months ago and reports
no problems. Laboratory testing reveals
an LDL-cholesterol level of 70 mg/dL, an
HDL-cholesterol level of 55 mg/dL, an
alanine aminotransferase (ALT) level of 69
U/L (N 7-30), and an aspartate
aminotransferase (AST) level of 60 U/L
(N 9-25).
Which one of the following would be most
appropriate at this time? (check one)

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A. Continue the current therapy with


routine monitoring. The patient is at her
LDL and HDL goals and has no
complaints, so she should be continued on
her current regimen with routine
monitoring (SOR C). Research has
proven that up to a threefold increase
above the upper limit of normal in liver
enzymes is acceptable for patients on
statins. Too often, slight elevations in liver
enzymes lead to unnecessary dosage
decreases, discontinuation of statin
therapy, or additional testing.

A. Continue the current therapy with


routine monitoring
B. Decrease the dosage of the statin and
monitor liver enzymes
C. Discontinue the statin and monitor liver
enzymes
D. Discontinue the statin and begin niacin
E. Substitute another statin

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The Strength-of-Recommendation
Taxonomy (SORT) is used to grade key
recommendations in clinical review
articles. Which one of the following grades
indicates that a recommendation is based
on consistent, good-quality, patientoriented evidence? (check one)
A. A
B. B
C. C
D. X

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A. A. When possible, it is important for


the family physician to base clinical
decisions on the best evidence. Strengthof-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 patientoriented 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.

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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

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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 antiHBeAg, accompanied by normalization of
liver enzymes and greatly reduced levels of
hepatitis B virus in the bloodstream.

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A 42-year-old male presents with anterior


neck pain. His thyroid gland is markedly
tender on examination, but there is no
overlying erythema. He also has a bilateral
hand tremor. His erythrocyte
sedimentation rate is 82 mm/hr (N 1-13)
and his WBC count is 11,500/mm3 (N
4300-10,800). His free T4 is elevated,
TSH is suppressed, and radioactive iodine
uptake is abnormally low.
Which one of the following treatment
options would be most helpful at this time?
(check one)

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C. Prednisone. This patient has signs and


symptoms of painful subacute thyroiditis,
including a painful thyroid gland,
hyperthyroidism, and an elevated
erythrocyte sedimentation rate. It is
unclear whether there is a viral etiology to
this self-limited disorder. Thyroid function
returns to normal in most patients after
several weeks, and may be followed by a
temporary hypothyroid state. Treatment is
symptomatic. Although NSAIDs can be
helpful for mild pain, high-dose
glucocorticoids provide quicker relief for
the more severe symptoms.

A. Levothyroxine (Synthroid) and


NSAIDs
B. Propylthiouracil
C. Prednisone
D. Nafcillin
E. Thyroidectomy

Levothyroxine is not indicated in this


hyperthyroid state. Neither thyroidectomy
nor antibiotics is indicated for this
problem.

A 60-year-old female with moderate


COPD presents with ongoing dyspnea in
spite of treatment with both an inhaled
long-acting -agonist and a long-acting
anticholinergic agent. Your evaluation
reveals an oxygen saturation of 88% and a
PaO2 of 55%. Echocardiography reveals
a normal ejection fraction but moderate
pulmonary hypertension.
Which one of the following would be most
appropriate at this time? (check one)

B. Supplemental oxygen. This patient with


moderate COPD and moderate
nonpulmonary arterial hypertension
pulmonary hypertension is hypoxic and
meets the criteria for use of supplemental
oxygen (SOR A). Sildenafil and nifedipine
are utilized in pulmonary arterial
hypertension, but evidence is lacking for
their use in pulmonary hypertension
associated with chronic lung disease
and/or hypoxemia. Low-dose prednisone
may be a future option.

A. No changes in the current medical


regimen
B. Supplemental oxygen
C. Low-dose sildenafil (Revatio)
D. Nifedipine (Procardia)
E. Low-dose prednisone
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E. Order CT of the abdomen. Perinephric


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===========================
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)
A. Add vancomycin (Vancocin) to the
regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen

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abscess is an elusive diagnostic problem


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

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A 72-year-old female sees you for


preoperative evaluation prior to cataract
surgery. Her history and physical
examination are unremarkable, and she
has no medical problems other than
bilateral cataracts.
Which one of the following is
recommended prior to surgery in this
patient? (check one)
A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
You see a 9-year-old female for
evaluation of her asthma. She and her
mother report that she has shortness of
breath and wheezing 3-4 times per week,
which improves with use of her albuterol
inhaler. She does not awaken at night due
to symptoms, and as long as she has her
albuterol inhaler with her she does not feel
her activities are limited by her symptoms.
About once per year she requires
prednisone for an exacerbation, often
triggered by a viral infection.
Based on this information you classify her
asthma severity as: (check one)

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E. No testing. According to a recent


Cochrane review, routine preoperative
testing prior to cataract surgery does not
decrease intraoperative or postoperative
complications (SOR A). The American
Heart Association recommends against
routine preoperative testing in
asymptomatic patients undergoing lowrisk procedures, since the cardiac risk
associated with such procedures is less
than 1%.

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.

A. intermittent
B. mild persistent
C. moderate persistent
D. severe persistent

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Which one of the following is found most


consistently in patients diagnosed with
irritable bowel syndrome? (check one)
A. Passage of blood per rectum
B. Passage of mucus per rectum
C. Abdominal pain
D. Constipation
E. Diarrhea
Which one of the following is diagnostic
for type 2 diabetes mellitus? (check one)
A. A fasting plasma glucose level 126
mg/dL on two separate occasions
B. An oral glucose tolerance test (75-g
load) with a 2-hour glucose level 160
mg/dL
C. A random blood glucose level 200
mg/dL on two occasions in an
asymptomatic person
D. A hemoglobin A 1c 6.0% on two
separate occasions

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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).
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.

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A 42-year-old African-American male


recently traveled to the Caribbean for a
scuba diving trip. Since his return he has
noted brief intermittent episodes of vertigo
not associated with nausea or vomiting.
He is concerned, however, because these
episodes occurred after sneezing or
coughing and then a couple of times after
straining while lifting something. He has
had no hearing loss, and no vertigo with
positional changes such as bending over or
turning over in bed. The most likely cause
of this patients vertigo is (check one)
A. vestibular neuronitis
B. Menieres disease
C. benign paroxysmal positional vertigo
D. a perilymphatic fistula
E. multiple sclerosis triggered by a rapid
change in climate

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D. a perilymphatic fistula. A perilymphatic


fistula between the middle and inner ear
may be caused by barotrauma from scuba
diving, as well as by direct blows, heavy
weight bearing, and excessive straining
(e.g., with sneezing or bowel movements.)
This patients recent trip involved two of
these potential factors. Vestibular
neuronitis is a more sudden, unremitting
syndrome. Menieres disease is manifested
by episodes of vertigo, associated with
hearing loss and often with nausea and
vomiting. Benign paroxysmal positional
vertigo is more likely in older individuals,
and is associated with postural change.
Multiple sclerosis requires symptoms in
multiple areas and is not thought to be
provoked by climate change. Reference:
Labuguen RH: Initial evaluation of vertigo.
Am Fam Physician 2006;73(2):244-251,
254.

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An 8-year-old female is brought to your


office because she has begun to limp. She
has had a fever of 38.8C (101.8F) and
says that it hurts to bear weight on her
right leg. She has no history of trauma.
On examination, she walks with an
antalgic gait and hesitates to bear weight
on the leg. Range of motion of the right hip
is limited in all directions and is painful.
Her sacroiliac joint is not tender, and the
psoas sign is negative. Laboratory testing
reveals an erythrocyte sedimentation rate
of 55 mm/hr (N 0-10), a WBC count of
15,500/mm 3 (N 4500-13,500), and a Creactiveprotein level of 2.5 mg/dL (N 0.51.0).
Which one of the following will provide
the most useful diagnostic information to
further evaluate this patient's problem?
(check one)
A. MRI
B. CT
C. A bone scan
D. Ultrasonography
E. Plain-film radiography
A 17-year-old female sees you for a
preparticipation evaluation. She has run 5
miles a day for the last 6 months, and has
lost 6 lb over the past 2 months. Her last
menstrual period was 3 months ago. Other
than the fact that she appears to be slightly
underweight, her examination is normal.
To fit the criteria for the female athlete
triad, she must have which one of the
following? (check one)
A. A formal diagnosis of an eating
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D. Ultrasonography. This child meets the


criteria for possible septic arthritis. In this
case ultrasonography is recommended
over other imaging procedures. It is highly
sensitive for detecting effusion of the hip
joint. If an effusion is present, urgent
ultrasound-guided aspiration should be
performed. Bone scintigraphy is excellent
for evaluating a limping child when the
history, physical examination, and
radiographic and sonographic findings fail
to localize the pathology. CT is indicated
when cortical bone must be visualized.
MRI provides excellent visualization of
joints, soft tissues, cartilage, and medullary
bone. It is especially useful for confirming
osteomyelitis, delineating the extent of
malignancies, identifying stress fractures,
and diagnosing early 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.

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.
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disorder
B. Amenorrhea for 1 year
C. A Z-score on bone-density testing of
-2.5 or less
D. Withdrawal bleeding after
progesterone administration
E. A history of a stress fracture resulting
from minimal trauma

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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.

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Which one of the following is the most


common cause of recurrent and persistent
acute otitis media in children? (check one)
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Penicillin-resistant Streptococcus
pneumoniae
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
A 65-year-old asymptomatic female is
found to have extensive sigmoid
diverticulosis on screening colonoscopy.
She asks whether there are any dietary
changes she should make.
In addition to increasing fiber intake,
which one of the following would you
recommend? (check one)

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C. Penicillin-resistant Streptococcus
pneumoniae. Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella
catarrhalis are the most common bacterial
isolates from the middle ear fluid of
children with acute otitis media. Penicillinresistant S. pneumoniae is the most
common cause of recurrent and persistent
acute otitis media.
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.

A. Limiting intake of dairy products


B. Limiting intake of spicy foods
C. Limiting intake of wheat flour
D. Limiting intake of nuts
E. No limitations on other intake

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============================
===========================
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

Which one of the following is the best


radiographic test for confirming the
diagnosis of renal colic? (check one)
A. A KUB radiograph
B. Ultrasonography
C. CT
D. Intravenous pyelography
E. MRI

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D. Vasopressin (Pitressin). For persistent


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

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A 50-year-old male has a preemployment chest radiograph showing a


pulmonary nodule. There are no previous
studies available.
Which one of the following would raise the
most suspicion that this is a malignant
lesion if found on the radiograph? . (check
one)
A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
A previously healthy 67-year-old male
sees you for a routine health maintenance
visit. During the physical examination you
discover a harsh systolic murmur that is
loudest over the second right intercostal
space and radiates to the carotid arteries.
The patient denies any symptoms of
dyspnea, angina, syncope, or decreased
exertional tolerance. An echocardiogram
shows severe aortic stenosis, with an
aortic valve area of <1 cm 2, a mean
gradiant >40 mm Hg, and an ejection
fraction of 60%.
Which one of the following would be most
appropriate at this point?
(check one)
A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. Referral for aortic valve replacement
E. Watchful waiting

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A. The absence of calcification.


Pulmonary nodules are a common finding
on routine studies, including plain chest
radiographs, and require evaluation.
Radiographic features of benign nodules
include a diameter <5 mm, a smooth
border, a solid appearance, concentric
calcification, and a doubling time of less
than 1 month or more than 1 year.
Features of malignant nodules include a
size >10 mm, an irregular border, a
"ground glass" appearance, either no
calcification or an eccentric calcification,
and a doubling time of 1 month to 1 year
(SOR B).
E. Watchful waiting. Watchful waiting is
recommended for most patients with
asymptomatic aortic stenosis, including
those with severe disease (SOR B). This
is because the surgical risk of aortic valve
replacement outweighs the approximately
1% annual risk of sudden death in
asymptomatic patients with aortic stenosis.
Peripheral -blockers, such as prazosin,
should be avoided because of the risk of
hypotension or syncope. Coronary
angiography should be reserved for
symptomatic patients who do not have
evidence of severe aortic stenosis on
echocardiography performed to evaluate
their symptoms, or for preoperative
evaluation prior to aortic valve
replacement. Exercise stress testing is not
safe with severe aortic stenosis because of
the risk of death during the test.

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A 43-year-old female presents to your


office for evaluation of a chronic cough
that has been present for the past 6
months. She is not a smoker, and is not
aware of any exposure to environmental
irritants. She does not have any systemic
complaints such as fever or weight loss,
and does not have any symptoms of
heartburn or regurgitation. She is not on
any regular medications.
Auscultation of the lungs and a chest
radiograph show no evidence of acute
disease. A trial of an inhaled
bronchodilator and antihistamine therapy
does not improve the patient's symptoms.
Which one of the following would be the
most appropriate next step?
(check one)
A. A methacholine inhalation challenge test
B. Pulmonary function testing
C. CT of the chest
D. A trial of a proton pump inhibitor
E. 24-hour pH monitoring

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D. A trial of a proton pump inhibitor.


Gastroesophageal reflux disease (GERD)
is one of the most common causes of
chronic cough. Patients with chronic cough
have a high likelihood of having GERD,
even in the absence of gastrointestinal
symptoms (level of evidence 3). In fact, up
to 75% of patients with a cough caused by
GERD may have no gastrointestinal
symptoms. The cough is thought to be
triggered by microaspiration of acidic
gastric contents into the larynx and upper
bronchial tree.
The American College of Chest Physicians
states that patients with a chronic cough
should be given a trial of antisecretory
therapy (SOR B). Aggressive acid
reduction using a proton pump inhibitor
twice daily before meals for 3-4 months is
the best way to demonstrate a causal
relationship between GERD and extraesophageal symptoms (SOR B).
Methacholine inhalation testing is not
necessary in this patient, since
symptomatic asthma has been ruled out by
the lack of response to bronchodilator
therapy. Chest CT and pulmonary function
tests are not indicated given the lack of
findings from the history, physical
examination, and chest film to suggest
underlying pulmonary disease. An initial
therapeutic trial of proton pump inhibitors
is favored over 24-hour pH monitoring
because it is less uncomfortable to the
patient and has a better clinical correlation.

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A 27-year-old white male construction


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

A 29-year-old gravida 2 para 1 presents


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

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D. An increased risk for the condition in


the children of affected individuals.
Psoriasis is a genetic inflammatory
condition that has been associated with a
significant risk of cardiovascular morbidity
and mortality. Children of patients with the
disorder are at increased risk. This is
especially true if both parents have the
disorder. Life expectancy is somewhat
reduced in patients with severe psoriasis,
particularly if the disease had an early
onset. Plaque psoriasis is usually a lifelong
disease; this is in contrast to guttate
psoriasis, which may be self-limited and
never recur.
Cigarette smoking may increase the risk of
developing psoriasis. Psoriasis is also
associated with an increased likelihood of
obesity, diabetes mellitus, and metabolic
syndrome.
C. Increase the levothyroxine dosage.
Maternal hypothyroidism can have serious
effects on the fetus, so thyroid dysfunction
should be treated during pregnancy.
Because of hormonal and metabolic
changes in early pregnancy, the
levothyroxine dosage often needs to be
increased at 4-6 weeks gestation, and the
patient eventually may require a
30%-50% increase in dosage in order to
maintain her euthyroid status.

A. Add liothyronine (Cytomel) to her


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

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A 37-year-old recreational skier is unable


to lift his right arm after falling on his right
side with his arm elevated. Radiographs of
the right shoulder are negative, but
diagnostic ultrasonography shows a
complete rotator cuff tear.
Which one of the following is most
accurate with regard to treatment? (check
one)
A. Surgery is most likely to be beneficial if
performed less than 6 weeks after the
injury
B. Treatment with NSAIDs for 3 months
is recommended before further
intervention
C. Subacromial corticosteroid injections
will provide functional and symptomatic
relief in the majority of patients
D. Surgical repair of rotator cuff tears to
restore function is necessary only in
geriatric patients
E. Therapeutic ultrasound of the shoulder
will make the condition tolerable during
spontaneous healing

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A. Surgery is most likely to be beneficial if


performed less than 6 weeks after the
injury. Surgery for rotator cuff tears is
most beneficial in young, active patients. In
cases of acute, traumatic, complete rotator
cuff tears, repair is recommended in less
than 6 weeks, as muscle atrophy is
associated with reduced surgical benefit
(SOR B). Advanced age and limited
strength are also associated with reduced
surgical benefit.
NSAIDs are used for analgesia. Their
benefit has not been shown to exceed that
of other simple analgesics, and the sideeffect profile may be higher.
Corticosteroid injections will not improve
a complete tear. Some experts also
recommend avoiding their use in partial or
complete tendon tears. Therapeutic
ultrasound does not add to the benefit
from range-of-motion exercises and
exercises to strengthen the involved
muscle groups.

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A 69-year-old female presents with


postmenopausal bleeding. You consider
whether to begin your evaluation with
vaginal probe ultrasonography to assess
the thickness of her endometrium.
In evaluating the usefulness of this test to
either support or exclude a diagnosis of
endometrial cancer, which one of the
following statistics is most useful? (check
one)
A. Likelihood ratio
B. Number needed to treat
C. Prevalence
D. Incidence
E. Relative risk

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A. Likelihood ratio. There has been a


large increase in the number of diagnostic
tests available over the past 20 years.
Although tests may aid in supporting or
excluding a diagnosis, they are associated
with expense and the potential for harm. In
addition, the characteristics of a particular
test and how the results will affect
management and outcomes must be
considered. The statistics that are clinically
useful for evaluating diagnostic tests
include the positive predictive value,
negative predictive value, and likelihood
ratios.
Likelihood ratios indicate how a positive
or negative test correlates with the
likelihood of disease. Ratios greater than
5-10 greatly increase the likelihood of
disease, and those less than 0.1-0.2
greatly decrease it. In the example given, if
the patient's endometrial stripe is >25 mm,
the likelihood ratio is 15.2 and her posttest probability of endometrial cancer is
63%. However, if it is 4 mm, the
likelihood ratio is 0.02 and her post-test
probability of endometrial cancer is 0.2%.
The number needed to treat is useful for
evaluating data regarding treatments, not
diagnosis. Prevalence is the existence of a
disease in the current population, and
incidence describes the occurrence of new
cases of disease in a population over a
defined time period. The relative risk is the
risk of an event in the experimental group
versus the control group in a clinical trial.

A 72-year-old male with a history of


hypertension and a previous myocardial
infarction is diagnosed with heart failure.
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E. Lisinopril (Prinivil, Zestril). ACE


inhibitors such as lisinopril are indicated
for all patients with heart failure due to
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Echocardiography reveals systolic


dysfunction, and recent laboratory tests
indicated normal renal function, with a
serum creatinine level of 1.1 mg/dL (N
<1.5), a sodium level of 139 mEq/L (N
136-145), and a potassium level of 3.5
mEq/L (N 3.5-5.0). He is currently
asymptomatic.
Which one of the following medications
would be the best choice for initial
management in this patient? (check one)

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).

A. Furosemide (Lasix)
B. Isosorbide dinitrate (Isordil)
C. Spironolactone (Aldactone)
D. Digoxin
E. Lisinopril (Prinivil, Zestril)

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.

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============================
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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)
A. A short-acting inhaled -agonist as
needed
B. Low-dose inhaled corticosteroids daily
C. A leukotriene receptor antagonist daily
D. Medium-dose inhaled corticosteroids
daily
E. Low-dose inhaled corticosteroids plus
a long-acting inhaled -agonist daily
A 55-year-old female with diabetes
mellitus, hypertension, and hyperlipidemia
presents to your office for routine followup. Her serum creatinine level is 1.5
mg/dL (estimated creatinine clearance 50
mL/min).
Which one of the following diabetes
medications would be contraindicated in
this patient? (check one)
A. Metformin (Glucophage)
B. Exenatide (Byetta)
C. Acarbose (Precose)
D. Insulin glargine (Lantus)
E. Pioglitazone (Actos)
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A. A short-acting inhaled -agonist as


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

A. Metformin (Glucophage). Metformin is


contraindicated in patients with chronic
kidney disease. It should be stopped in
females with
a creatinine level 1.4 mg/dL and in males
with a creatinine level 1.5 mg/dL.
Pioglitazone should not be used in patients
with hepatic disease. Acarbose should be
avoided in patients with cirrhosis or a
creatinine level >2.0 mg/dL. Exenatide is
not recommended in patients with a
creatinine clearance <30 mL/min. Insulin
glargine can be used in patients with renal
disease at any stage, but the dosage may
need to be decreased.
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A 54-year-old female presents with a 2month history of intense vulvar itching that
has not improved with topical antifungal
treatment. On examination you note areas
of white, thickened, excoriated skin.
Concerned about malignancy you perform
punch biopsies, which reveal lichen
sclerosus.
The treatment of choice for this condition
is topical application of: (check one)

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B. fluorinated corticosteroids. Lichen


sclerosus is a chronic, progressive,
inflammatory skin condition found in the
anogenital region. It is characterized by
intense vulvar itching. The treatment of
choice is high-potency topical
corticosteroids. Testosterone has been
found to be no more effective than
petrolatum. Fluorouracil is an
antineoplastic agent most frequently used
to treat actinic skin changes or superficial
basal cell carcinomas.

A. conjugated estrogens
B. fluorinated corticosteroids
C. petrolatum
D. 2% testosterone
E. fluorouracil (Efudex)
Staff members of an assisted-living facility
ask for your advice regarding aerobic
exercise programs for their older
residents. The evidence is greatest for
which one of the following benefits of
physical activity in the elderly? (check
one)

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.

A. Maintaining weight after weight loss


B. Improving quality of sleep
C. Increasing bone density
D. Reducing the risk of falls

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The U.S. Preventive Services Task Force


(USPSTF) has stated that the potential
cardiovascular benefits of daily aspirin use
outweigh the potential harms of
gastrointestinal hemorrhage in certain
populations. The USPSTF currently
recommends daily aspirin use for which
one of the following populations? (check
one)
A. Males 25-44 years of age
B. Males over 80 years of age
C. Females 25-44 years of age
D. Females over 45 years of age
E. Females 55-79 years of age

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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).

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You see a newly adopted 5-month-old for


his first well child visit. The parents ask
when the child can sit in a safety seat in the
car facing forward.
You would advise that the child should
face rearward until he is at least: (check
one)
A. 12 months of age AND weighs 20 lb
B. 15 months of age AND weighs 25 lb
C. 15 months of age OR weighs 25 lb
D. 18 months of age AND weighs 30 lb
E. 18 months of age OR weighs 30 lb

Which one of the following is most


appropriate for the treatment of
fibromyalgia syndrome? (check one)
A. Metaxalone (Skelaxin)
B. Hydrocodone
C. Naproxen
D. Tizanidine (Zanaflex)
E. Amitriptyline

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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 rearfacing 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 6-month-old child who
weighs 21 lb should also face rearward.
E. Amitriptyline. A meta-analysis of
antidepressant medications for the
treatment of fibromyalgia syndrome
concluded that short-term use of
amitriptyline and duloxetine can be
considered for the treatment of pain and
sleep disturbance in patients with
fibromyalgia. In addition, a 2008
evidence-based review for the
management of fibromyalgia syndrome
performed for the European League
Against Rheumatism recommends heated
pool treatment with or without exercise,
tramadol for the management of pain, and
certain antidepressants,including
amitriptyline. Evidence for long-term
effectiveness of antidepressants in
fibromyalgia syndrome is lacking,
however.

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In the secondary prevention of ischemic


cardiac events, which one of the following
is most likely to be beneficial in a 68-yearold female with known coronary artery
disease and preserved left ventricular
function? (check one)
A. ACE inhibitors
B. Hormone therapy
C. Calcium channel blockers
D. Vitamin E
E. Oral glycoprotein IIb/IIIa receptor
inhibitors

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A. ACE inhibitors. Secondary prevention


of cardiac events consists of long-term
treatment to prevent recurrent cardiac
morbidity and mortality in patients who
have either already had an acute
myocardial infarction or are at high risk
because of severe coronary artery
stenosis, angina, or prior coronary surgical
procedures. Effective treatments include
aspirin, -blockers after myocardial
infarction, ACE inhibitors in patients at
high risk after myocardial infarction,
angiotensin II receptor blockers in those
with coronary artery disease, and
amiodarone in patients who have had a
myocardial infarction and have a high risk
of death from cardiac arrhythmias.
Oral glycoprotein IIb/IIIa receptor
inhibitors appear to increase the risk of
mortality when compared with aspirin.
Calcium channel blockers, class I antiarrhythmic 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.

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A chest radiograph of the driver of an


automobile involved in a head-on collision
shows a widened mediastinum. This
suggests: (check one)
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
The most common initial symptom of
Hodgkin lymphoma is: (check one)
A. unexplained fever
B. night sweats
C. weight loss
D. painless lymphadenopathy
E. cough

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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).
D. painless lymphadenopathy. The most
common presenting symptom of Hodgkin
lymphoma is painless lymphadenopathy.
Approximately one-third of patients with
Hodgkin lymphoma present with
unexplained fever, night sweats, and
recent weight loss, collectively known as
"B symptoms." Other common symptoms
include cough, chest pain, dyspnea, and
superior vena cava obstruction caused by
adenopathy in the chest and mediastinum.

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============================
===========================
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
Hantavirus pulmonary syndrome results
from exposure to the excreta of: (check
one)
A. migratory fowl
B. bats
C. parrots
D. mice
E. turtles

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B. Custom-made shoes to protect the


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

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.

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A 28-year-old white female consults you


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

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E. cyclic administration of progesterone


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

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A 45-year-old male with chronic


nonmalignant back pain is on a chronic
narcotic regimen. Which one of the
following behaviors is LEAST likely to be
associated with pseudoaddiction, as
opposed to true addiction? (check one)
A. Requesting a specific drug
B. Aggressive complaining about needing
more medication
C. Hoarding drugs during periods of
reduced symptoms
D. Requesting medication exactly at
prescribed times when hospitalized
E. Concurrent abuse of alcohol or illicit
drugs

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E. Concurrent abuse of alcohol or illicit


drugs. The use of narcotics for chronic
nonmalignant pain is becoming more
commonplace. Guidelines have been
developed to help direct the use of these
medications when clinically appropriate.
However, even when given appropriately,
the use of opioid medications for pain
relief can cause both the physician and the
patient to be concerned about the
possibility of addiction.
Addiction is a neurobiologic, multifactorial
disease characterized by impaired control,
compulsive drug use, and continued use
despite harm. Pseudoaddiction is a term
used to describe patient behaviors that
may occur when pain is undertreated.
Patients with unrelieved pain may become
focused on obtaining specific medications,
seem to watch the clock, or engage in
other behaviors that appear to be due to
inappropriate drug seeking.
Pseudoaddiction can be distinguished from
true addiction because the behaviors will
resolve when the pain is effectively
treated.
The concurrent use of alcohol and/or illicit
drugs complicates the management of
chronic pain in patients. If these are
known problems, patients should be
referred for psychiatric or pain specialty
evaluation before the decision is made to
use opioids. Agreements for use of
chronic opioids should include the
expectation that alcohol and illicit drugs
will not be used concurrently, and doing
so suggests addiction rather than
pseudoaddiction.

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Which one of the following is true


regarding death certificates? (check one)
A. The immediate cause of death is the
final or terminal cause of death, such as
cardiac arrest
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
C. In a case of unknown or probable
cause of death, the manner of death is
designated as "uncertain"
D. Death certificates are part of the
patient's medical record and, as such, are
confidential and regulated by HIPAA laws
E. In a case of death due to an accidental
fall, the immediate attending physician
must complete the death certificate

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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.

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A 10-week-old term male infant is


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

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C. A trial of nebulized albuterol


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

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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

The FDA recommends that over-thecounter cough and cold products not be
used in children below the age of: (check
one)
A. 1 year
B. 2 years
C. 3 years
D. 4 years
E. 5 years

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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.
B. 2 years. In 2008 the FDA issued a
public health advisory for parents and
caregivers, recommending that over-thecounter cough and cold products not be
used to treat infants and children younger
than 2 years of age, because serious and
potentially life-threatening side effects can
occur from such use. These products
include decongestants, expectorants,
antihistamines, and antitussives.

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In a patient with hyperuricemia who has


experienced an attack of gout, which one
of the following is LEAST likely to
precipitate another gout attack? (check
one)
A. Red meat
B. Milk
C. Seafood
D. Nuts
E. Beans
Which one of the pharmacologic effects of
transdermal medications changes the
LEAST with aging? (check one)
A. Liver metabolism of the drugs
B. Renal excretion of the drugs
C. Distribution within the body
D. Transdermal absorption of the drugs
============================
===========================
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.

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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.

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.
B. Excision with a 1-mm margin. The
diagnosis of melanoma should be made by
simple excision with clear margins. A
shave biopsy should be avoided because
determining the thickness of the lesion is
critical for staging. Wide excision with or
without node dissection is indicated for
confirmed melanoma, depending on the
findings from the initial excisional biopsy.

What should be the first step in


management? (check one)
A. A shave biopsy
B. Excision with a 1-mm margin
C. Wide excision with a 1-cm margin
D. Wide excision with a 1-cm margin
E. Excision with sentinel node dissection

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Which one of the following is true


regarding the treatment of generalized
anxiety disorder? (check one)
A. Cognitive-behavioral 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

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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.

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A 20-month-old male presents with a


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

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C. Amoxicillin. This patient has acute


bilateral otitis media, with presumed
tympanic membrane perforation, and
qualifies by any criterion for treatment with
antibiotics. Amoxicillin, 80-90 mg/kg/day,
should be the first-line antibiotic for most
children with acute otitis media (SOR B).
The other medications listed are either
ineffective because of resistance (e.g.,
penicillin), are second-line treatments
(e.g., amoxicillin/clavulanate), or should be
used in patients with a penicillin allergy or
in other special situations.

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

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The Centers for Disease Control and


Prevention recommends empiric treatment
of male sexual partners for which one of
the following conditions? (check one)
A. Vaginal candidiasis
B. Vaginal warts
C. Pelvic inflammatory disease
D. Bacterial vaginosis

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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.

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An asymptomatic 68-year-old male sees


you for a health maintenance visit. He is a
former cigarette smoker, but quit 20 years
ago.
According to the U.S. Preventive Services
Task Force, evidence shows that the
potential benefit exceeds the risk for which
one of the following screening tests in this
patient? (check one)
A. A chest radiograph
B. Abdominal ultrasonography
C. Ophthalmic tonometry
D. A prostate-specific antigen level
E. An EKG

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
65-75 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.

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A 52-year-old hypertensive male has had


two previous myocardial infarctions. In
spite of his best efforts, he has not
achieved significant weight loss and he
finds it difficult to follow a heart-healthy
diet. He takes rosuvastatin (Crestor), 20
mg/day, and his last lipid profile showed a
total cholesterol level of 218 mg/dL, a
triglyceride level of 190 mg/dL, an HDLcholesterol level of 45 mg/dL, and an
LDL-cholesterol level of 118 mg/dL.

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A. Increase the rosuvastatin dosage. This


patient's goal LDL-cholesterol level is 70
mg/dL, and he is not at the maximum
dosage of a potent statin. There is no data
that shows that adding a different statin
will be beneficial, and outcomes data for
the other actions is lacking. For patients
not at their goal LDL-cholesterol level, the
maximum dosage of a statin should be
reached before alternative therapy is
chosen.

Which one of the following would be the


most appropriate change in management?
(check one)
A. Increase the rosuvastatin dosage
B. Add atorvastatin (Lipitor)
C. Add niacin
D. Add fenofibrate (Lipofen, Tricor)
E. Add ezetimibe (Zetia)

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Screening for colon cancer would be


recommended for which one of the
following patients? (check one)
A. A 35-year-old male whose mother was
diagnosed with colon cancer at age 52
B. A 40-year-old female whose mother
was diagnosed with colon cancer at age
54
C. A 44-year-old female whose father
had a tubular adenoma <1 cm in size
removed during colonoscopy at age 50
D. A 46-year-old male whose paternal
uncle was diagnosed with colon cancer at
age 51
E. A 48-year-old female whose father
was diagnosed with colon cancer at age
74

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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.

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A hemoglobin A1c of 7.0% would


correspond to which one of the following
mean (average) plasma glucose levels?
(check one)
A. 126 mg/dL
B. 154 mg/dL
C. 183 mg/dL
D. 212 mg/dL
E. 240 mg/dL

A 50-year-old male is brought to the


emergency department with shortness of
breath, chest tightness, tremulousness, and
diaphoresis. Aside from tachypnea, the
physical examination is normal. Arterial
blood gases on room air show a pO2 of
98 mm Hg (N 80-100), a pCO2 of 24
mm Hg (N 35-45), and a pH of 7.57 (N
7.38-7.44).
The most likely cause of the patient's
blood gas abnormalities is: (check one)
A. carbon monoxide poisoning
B. anxiety disorder with hyperventilation
C. an acute exacerbation of asthma
D. pulmonary embolus
E. pneumothorax

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B. 154 mg/dL. A hemoglobin


A1c(HbA1c) of 6.0% correlates with a
mean plasma glucose level of 126 mg/dL
or 7.0 1c 1c mmol/dL. A calculator to
convert HbA1clevels into estimated
average glucose levels is available at
http://professional.diabetes.org/eAG.
A rough guide for estimating average
plasma glucose levels assumes that an
1cof 6.0% equals an average glucose level
of 120 mg/dL. Each percentage point
increase in 1c is equivalent to a 30-mg/dL
rise in average glucose. An HbA1cof
7.0% is therefore roughly equivalent to an
average glucose level of 150 mg/dL, and
an HbA1c of 8.0% translates to an
average glucose level of 180 mg/dL.
B. anxiety disorder with hyperventilation.
The elevated pH, normal oxygen
saturation, and low pCO2 are
characteristic of acute respiratory
alkalosis, as seen with acute
hyperventilation states. In patients with a
pulmonary embolism, pO2 and pCO2 are
decreased, while the pH is elevated,
indicating the acute nature of the disorder.
With the other diagnoses, findings on the
physical examination would be different
than those seen in this patient. Vital signs
would be normal with carbon monoxide
poisoning, and patients with an asthma
exacerbation have a prominent cough and
wheezing, and possibly other
abnormalities. Tension pneumothorax
causes severe cardiac and respiratory
distress, with significant physical findings
including tachycardia, hypotension, and
decreased mental activity.

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A 58-year-old male presents with recent


behavior and personality changes, and you
suspect dementia. Which one of the
following is most likely to present in this
manner? (check one)
A. Alzheimer's disease
B. Vascular dementia
C. Mixed Alzheimer's disease and
vascular dementia
D. Frontotemporal dementia
E. Progressive supranuclear palsy

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D. Frontotemporal dementia.
Frontotemporal dementia is the second
most common cause of early-onset
dementia. It often presents with behavioral
and personality changes. Examples include
disinhibition, impairment of personal
conduct, loss of emotional sensitivity, loss
of insight, and executive dysfunctions.
Alzheimer's disease presents with memory
loss and visuospatial problems. Vascular
dementia is associated with risk factors for
stroke, or occurs in relation to a stroke,
with a stepwise progression. Alzheimer's
disease and vascular dementia can occur
together, with features of both.
Progressive supranuclear palsy is
characterized by early falls, vertical
(especially downward) gaze, axial rigidity
greater than appendicular rigidity, and
levodopa resistance.

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============================
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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.

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E. Tolerance to morphine. This patient has


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

Which one of the following is the most


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

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A 72-year-old white male presents with a


complaint of headache, blurred vision, and
severe right eye pain. His symptoms began
acutely about 1 hour ago. Examination of
the eye reveals a mid-dilated, sluggish
pupil; a hazy cornea; and a red
conjunctiva.
Which one of the following is the most
likely diagnosis? (check one)
A. Retinal detachment
B. Central retinal artery occlusion
C. Mechanical injury to the globe
D. Acute angle-closure glaucoma

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D. Acute angle-closure glaucoma. This


patient presents with acute angle-closure
glaucoma, manifested by an acute onset of
severe pain, blurred vision, halos around
lights, increased intraocular pressure, red
conjunctiva, a mid-dilated and sluggish
pupil, and a normal or hazy cornea.
Findings with retinal detachment include
either normal vision or peripheral or
central vision loss; absence of pain;
increasing floaters; and a normal
conjunctiva, cornea, and pupil. Central
retinal artery occlusion findings include
amaurosis fugax, a red conjunctiva, a pale
fundus, a cherry-red spot at the fovea, and
"boxcarring" of the retinal vessels. In
patients with mechanical injury to the
globe, findings include moderate to severe
pain, normal or decreased vision,
subconjunctival hemorrhage completely
surrounding the cornea, and a pupil that is
irregular or deviated toward the injury
(SOR B).

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The mother of an 8-year-old female is


concerned about purple "warts" on her
daughter's hands. The mother explains that
the lesions started a few months ago on
the right hand along the top of most of the
knuckles and interphalangeal joints, and
she has recently noticed them on the left
hand. The child has no other complaints
and the mother denies any unusual
behaviors. A physical examination is
unremarkable except for the slightly
violaceous, flat-topped lesions the mother
described.

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A. Dermatomyositis. One of the most


characteristic findings in dermatomyositis
is Gottron's papules, which are flattopped, sometimes violaceous papules
that often occur on most, if not all, of the
knuckles and interphalangeal joints.

What is the most likely cause for this


patient's finger lesions? (check one)
A. Dermatomyositis
B. Aggressive warts
C. Rubbing/wringing of the hands
D. Bulimia nervosa
E. Child abuse
A 20-year-old patient comes to the
emergency department complaining of
shortness of breath. On examination his
heart rate is 180 beats/min, and his blood
pressure is 122/68 mm Hg. An EKG
reveals a narrow complex tachycardia
with a regular rhythm.
Which one of the following would be the
most appropriate initial treatment? (check
one)

C. Adenosine (Adenocard). After vagal


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

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

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Which one of the following is true


regarding the risk of inducing cancer with
CT scanning? (check one)
A. CT of the chest is associated with a
greater risk than CT of the head
B. The risk increases with age at the time
of the scan
C. Males have a greater risk of ultimately
developing CT-induced lung cancer than
females
D. Current techniques with rapid scanners
make the risk comparable to that
associated with standard radiographs of
the same area
E. The risk in neonates is markedly
reduced because of the efficiency of DNA
repair processes at this age
A patient complains of throbbing bone
pain in her lower back and legs. She also
has felt weaker recently. Which one of the
following tests would confirm a vitamin D
deficiency? (check one)
A. 25-hydroxyvitamin D
B. 1,25-dihydroxyvitamin D
C. Ergocalciferol (vitamin D2 )
D. Cholecalciferol (vitamin D3 )

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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.

A. 25-hydroxyvitamin D. Serum 25hydroxyvitamin D should be obtained in


any patient with suspected vitamin D
deficiency because it is the major
circulating form of vitamin D (SOR A).
1,25-Dihydroxyvitamin D is the most
active metabolite, but levels can be
increased by secondary
hyperparathyroidism. In persons with
vitamin D deficiency, ergocalciferol
(vitamin D ) or cholecalciferol (vitamin D )
can be used to replenish stores (SOR 2
3B).

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When obtaining informed consent from a


patient, which one of the following is NOT
required for a patient to legally have
decision-making capacity? (check one)
A. The absence of mental illness
B. The ability to express choice
C. The ability to understand relevant
information
D. The ability to engage in reasoning
E. The ability to appreciate the significance
of information and its consequences

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A. The absence of mental illness. Patients


with mental illness may have decisionmaking 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.

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A patient is sent to you by his employer


after falling down some steps and twisting
his ankle and foot. Which one of the
following would be the most appropriate
reason to obtain foot or ankle
radiographs? (check one)
A. Notable swelling and discoloration
over the anterior talofibular ligament
B. A complaint of marked pain with
weight bearing as he walks into the
examining room
C. Pain in the maleolar zone and bone
tenderness of the posterior medial
malleolus
D. The absence of passive plantar foot
flexion when the calf is squeezed
(Thompson test)

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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.

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A 77-year-old white male complains of


urinary incontinence of more than one
year's duration. The incontinence occurs
with sudden urgency. No association with
coughing or positional change has been
noted, and there is no history of fever or
dysuria. He underwent transurethral
resection of the prostate (TURP) for
benign prostatic hypertrophy a year ago,
and he says his urinary stream has
improved. A rectal examination reveals a
smoothly enlarged prostate without
nodularity, and normal sphincter tone. No
residual urine is found with post-void
catheterization.
Which one of the following is the most
likely cause of this patient's incontinence?
(check one)
A. Detrusor instability
B. Urinary tract infection
C. Overflow
D. Fecal impaction
E. Recurrent bladder outlet obstruction

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A. Detrusor instability. In elderly patients,


detrusor instability is the most common
cause of urinary incontinence in both men
and women. Incontinence may actually
become worse after surgical relief of
obstructive prostatic hypertrophy.
Infection is unlikely as the cause of
persistent incontinence in this patient in the
absence of fever or symptoms of urinary
tract infection. Overflow is unlikely in the
absence of residual urine. Impaction is a
relatively rare cause of urinary
incontinence, and associated findings
would be present on rectal examination.
Normalization of the urinary stream and
the absence of residual urine reduce the
likelihood of recurrent obstruction. The
prostate would be expected to remain
enlarged on rectal examination after
transurethral resection of the prostate
(TURP).

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A 47-year-old male is preparing for a 3day trip to central Mexico to present the
keynote address for an international law
symposium. He asks you for an antibiotic
to be taken prophylactically to prevent
bacterial diarrhea.
Which one of the following would you
recommend? (check one)
A. Trimethoprim/sulfamethoxazole
(Bactrim, Septra)
B. Rifaximin (Xifaxan)
C. Doxycycline
D. Nitrofurantoin (Macrobid)

============================
===========================
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)

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B. Rifaximin (Xifaxan). While prophylactic


antibiotics are not generally recommended
for prevention of traveler's diarrhea, they
may be useful under special circumstances
for certain high-risk hosts, such as the
immunocompromised, or for those
embarking on critical short trips for which
even a short period of diarrhea might
cause undue hardship. Rifaximin, a
nonabsorbable antibiotic, has been shown
to reduce the risk for traveler's diarrhea by
77%. Trimethoprim/sulfamethoxazole and
doxycycline are no longer considered
effective antimicrobial agents against
enteric bacterial pathogens. Increasing
resistance to the fluoroquinolones,
especially among Campylobacter species,
is limiting their use as prophylactic agents.
B. Cluster headache. Cluster headache is
predominantly a male disorder. The mean
age of onset is 27-30 years. Attacks often
occur in cycles and are unilateral. Migraine
headaches are more common in women,
start at an earlier age (second or third
decade), and last longer (4-24 hours).
Temporal arteritis occurs in patients above
age 50. Trigeminal neuralgia usually occurs
in paroxysms lasting 20-30 seconds.

A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia

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A 24-year-old male presents with a fever


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

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A. Oseltamivir (Tamiflu). The currently


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

A. Oseltamivir (Tamiflu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment

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A 59-year-old white male is being


evaluated for hypertension. His blood
pressure is 150/95 mm Hg. His medical
history includes impotence, asthma, gout,
first degree heart block, diet-controlled
diabetes mellitus, and depression, but he is
currently taking no medications. He has a
past history of alcohol abuse, but quit
drinking 10 years ago.
Which one of the following would be the
best choice for INITIAL therapy of his
hypertension? (check one)
A. Propranolol (Inderal)
B. Verapamil (Calan, Isoptin)
C. Clonidine (Catapres)
D. Hydrochlorothiazide/triamterene
(Dyazide)
E. Enalapril (Vasotec)
A 51-year-old immigrant from Vietnam
presents with a 3-week history of
nocturnal fever, sweats, cough, and weight
loss. A chest radiograph reveals a right
upper lobe cavitary infiltrate. A PPD
produces 17 mm of induration, and acidfast bacilli are present on a smear of
induced sputum.
While awaiting formal laboratory
identification of the bacterium, which one
of the following would be most
appropriate? (check one)
A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin),
and pyrazinamide
An incidental 2-cm adrenal nodule is
discovered on renal CT performed to
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E. Enalapril (Vasotec). Because of their


favorable side-effect profile, ACE
inhibitors (e.g., enalapril) may be the drugs
of first choice for the majority of
unselected hypertensive patients. ACE
inhibitors are not associated with
depression or sedation, and they are safe
to use in patients with diabetes mellitus.
Centrally-acting -blockers can be
associated with depression. Calciumchannel blockers, -blockers, and other
sympatholytic drugs affect cardiac
conductivity.-Blockers are
contraindicated in patients with asthma,
and are also associated with impotence.
Thiazide diuretics raise uric acid and blood
glucose levels.

E. INH, ethambutol, rifampin (Rifadin),


and pyrazinamide. Leading authorities,
including experts from the American
Thoracic Society, CDC, and Infectious
Diseases Society of America, mandate
aggressive initial four-drug treatment when
tuberculosis is suspected. Delays in
diagnosis and treatment not only increase
the possibility of disease transmission, but
also lead to higher morbidity and mortality.
Standard regimens including INH,
ethambutol, rifampin, and pyrazinamide
are recommended, although one regimen
does not include pyrazinamide but extends
coverage with the other antibiotics.
Treatment regimens can be modified once
culture results are available.

B. Evaluation for adrenal hormonal


secretion. The incidental discovery of
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evaluate hematuria in a 57-year-old female


with flank pain. She has no past medical
history of palpitations, headache,
hirsutism, sweating, osteoporosis, diabetes
mellitus, or hypertension. A physical
examination is normal, with the exception
of a blood pressure of 144/86 mm Hg.
Laboratory evaluation reveals a serum
sodium level of 140 mmol/L (N 135-145)
and a serum potassium level of 3.8
mmol/L (N 3.5-5.0).
What is the most appropriate next step in
the evaluation of this patient? (check one)
A. Repeat CT in 12 months
B. Evaluation for adrenal hormonal
secretion
C. Fine-needle aspiration of the nodule
D. MRI of the abdomen
E. Referral to a general surgeon for
exploratory laparotomy

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adrenal masses presents a common clinical


challenge. Such masses are found on
abdominal CT in 4% of cases, and the
incidence of adrenal masses increases to
7% in adults over 70 years of age. While
the majority of masses are benign, as
many as 11% are hypersecreting tumors
and approximately 7% are malignant
tumors; the size of the mass and its
appearance on imaging are major
predictors of malignancy. Once an adrenal
mass is identified, adrenal function must be
assessed with an overnight dexamethasone
suppression test. A morning cortisol level
>5 g/dL after a 1-mg dose indicates
adrenal hyperfunction. Additional testing
should include 24-hour fractionated
metanephrines and catecholamines to rule
out pheochromocytoma. If the patient has
hypertension, morning plasma aldosterone
activity and plasma renin activity should be
assessed to rule out a primary
aldosterone-secreting adenoma.
Nonfunctioning masses require assessment
with CT attenuation, chemical shift MRI,
and/or scintigraphy to distinguish malignant
masses. PET scanning is useful to verify
malignant disease. Nonfunctioning benign
masses can be monitored for changes in
size and for the onset of hypersecretory
states, although the appropriate interval
and studies are controversial. MRI may be
preferred over CT because of concerns
about excessive radiation exposure. Fineneedle aspiration of the mass can be
performed to differentiate between adrenal
and non-adrenal tissue after malignancy
and pheochromocytoma have been
excluded.

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Which one of the following has been


shown to benefit from screening for
asymptomatic bacteriuria? (check one)
A. Women with diabetes mellitus
B. Men with prostatic enlargement on
examination
C. All adults with newly diagnosed
hypertension
D. Nursing-home residents with an
indwelling Foley catheter
E. Women who are pregnant
In a patient with microcytic anemia, which
one of the following patterns of laboratory
abnormalities would be most consistent
with iron deficiency as the underlying
cause? (check one)
A. Ferritin low, total iron binding capacity
(TIBC) low, serum iron low
B. Ferritin low, TIBC low, serum iron high
C. Ferritin low, TIBC high, serum iron low
D. Ferritin high, TIBC low, serum iron low

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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).

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.

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A 16-year-old male is brought to your


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

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C. Explore whether his school counselor


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

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A 12-year-old female is brought to your


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

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D. acute rheumatic fever. Acute rheumatic


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

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A 73-year-old female presents with


complaints of dyspnea and decreasing
exercise tolerance over the past few
months. She says she has to prop herself
up on two pillows in order to breathe
better. She also complains of palpitations,
even at rest. She has long-standing
hypertension, but has not taken any
antihypertensive medications for several
years. She has no history of ischemic heart
disease. On examination her blood
pressure is 155/92 mm Hg, her pulse rate
is 108 beats/min and irregular, and her
lungs have bibasilar crackles. An EKG
reveals atrial fibrillation, but no changes of
acute ischemia.
Which one of the following would be most
useful for determining her initial treatment?
(check one)
A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level

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C. Echocardiography. This patient's


history and clinical examination suggest
heart failure. The most important
distinction to make is whether it is diastolic
or systolic, as the drug treatment may be
somewhat different. Physical findings and
chest radiographs do not distinguish
systolic from diastolic heart failure. An
echocardiogram is the study of choice, as
it will assess left ventricular function.
In diastolic dysfunction, the left ventricular
ejection fraction is normal or slightly
elevated. Diastolic failure is more common
in elderly females and patients with
hypertension, and less common in patients
with a previous history of coronary artery
disease. Diuretics and angiotensin receptor
blockers (ARBs) are useful treatments.
Because of their effects on diastolic filling
times, tachycardia and atrial fibrillation
often cause decompensation in patients
with diastolic heart failure.
At this time, cardiac catheterization is not
indicated, and a stress test will not provide
useful information. If the patient had
systolic failure, a workup for ischemic
disease would be needed, but most cases
of diastolic dysfunction are not caused by
ischemia. While hyperthyroidism can
cause tachycardia and atrial fibrillation, the
more immediate issue in this patient is the
heart failure, which requires diagnosis and
treatment. A pulmonary embolus can
cause shortness of breath but usually has
an acute onset, so a D-dimer level would
not help at this time.

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============================
===========================
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
A 62-year-old male on hemodialysis
develops a pruritic rash on his arms and
chest, with erythematous, thickened
plaques and edema. He had brain imaging
with a gadolinium-enhanced MRI for
neurologic symptoms 10 days ago.
Which one of the following is true
regarding this problem? (check one)
A. A skin biopsy is diagnostic
B. The problem is limited to the skin
C. Immediate treatment is critical
D. The disease is more common in males
E. Death from the disease is unusual

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E. Any terminal patient with a life


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

A. A skin biopsy is diagnostic. This patient


has gadolinium-associated nephrogenic
systemic fibrosis, which is associated with
the use of gadolinium-based contrast
material in patients with severe renal
dysfunction, often on dialysis. Associated
proinflammatory states, such as recent
surgery, malignancy, and ischemia, are
often present as well. This condition
occurs without regard to gender, race, or
age. Dermatologic manifestations are
usually seen, but multiple organ systems
may be involved. There is no effective
treatment, and mortality is approximately
30%. A deep biopsy of the affected skin
is diagnostic.

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A 3-year-old male is brought to the


emergency department by his parents,
who report seeing him swallow a handful
of adult ibuprofen tablets 20 minutes ago.
Which one of the following would be the
most appropriate initial management of this
patient? (check one)
A. Oral ipecac
B. Oral activated charcoal
C. Gastric lavage
D. Whole-bowel irrigation
E. Close observation

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B. Oral activated charcoal. A single dose


of activated charcoal is the
decontamination treatment of choice for
most medication ingestions. It should be
used within 1 hour of ingestion of a
potentially toxic amount of medication
(SOR C). Gastric lavage, cathartics, or
whole bowel irrigation is best for ingestion
of medications that are poorly absorbed
by activated charcoal (iron, lithium) or
medications in sustained-release or
enteric-coated formulations. Ipecac has no
role in home use or in the health care
setting (SOR C).

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A 26-year-old gravida 3 para 2 was


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

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

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A 45-year-old Hispanic male with


schizophrenia presents with an
exacerbation of his COPD. He currently
takes only ziprasidone (Geodon). He asks
for a prescription for clarithromycin
(Biaxin) because it has worked well for
previous exacerbations.
Which one of the following effects of this
drug combination should you be alert for?
(check one)
A. Stevens-Johnson syndrome
B. Prolonged QT interval
C. Seizures
D. Diarrhea
E. Hypoglycemia

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B. Prolonged QT interval. Ziprasidone is a


second-generation antipsychotic used in
the treatment of schizophrenia. These
drugs cause QT-interval prolongation,
which can in turn lead to torsades de
pointes and sudden cardiac death. This
risk is further increased when these drugs
are combined with certain antibiotics (e.g.,
clarithromycin), antiarrhythmics (class I
and III), and tricyclic antidepressants. The
FDA has issued a black box warning for
both first- and second-generation
antipsychotic drugs due to a 1.6- to 1.7fold increase in the risk of sudden cardiac
death and cerebrovascular accidents
associated with their use in the elderly
population (SOR A). None of the other
conditions listed is associated with this
drug combination.

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A 44-year-old female presents with a


complaint of increasingly dry eyes over the
past 3-4 months, and says she can no
longer wear contacts due to the
discomfort and itching. She also
apologizes for chewing gum during the
visit, explaining that it helps keep her
mouth moist. On examination you note
decreased tear production, decreased
saliva production, and new dental caries.
She stopped taking a daily over-thecounter allergy medication about 1 month
ago.
Which one of the following is the most
likely diagnosis? (check one)
A. Sarcoidosis
B. Sjgren's syndrome
C. Ocular rosacea
D. Allergic conjunctivitis
E. Medication side effect

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B. Sjgren's syndrome. Sjgren's


syndrome is one of the three most
common systemic autoimmune diseases. It
results from lymphocytic infiltration of
exocrine glands and leads to acinar gland
degeneration, necrosis, atrophy, and
decreased function. A positive anti-SS-A
or anti-SS-B antigen test or a positive
salivary gland biopsy is a criterion for
classification of this diagnosis. In addition
to ocular and oral complaints, clinical
manifestations include arthralgias,
thyroiditis, pulmonary disease, and GERD.
Most patients with sarcoidosis present
with shortness of breath or skin
manifestations, and patients with lupus
generally have fatigue and joint pain.
Ocular rosacea causes eye symptoms very
similar to those of Sjgren's syndrome, but
oral findings would not be expected.
Drugs such as anticholinergics can cause a
dry mouth, but this would be unlikely a
month after the medication was
discontinued (SOR B).

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A 14-year-old female is brought to your


office by her mother because of a 3-month
history of irritability, hypersomnia, decline
in school performance, and lack of interest
in her previous extracurricular activities.
The mother is also your patient, and you
know that she has a history of depression
and has recently separated from her
husband. After an appropriate workup,
you diagnose depression in the daughter.
For initial therapy you recommend: (check
one)
A. amitriptyline
B. methylphenidate (Ritalin)
C. divalproex sodium (Depakote)
D. cognitive-behavioral therapy
A 55-year-old hospitalized white male
with a history of rheumatic aortic and
mitral valve disease has a 3-day history of
fever, back pain, and myalgias. No
definite focus of infection is found on your
initial examination. His WBC count is
24,000/mm3(N 4300-10,800) with 40%
polymorphonuclear leukocytes and 40%
band forms. The following day, two blood
cultures have grown gram-positive cocci in
clusters.
Until the specific organism sensitivity is
known, the most appropriate antibiotic
treatment would be: (check one)
A. ciprofloxacin (Cipro)
B. nafcillin
C. streptomycin and penicillin
D. ceftriaxone (Rocephin)
E. vancomycin and gentamicin

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D. cognitive-behavioral therapy. This


patient has multiple risk factors for
depression: the hormonal changes of
puberty, a family history of depression,
and psychosocial stressors. Cognitivebehavioral therapy is effective in treating
mild to moderate depression in children
and adolescents (SOR A). SSRIs are an
adjunctive treatment reserved for
treatment of severe depression, and have
limited evidence for effectiveness in
children and adolescents.
Amitriptyline should not be used because
of its limited effectiveness and adverse
effects (SOR A). Methylphenidate is used
for treating attention deficit disorder, not
depression. Divalproex sodium is used to
treat bipolar disorder.
E. vancomycin and gentamicin. This
patient has endocarditis caused by a
gram-positive coccus. Until sensitivities of
the organism are known, treatment should
include intravenous antibiotic coverage for
Enterococcus, Streptococcus, and
methicillin-sensitive and methicillinresistant Staphylococcus. A patient who
does not have a prosthetic valve should be
started on vancomycin and gentamicin,
with monitoring of serum levels.
Enterococcus and methicillin-resistant
Staphylococcus are often resistant to
cephalosporins. If the organism proves to
be Staphylococcus sensitive to nafcillin,
the patient can be switched to a regimen
of nafcillin and gentamicin.

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A 40-year-old white female lawyer sees


you for the first time. When providing a
history, she describes several problems,
including anxiety, sleep disorders, fatigue,
persistent depressed mood, and
decreased libido. These symptoms have
been present for several years and are
worse prior to menses, although they also
occur to some degree during menses and
throughout the month. Her menstrual
periods are regular for the most part.
The most likely diagnosis at this time is:
(check one)
A. premenstrual syndrome
B. dysthymia
C. dementia
D. menopause
E. anorexia nervosa
A mother brings her 2-month-old infant to
the emergency department because of
profuse vomiting and severe diarrhea. The
infant is dehydrated, has a cardiac
arrhythmia, appears to have ambiguous
genitalia, and is in distress.
This presentation suggests a diagnosis of:
(check one)
A. acute gastroenteritis
B. hypertrophic pyloric stenosis
C. congenital adrenal hyperplasia
D. congenital intestinal malrotation
E. Turner's syndrome

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B. dysthymia. Psychological disorders,


including anxiety, depression, and
dysthymia, are frequently confused with
premenstrual syndrome (PMS), and must
be ruled out before initiating therapy.
Symptoms are cyclic in true PMS. The
most accurate way to make the diagnosis
is to have the patient keep a menstrual
calendar for at least two cycles, carefully
recording daily symptoms. Dysthymia
consists of a pattern of ongoing, mild
depressive symptoms that have been
present for 2 years or more and are less
severe than those of major depression.
This diagnosis is consistent with the
findings in the patient described here.

C. congenital adrenal hyperplasia.


Congenital adrenal hyperplasia is a family
of diseases caused by an inherited
deficiency of any of the enzymes
necessary for the biosynthesis of cortisol.
In patients with the salt-losing variant,
symptoms begin shortly after birth with
failure to regain birth weight, progressive
weight loss, and dehydration. Vomiting is
prominent, and anorexia is also present.
Disturbances in cardiac rate and rhythm
may occur, along with cyanosis and
dyspnea. In the male, various degrees of
hypospadias may be seen, with or without
a bifid scrotum or cryptorchidism.

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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 12.016.0).
Which one of the following additional
findings would help establish the diagnosis
of polycythemia vera? (check one)
A. A platelet count >400,000/mm3
B. An O2 saturation <90%
C. A WBC count <4500/mm (N 430010,800)3
D. An elevated uric acid level

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


Polycythemia vera should be suspected in
African-Americans or white females
whose hemoglobin level is >16 g/dL or
whose hematocrit is >47%. For white
males, the thresholds are 18 g/dL and
52%. It should also be suspected in
patients with portal vein thrombosis and
splenomegaly, with or without
thrombocytosis and leukocytosis. Major
criteria include an increased red cell mass,
a normal O2 saturation,and the presence
ofsplenomegaly. Minor criteria
includeelevated vitamin B 12 levels,
elevated leukocyte alkaline phosphatase, a
platelet count >400,000/mm3 and a WBC
count >12,000/mm3 . Patients with
polycythemia vera may present with gout
and an elevated uric acid level, but neither
is considered a criterion for the diagnosis.

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Over the last 6 months a developmentally


normal 12-year-old white female has
experienced intermittent abdominal pain,
which has made her quite irritable. She
also complains of joint pain and general
malaise. She has lost 5 kg (11 lb) and has
developed an anal fissure.
Which one of the following is the most
likely cause of these symptoms? (check
one)
A. Celiac disease (gluten enteropathy)
B. Irritable bowel syndrome
C. Hepatitis A
D. Crohn's disease
E. Giardiasis

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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.

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A 67-year-old female has started


receiving home hospice care. Her
attending physician can bill through which
one of the following? (check one)
A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D
E. The attending physician cannot bill
Medicare

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B. Medicare Part B. As long as the


attending physician is not employed by
hospice, Medicare Part B can be billed.
Medicare Part A (hospital insurance)
covers inpatient care in hospitals and
skilled nursing facilities, hospice, and home
health services, but not custodial or longterm care. Medicare Part B (medical
insurance) covers outpatient physician
services, including office visits and home
health services.
Medicare Part C (Medicare Advantage
Plans) is offered by private companies,
and combines Part A and Part B
coverage. These plans always cover
emergency and urgent care, and may offer
extra coverage such as vision, hearing,
dental, and/or health and wellness
programs. Most plans also include
Medicare Part D, which provides
prescription drug coverage. Medicare Part
D plans vary with regard to cost and drugs
covered.

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Which one of the following is considered


first-line therapy for nausea and vomiting
of pregnancy? (check one)
A. Ginger
B. Blue cohosh
C. Cranberry
D. Vitamin B6
E. Fenugreek

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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.

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A 45-year-old female presents to your


office because she has had a lump on her
neck for the past 2 weeks. She has no
recent or current respiratory symptoms,
fever, weight loss, or other constitutional
symptoms. She has a history of wellcontrolled hypertension, but is otherwise
healthy. On examination you note a
nontender, 2-cm, soft node in the anterior
cervical chain. The remainder of the
examination is unremarkable.
Which one of the following would be most
appropriate at this point?
(check one)
A. Immediate biopsy
B. Treatment with antibiotics, then a
biopsy if the problem does not resolve
C. Monitoring clinically for 4-6 weeks,
then a biopsy if the node persists or
enlarges
D. Serial ultrasonography to monitor for
changes in the node

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C. Monitoring clinically for 4-6 weeks,


then a biopsy if the node persists or
enlarges. There is limited evidence to
guide clinicians in the management of an
isolated, enlarged cervical lymph node,
even though this is a common occurrence.
Evaluation and management is guided by
the presence or absence of inflammation,
the duration and size of the node, and
associated patient symptoms. In addition,
the presence of risk factors for malignancy
should be taken into account.
Immediate biopsy is warranted if the
patient does not have inflammatory
symptoms and the lymph node is >3 cm, if
the node is in the supraclavicular area, or if
the patient has coexistent constitutional
symptoms such as night sweats or weight
loss. Immediate evaluation is also
indicated if the patient has risk factors for
malignancy. Treatment with antibiotics is
warranted in patients who have
inflammatory symptoms such as pain,
erythema, fever, or a recent infection.
In a patient with no risk factors for
malignancy and no concerning symptoms,
monitoring the node for 4-6 weeks is
recommended. If the node continues to
enlarge or persists after this time, then
further evaluation is indicated. This may
include a biopsy or imaging with CT or
ultrasonography. The utility of serial
ultrasound examinations to monitor lymph
nodes has not been demonstrated.

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A 45-year-old male is seen in the


emergency department with a 2-hour
history of substernal chest pain. An EKG
shows an ST-segment elevation of 0.3 mV
in leads V4-V6.
In addition to evaluation for reperfusion
therapy, which one of the following would
be appropriate?
(check one)
A. Enteric aspirin, 81 mg
B. Intravenous metoprolol (Lopressor)
C. Oral clopidogrel (Plavix)
D. Warfarin (Coumadin), after blood is
drawn to establish his baseline INR
E. Delaying treatment pending results of
two sets of cardiac enzyme measurements

A 36-year-old female sees you for a 6week postpartum visit. Her pregnancy
was complicated by gestational diabetes
mellitus. Her BMI at this visit is 33.0
kg/m2 and she has a family historyof
diabetes mellitus.
This patient's greatest risk factor for
developing type 2 diabetes mellitus is her:
(check one)
A. age
B. obesity
C. history of a completed pregnancy
D. history of gestational diabetes
E. family history of diabetes

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C. Oral clopidogrel (Plavix). This patient


has an ST-segment elevation myocardial
infarction (STEMI). STEMI is defined as
an ST-segment elevation of greater than
0.1 mV in at least two contiguous
precordial or adjacent limb leads. The
most important goal is to begin fibrinolysis
less than 30 minutes after the first contact
with the health system. The patient should
be given oral clopidogrel, and should also
chew 162-325 mg of aspirin.
Enteric aspirin has a delayed effect.
Intravenous -blockers such as
metoprolol should not be routinely given,
and warfarin is not indicated. Delaying
treatment until cardiac enzyme results are
available in a patient with a definite
myocardial infarction is not appropriate.
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.

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You see a 68-year-old mechanic for a


routine evaluation. He has a 2-year history
of hypertension. His weight is normal and
he adheres to his medication regimen. His
current medications are metoprolol
(Lopressor), 100 mg twice daily;
olmesartan (Benicar), 40 mg/day; and
hydrochlorothiazide, 25 mg/day. His
serum glucose levels have always been
normal, but his lipid levels are elevated.
A physical examination is unremarkable
except for an enlarged prostate and a
blood pressure of 150/94 mm Hg.
Laboratory studies show a serum
creatinine level of 1.6 mg/dL (N 0.6-1.5)
and a serum potassium level of 4.9
mmol/L (N 3.5-5.0).

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B. Substitute furosemide (Lasix) for


hydrochlorothiazide. Resistant or
refractory hypertension is defined as a
blood pressure 140/90 mm Hg, or
130/80 mm Hg in patients with diabetes
mellitus or renal disease (i.e., with a
creatinine level >1.5 mg/dL or urinary
protein excretion >300 mg over 24
hours), despite adherence to treatment
with full doses of at least three
antihypertensive medications, including a
diuretic. JNC 7 guidelines suggest adding
a loop diuretic if serum creatinine is >1.5
mg/dL in patients with resistant
hypertension.

The patient's record shows blood


pressures ranging from 145/80 mm Hg to
148/96 mm Hg over the past year.
Which one of the following would be most
appropriate at this point? (check one)
A. Continue his current management with
no changes
B. Substitute furosemide (Lasix) for
hydrochlorothiazide
C. Add clonidine (Catapres)
D. Add spironolactone (Aldactone)
E. Add hydralazine (Apresoline)
Actinic keratoses of the skin may progress
to: (check one)
A. nodular basal cell cancer
B. pigmented basal cell cancer
C. squamous cell cancer
D. Merkel cell cancer
E. malignant melanoma
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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.

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A 52-year-old male presents with a small


nodule in his palm just proximal to the
fourth metacarpophalangeal joint. It has
grown larger since it first appeared, and he
now has mild flexion of the finger, which
he is unable to straighten. He reports that
his father had similar problems with his
fingers. On examination you note pitting of
the skin over the nodule.
The most likely diagnosis is:
(check one)
A. degenerative joint disease
B. trigger finger
C. Dupuytren's contracture
D. a ganglion
E. flexor tenosynovitis

============================
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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)

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C. Dupuytren's contracture. Dupuytren's


contracture is characterized by changes in
the palmar fascia, with progressive
thickening and nodule formation that can
progress to a contracture of the associated
finger. The fourth finger is most commonly
affected. Pitting or dimpling can occur
over the nodule because of the connection
with the skin.
Degenerative joint disease is not
associated with a palmar nodule. Trigger
finger is related to the tendon, not the
palmar fascia, and causes the finger to
lock and release. Ganglions also affect the
tendons or joints, are not located in the
fascia, and are not associated with
contractures. Flexor tenosynovitis, an
inflammation, is associated with pain,
which is not usually seen with Dupuytren's
contracture.
A. Lindane 1%. Lindane's efficacy has
waned over the years and it is
inconsistently ovicidal. Because of its
neurotoxicity, lindane carries a black box
warning and is specifically recommended
only as second-line treatment by the FDA.
Pyrethroid resistance is widespread, but
permethrin is still considered to be a firstline treatment because of its favorable
safety profile. The efficacy of malathion is
attributed to its triple action with isopropyl
alcohol and terpineol, likely making this a
resistance-breaking formulation. The
probability of simultaneously developing
resistance to all three substances is small.
Malathion is both ovicidal and
pediculicidal.

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Which one of the following is a frequent


cause of cross-reactive food-allergy
symptoms in latex-allergic individuals?
(check one)
A. Avocadoes
B. Goat's milk
C. Pecans
D. Pastrami
E. Peppermint

A 42-year-old female is found to have a


thyroid nodule during her annual physical
examination. Her TSH level is normal.
Ultrasonography of her thyroid gland
shows a solitary nodule measuring 1.2 cm.
Which one of the following would be most
appropriate at this point? (check one)
A. A radionuclide thyroid scan
B. A fine-needle aspiration biopsy of the
nodule
C. Partial thyroidectomy
D. Total thyroidectomy
E. Reassurance
A 19-year-old female high-school student
is brought to your office by a friend who is
concerned about the patient having cut her
wrists. The patient denies that she was
trying to kill herself, and states that she did
this because she "just got so angry" at her
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A. Avocadoes. The majority of patients


who are latex-allergic are believed to
develop IgE antibodies that cross-react
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 "latexfruit syndrome." Although many fruits and
vegetables have been implicated, fruits
most commonly linked to this problem are
bananas, avocadoes, and kiwi.
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).
E. Psychotherapy. This patient displays
most of the criteria for borderline
personality disorder. This is a maladaptive
personality type that is present from a
young age, with a strong genetic
predisposition. It is estimated to be
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boyfriend when she caught him sending a


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

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present in 1% of the general population


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

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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

An 8-year-old female is brought to your


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

Which one of the following hospitalized


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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.
A. Henoch-Schnlein purpura. The
combination of arthritis with a typical
palpable purpuric rash is consistent with a
diagnosis of Henoch-Schnlein purpura.
This most often occurs in children from 2
to 8 years old. Arthritis is present in about
two-thirds of those affected.
Gastrointestinal and renal involvement are
also common.
Rocky Mountain spotted fever presents
with a rash, but arthralgias are not typical.
These patients are usually sick with a fever
and headache. Juvenile rheumatoid
arthritis is associated with a salmon-pink
maculopapular rash, but not purpura. The
rash associated with Lyme disease is
erythema migrans, which is a bull's-eye
lesion at the site of a tick bite. The rash
associated with rheumatic fever is
erythema marginatum, which is a pink,
raised, macular rash with sharply
demarcated borders.
E. A 67-year-old female with hemiparesis,
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patients is the most appropriate candidate


for thromboembolism prophylaxis with
enoxaparin (Lovenox)? (check one)
A. An ambulatory 22-year-old obese
male admitted for an appendectomy
B. A 48-year-old male with atrial
fibrillation on chronic therapeutic
anticoagulation, admitted for cellulitis
C. A 48-year-old male with end-stage
liver disease and coagulopathy
D. A 52-year-old female on chronic
estrogen therapy, admitted with severe
thrombocytopenia
E. A 67-year-old female with hemiparesis,
admitted for community-acquired
pneumonia

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admitted for community-acquired


pneumonia. Venous thromboembolism is a
frequent cause of preventable death and
illness in hospitalized patients.
Approximately 10%-15% of high-risk
patients who do not receive prophylaxis
develop venous thrombosis. Pulmonary
embolism is thought to be associated with
5%-10% of deaths in hospitalized
patients. Anticoagulant prophylaxis
significantly reduces the risk of pulmonary
embolism and should be used in all highrisk patients.
Prophylaxis is generally recommended for
patients over the age of 40 who have
limited mobility for 3 days or more and
have at least one of the following risk
factors: acute infectious disease, New
York Heart Association class III or IV
heart failure, acute myocardial infarction,
acute respiratory disease, stroke,
rheumatic disease, inflammatory bowel
disease, previous venous
thromboembolism, older age (especially
>75 years), recent surgery or trauma,
immobility or paresis, obesity (BMI >30
kg/m2), central venouscatheterization,
inherited or acquired thrombophilic
disorders, varicose veins, or estrogen
therapy.
Pharmacologic therapy with an
anticoagulant such as enoxaparin is clearly
indicated in the 67-year-old who has
limited mobility secondary to hemiparesis
and is being admitted for an acute
infectious disease. The patient on chronic
anticoagulation, the patient with severe
thrombocytopenia, and the patient with
coagulopathy are at high risk for bleeding
if given anticoagulants, and are better
candidates for nonpharmacologic
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therapies such as foot extension exercises,


graduated compression stockings, or
pneumatic compression devices. Although
the 22-year-old is obese and recently had
surgery, his young age and ambulatory
status make anticoagulant prophylaxis less
necessary.
A 25-year-old white male who has a
poorly controlled major seizure disorder
and a 6-week history of recurrent fever,
anorexia, and persistent, productive
coughing visits your office. On physical
examination he is noted to have a
temperature of 38.3C (101.0F), a
respiratory rate of 16/min, gingival
hyperplasia, and a fetid odor to his breath.
Auscultation of the lungs reveals rales in
the mid-portion of the right lung
posteriorly.
Which one of the following is most likely
to be found on a chest radiograph? (check
one)
A. Sarcoidosis
B. Miliary calcifications
C. A lung abscess
D. A right hilar mass
E. A right pleural effusion

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C. A lung abscess. Anaerobic lung


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

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Which one of the following should be


given intravenously in the initial treatment
of status epilepticus? (check one)
A. Propofol (Diprivan)
B. Phenobarbital
C. Lorazepam (Ativan)
D. Midazolam (Versed)

According to JNC 7, the risk of


cardiovascular disease begins to increase
when the systolic blood pressure exceeds
a threshold of : (check one)
A. 150 mm Hg
B. 140 mm Hg
C. 130 mm Hg
D. 125 mm Hg
E. 115 mm Hg

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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.
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.

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

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D. Insulin detemir (Levamir) daily plus


rapid-acting insulin with meals. Basal
insulin provides a relatively constant level
of insulin for 24 hours, with an onset of
action in 1 hour and no peak. NPH gives
approximately 12 hours of coverage with
a peak around 6-8 hours. Regular insulin
has an onset of action of about 30 minutes
and lasts about 5-8 hours, with a peak at
about 2-4 hours. New rapid-acting
analogue insulins have an onset of action
within 5-15 minutes, peak within 30-75
minutes, and last only about 2-3 hours
after administration. Thus, a 70/30 insulin
mix (typically 70% NPH and 30%
regular) provides coverage for 12 hours,
but the peaks of insulin release do not
closely mimic natural patterns. NPH given
twice daily along with an insulin slidingscale protocol using regular insulin is only
slightly closer than a 70/30 twice-daily
regimen. Rapid insulin alone does not
provide any basal insulin, and the patient
would therefore not have insulin available
during the night.

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An anxious and agitated 18-year-old


white male presents to your office with a
2-hour history of severe muscle spasms in
the neck and back. He was seen 2 days
ago in a local emergency department with
symptoms of gastroenteritis, treated with
intravenous fluids, and sent home with a
prescription for prochlorperazine
(Compazine) suppositories. The best
therapy for this problem is intravenous
administration of: (check one)

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B. diphenhydramine (Benadryl). While


rarely life threatening, an acute dystonic
reaction can be frightening and painful to
the patient and confusing to the treating
physician who may be unaware of what
medications the patient is taking. Dystonia
can be caused by any agent that blocks
dopamine, including prochlorperazine,
metoclopramide, and typical neuroleptic
agents such as haloperidol. The acute
treatment of choice is diphenhydramine or
benztropine.

A. atropine
B. diphenhydramine (Benadryl)
C. haloperidol
D. succinylcholine (Anectine)
E. carbamazepine (Tegretol)
In a patient with a severe anaphylactic
reaction to peanuts, the most appropriate
route for epinephrine is: (check one)
A. intramuscular
B. intravenous
C. oral
D. subcutaneous
E. sublingual

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A. intramuscular. Intramuscular
epinephrine is the recommended drug for
anaphylactic reactions (SOR A).
Epinephrine is absorbed more rapidly
intramuscularly than subcutaneously.

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A 19-year-old college student comes to


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

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D. partial avulsion of the medial nail plate


and phenolization of the matrix at this visit.
This ingrown nail meets the criteria for
moderate severity: increased swelling,
seropurulent drainage, infection, and
ulceration of the nail fold. In these cases,
antibiotics before or after phenolization of
the matrix do not decrease healing time,
postoperative morbidity, or recurrence
rates (SOR B). A conservative approach,
elevating the nail edge with a wisp of
cotton or a gutter splint, is reasonable in
patients with a mild to moderate ingrown
toenail who do not have significant pain,
substantial erythema, or purulent drainage.
Either immediate partial nail avulsion
followed by phenolization, or direct
surgical excision of the nail matrix is
effective for the treatment of ingrown nails
(SOR B). Pretreatment with soaking and
antibiotics has not been demonstrated to
add therapeutic benefit or to speed
resolution. Several studies demonstrate
that once the ingrown portion of the nail is
removed and matricectomy is performed,
the localized infection will resolve without
the need for antibiotic therapy. Bilateral
partial matricectomy maintains the
functional role of the nail plate (although it
narrows the nail plate) and should be
considered in patients with a severe
ingrown toenail or to manage recurrences.

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A 59-year-old male who is morbidly


obese suffers a cardiac arrest. Intravenous
access cannot be obtained. Which one of
the following is true regarding intraosseous
drug administration in this patient? (check
one)
A. The patient's age and size are a
contraindication to intraosseous
administration
B. The time needed to establish
intraosseous access is too great
C. Many drugs cannot be administered
intraosseously
D. Endotracheal administration is
preferred
E. There are no contraindications to
intraosseous administration in this patient

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E. There are no contraindications to


intraosseous administration in this patient.
The current American Heart Association
ACLS guidelines state that intraosseous
access can be obtained in almost all age
groups rapidly, and is preferred over the
endotracheal route. Any drug that can be
administered intravenously can be
administered intraosseously. Many drugs
administered via an endotracheal tube are
poorly absorbed, and drug levels vary
widely.

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Ultrasonography shows a complete


placenta previa in a 23-year-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

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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.

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Which one of the following classes of


diabetes medications acts primarily by
stimulating pancreatic insulin secretion?
(check one)
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)
A 30-year-old male presents with a 3week history of severe, burning pain in his
right shoulder. He recalls no mechanism of
injury. An examination reveals weakness
to resistance of the biceps and triceps, and
with external rotation of the shoulder. Full
range of motion of the neck and shoulder
does not worsen the pain.
Which one of the following would be most
likely to identify the cause of this patient's
problem? (check one)
A. Electromyography and nerve
conduction studies
B. MRI of the neck
C. MR arthrography (MRA) of the
shoulder
D. CT of the brain
E. Ultrasonography of the upper extremity

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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. 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.

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A 30-year-old African-American female is


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

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B. ovarian failure. The history and physical


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

A. hypothalamic amenorrhea
B. ovarian failure
C. pituitary microadenoma
D. polycystic ovary syndrome
A 30-year-old female presents to your
office for an initial visit. She reports a long
history of asthma that currently awakens
her three times per month, necessitating
the use of an albuterol inhaler (Proventil,
Ventolin).
According to current guidelines, which one
of the following would be optimal
treatment?
(check one)

D. Adding a low-dose inhaled


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

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


B. Adding a long-acting -agonist
C. Adding a leukotriene receptor
antagonist
D. Adding a low-dose inhaled
corticosteroid
E. Adding theophylline
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Random Board Review Questions 44
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A 34-year-old female with a history of
bilateral tubal ligation consults you
because of excessive body and facial hair.
She has a normal body weight, no other
signs of virilization, and regular menses.
Which one of the following is the most
appropriate treatment for her mild
hirsutism? (check one)

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

A. Spironolactone (Aldactone)
B. Leuprolide (Lupron)
C. Prednisone
D. Metformin (Glucophage)
An 80-year-old male nursing-home
resident is brought to the emergency
department because of a severe,
productive cough associated with a high
fever, hypoxia, and hypotension. The
patient is found to have a left lower lobe
pneumonia, and admission to the
intensive-care unit is advised.
Which one of the following is the most
appropriate antibiotic therapy for this
patient? (check one)

E. Ceftazidime (Fortaz),
imipenem/cilastatin (Primaxin), and
vancomycin (Vancocin). Empiric coverage
for methicillin-resistant Staphylococcus
aureus and double coverage for
pseudomonal pneumonia should be
prescribed in patients with nursing homeacquired pneumonia requiring intensivecare unit admission (SOR B).

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)

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A 67-year-old white female has a DXA


scan with a resulting T-score 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)

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B. Raloxifene (Evista). Raloxifene is a


selective estrogen receptor modulator.
While it increases the risk of venous
thromboembolism, it is indicated in this
patient to decrease the risk of invasive
breast cancer (SOR A). Bisphosphonates
inhibit osteoclastic activity. Zoledronic
acid, alendronate, and risedronate
decrease both hip and vertebral fractures,
whereas ibandronate decreases fracture
risk at the spine only. Calcitonin nasal
spray is an antiresorptive spray that
decreases the incidence of vertebral
compression fractures. Teriparatide is a
recombinant human parathyroid hormone
with potent bone anabolic activity,
effective against vertebral and
nonvertebral fractures. Hormone
replacement therapy is recommended for
osteoporosis only in women with
moderate or severe vasomotor symptoms.
The lowest possible dose should be used
for the shortest amount of time possible
(SOR C).

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A 50-year-old white female comes to you


because she has found a breast mass.
Your examination reveals a firm, fixed,
nontender, 2-cm mass. No axillary nodes
are palpable, nor is there any nipple
discharge. You send her for a
mammogram, and fine-needle aspiration is
performed to obtain cells for cytologic
examination. The mammogram is read as
"suspicious" and the fine-needle cytology
report reads, "a few benign ductal
epithelioid cells and adipose tissue."
Which one of the following would be the
most appropriate next step? (check one)
A. A repeat mammogram in 3 months
B. Repeat fine-needle aspiration in 3
months
C. An excisional biopsy of the mass
D. Referral for breast irradiation
E. Referral to a surgeon for simple
mastectomy
A 67-year-old female comes to your
office because she noticed flashing lights in
her left eye 2 hours ago, and since then
has had decreased vision in the lateral
aspect of that eye. On examination she has
a blind spot in the lateral visual field of her
left eye. Her fundus is difficult to examine
because of an early cataract.
Which one of the following is the most
likely diagnosis? (check one)

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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.
E. Retinal detachment. In a patient
complaining of flashes of light and a visual
field defect, retinal detachment is the most
likely diagnosis. Many cases of vitreous
detachment are asymptomatic, and it does
not cause sudden visual field defects in the
absence of a retinal detachment. A
vitreous hemorrhage would cause more
blurring of vision in the entire field of
vision. Ocular migraine causes binocular
symptoms.

A. Posterior vitreous detachment


B. Vitreous hemorrhage
C. Macular degeneration
D. Ocular migraine
E. Retinal detachment

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You are evaluating a 68-year-old male


with obstructive urinary symptoms. Which
one of the following medications may lead
to falsely depressed levels of prostatespecific antigen (PSA)? (check one)

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B. Finasteride (Proscar). Finasteride has


considerable efficacy in treating
obstructive symptoms, but it unfortunately
falsely depresses PSA levels. In patients
taking finasteride, this can affect the
evaluation for carcinoma of the prostate.

A. Terazosin (Hytrin)
B. Finasteride (Proscar)
C. Tamsulosin (Flomax)
D. Doxazosin (Cardura)
E. Lycopene

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A previously alert, otherwise healthy 74year-old African-American male has a


history of slowly developing progressive
memory loss and dementia associated with
urinary incontinence and gait disturbance
resembling ataxia. This presentation is
most consistent with: (check one)
A. normal pressure hydrocephalus
B. Alzheimer's disease
C. subacute sclerosing panencephalitis
D. multiple sclerosis

A. normal pressure hydrocephalus. In


normal pressure hydrocephalus a mild
impairment of memory typically develops
gradually over weeks or months,
accompanied by mental and physical
slowness. The condition progresses
insidiously to severe dementia. Patients
also develop an unsteady gait and urinary
incontinence, but there are no signs of
increased intracranial pressure.
In Alzheimer's disease the brain very
gradually atrophies. A disturbance in
memory for recent events is usually the
first symptom, along with some
disorientation to time and place;
otherwise, there are no symptoms for
some period of time. Subacute sclerosing
panencephalitis usually occurs in children
and young adults between the ages of 4
and 20 years and is characterized by
deterioration in behavior and work. The
most characteristic neurologic sign is mild
clonus.
Multiple sclerosis is characteristically
marked by recurrent attacks of
demyelinization. The clinical picture is
pleomorphic, but there are usually
sufficient typical features of incoordination,
paresthesias, and visual complaints.
Mental changes may occur in the
advanced stages of the disease. About
two-thirds of those affected are between
the ages of 20 and 40.

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You see a 1-year-old male for a routine


well child examination. Laboratory tests
reveal a hemoglobin level of 10 g/dL (N
9-14), a hematocrit of 31% (N 28-42), a
mean corpuscular volume of 68 :m3 (N
70-86), and a mean corpuscular
hemoglobin concentration of 25 g/dL (N
30-36). A trial of iron therapy results in no
improvement and a serum lead level is
normal.

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A. Hemoglobin electrophoresis. This


patient has a microcytic, hypochromic
anemia, which can be caused by iron
deficiency, thalassemia, sideroblastic
anemia, and lead poisoning. In a child with
a microcytic anemia who does not
respond to iron therapy, hemoglobin
electrophoresis is appropriate to diagnose
thalassemia. Hypothyroidism, vitamin B12
deficiency, and folate deficiency result in
macrocytic anemias.

Which one of the following would be the


most appropriate test at this time? (check
one)
A. Hemoglobin electrophoresis
B. Bone marrow examination
C. Vitamin B12 and folate levels
D. A TSH level
Which one of the following is most
accurate regarding somatization disorder?
(check one)
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

A 42-year-old white male develops


respiratory distress 12 hours after he
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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.
C. adult respiratory distress syndrome
(ARDS). Acute respiratory failure
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sustained a closed head injury and a femur


fracture. A physical examination reveals a
respiratory rate of 40/min. He has a pO2
of 45 mm Hg (N 75-100), a pCO2 of 25
mm Hg (N 35-45), and a blood pH of
7.46 (N 2 2 7.35-7.45). His hematocrit is
30.0% (N 37.0-49.0).
Of the following, the most likely diagnosis
is: (check one)

following severe injury and critical illness


has received increasing attention over the
last decade. With advances in the
management of hemorrhagic shock and
support of circulatory and renal function in
injured patients, it has become apparent
that 1%-2% of significantly injured
patients develop acute respiratory failure
in the post-injury period.

A. respiratory depression due to central


nervous system damage
B. heart failure
C. adult respiratory distress syndrome
(ARDS)
D. hypovolemic shock
E. tension pneumothorax

Initially this lung injury was thought to be


related to a particular clinical situation.
This is implied by such names as "shock
lung" and "traumatic wet lung," which have
been applied to acute respiratory
insufficiency. It is now recognized that the
pulmonary problems that follow a variety
of insults have many similarities in their
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

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far less frequent than milder abnormalities.


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

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D. The BUN/creatinine ratio. The most


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

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A 70-year-old Asian male presents with


hematochezia. He has stable vital signs.
Lower endoscopy is performed, but is
unsuccessful due to active bleeding.
Which one of the following would be most
appropriate at this point?
(check one)
A. Abdominal CT
B. A barium enema
C. A technetium-99m blood pool scan
D. Exploratory laparotomy
E. A small-bowel radiograph

A patient presenting with severe carbon


monoxide poisoning should be treated
with: (check one)
A. inhaled helium
B. supplemental oxygen
C. intravenous calcium gluconate
D. intravenous iron
E. intravenous magnesium
Which one of the following situations is
most likely to result in immunity from
court-awarded damages for personal
injuries occurring as a result of reasonable
and ordinary emergency care? (check
one)
A. Evaluating a football injury as a
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C. A technetium-99m blood pool scan. In


most patients with heavy gastrointestinal
bleeding, localizing the bleeding site, rather
than diagnosing the cause of the bleeding,
is the most important task. A lower GI
series is usually nondiagnostic during
heavy, active bleeding. A small-bowel
radiograph may be helpful after the active
bleeding has stopped, but not during the
acute phase of the bleeding. A blood pool
scan allows repeated scanning over a
prolonged period of time, with the goal of
permitting enough accumulation of the
isotope to direct the arteriographer to the
most likely source of the bleeding. If the
scan is negative, arteriography would be
unlikely to reveal the active source of
bleeding, and is also a more invasive
procedure. Exploratory laparotomy may
be indicated if a blood pool scan or an
arteriogram is nondiagnostic and the
patient continues to bleed heavily.
B. supplemental oxygen. Patients with
carbon monoxide poisoning should be
treated immediately with normobaric
oxygen, which speeds up the excretion of
carbon monoxide.

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
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school game
B. Stabilizing an injured victim at the scene
of an automobile accident until EMS
arrives
C. Providing emergency care to your
office nurse after he collapses while on the
job
D. Responding to the collapse of one of
your patients in the hospital parking lot
E. Treating an asthma attack while staffing
the first-aid shelter at an outdoor rock
concert

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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 in-flight
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.

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A patient who underwent coronary bypass


grafting several months ago has been
intolerant of all medications for cholesterol
lowering. However, on the
recommendation of a friend, he began
taking red yeast rice that he purchased at
a natural healing store. His cholesterol
level has improved with this product and
he has tolerated it so far.
You should consider monitoring which one
of the following in this patient, based on
the active ingredient in red yeast rice?
(check one)
A. WBC count
B. Platelet count
C. Prothrombin time
D. Liver enzymes
E. Kidney function tests
A 40-year-old nurse presents with a 1year history of rhinitis, and a more recent
onset of episodic wheezing and dyspnea.
Her symptoms seem to improve when she
is on vacation. She does not smoke,
although she says that her husband does.
Her FEV1 improves 20% with inhaled agonists.
Which one of the following is the most
likely diagnosis?
(check one)
A. Occupational asthma
B. Sarcoidosis
C. COPD
D. Anxiety
E. Vocal cord dysfunction

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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, LDL-cholesterol, 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.
A. Occupational asthma. Occupational
asthma merits special consideration in all
cases of new adult asthma or recurrence
of childhood asthma after a significant
asymptomatic period (SOR C).
Occupational asthma is often preceded by
the development of rhinitis in the
workplace and should be considered in
patients whose symptoms improve away
from work. Reversibility with -agonist
use makes COPD less likely, in addition
to the fact that the patient is a nonsmoker.
Cystic fibrosis is not a likely diagnosis in a
patient this age with a long history of being
asymptomatic. Sarcoidosis would be less
likely to cause reversible airway
obstruction and intermittent symptoms.
Vocal cord dysfunction would not be
expected to respond to bronchodilators.

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A previously healthy 60-year-old male is


diagnosed with multiple myeloma after a
workup for an incidental finding on routine
laboratory work. He has no identified
organ or tissue damage and is
asymptomatic.
Which one of the following would be
appropriate treatment of this patient's
condition?
(check one)
A. No treatment
B. Chemotherapy
C. Autologous stem cell transplantation
D. Radiation

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A. No treatment. This patient has


smoldering (asymptomatic) multiple
myeloma. He does not have any organ or
tissue damage related to this disease and
has no symptoms. Early treatment of these
patients does not improve mortality (SOR
A) and may increase the likelihood of
developing acute leukemia. The standard
treatment for symptomatic patients under
age 65 is autologous stem cell
transplantation. Patients over 65 who are
healthy enough to undergo transplantation
would also be appropriate candidates.
Patients who are not candidates for
autologous stem cell transplantation
generally receive melphalan and
prednisolone with or without thalidomide.
Radiotherapy can be used to relieve
metastatic bone pain or spinal cord
compression.

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A 35-year-old male presents with a 4month history of pain in the lower lumbar
region without radiation. He works in retail
sales, and the pain and stiffness prevent
him from working. He estimates the pain
to be 7 on a 10-point scale. He has been
under the care of a chiropractor and has
experienced some relief with spinal
manipulation. His history is negative for
red flags indicating a serious cause for his
pain.
The only positive findings on a physical
examination are diffuse mild tenderness
over the lumbar region and mild limitation
of lumbar mobility on forward and lateral
flexion/extension maneuvers. Appropriate
laboratory tests and imaging studies are all
within normal limits.
In addition to appropriate analgesics,
which one of the following modalities has
the best evidence of long-term benefit in
this situation?
(check one)

D. Multidisciplinary rehabilitation. This


patient has nonspecific chronic back pain,
most likely a lumbar strain or sprain. In
addition to analgesics (e.g.,
acetaminophen or NSAIDs) (SOR A) and
spinal manipulation (SOR B), a
multidisciplinary rehabilitation program is
the best choice for management (SOR A).
This program includes a physician and at
least one additional intervention
(psychological, social, or vocational).
Such programs alleviate subjective
disability, reduce pain, return the person to
work earlier, and reduce the amount of
sick time taken in the first year by 7 days.
Benefits persist for up to 5 years. Back
school, TENS, and SSRIs have been
found to have negative or conflicting
evidence of effectiveness (SOR C). There
is no evidence to support the use of
epidural corticosteroid injections in
patients without radicular signs or
symptoms (SOR C).

A. Transdermal electric nerve stimulation


(TENS)
B. Epidural corticosteroid injections
C. SSRIs
D. Multidisciplinary rehabilitation

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A 55-year-old male presents to your


office for evaluation of increasing dyspnea
with exertion over the past 2 weeks. He
has smoked 2 packs of cigarettes per day
since the age of 20. He has had a chronic
cough for years, along with daily sputum
production. He was given an albuterol
inhaler for wheezing in the past, which he
uses intermittently. On examination he has
a severe decrease in breath sounds, no
evidence of jugular venous distention, no
cardiac murmur, and no peripheral edema.
A chest film shows hyperinflation, but no
infiltrates or pleural effusion. Office
spirometry shows that his FEV1 is only
55% of the predicted value.
You consider using inhaled corticosteroids
as part of the treatment regimen for this
patient. This has been shown to: (check
one)
A. increase cataract formation
B. increase the incidence of fracture
C. increase the risk of pneumonia
D. slow the progression of the disease
E. improve overall mortality from the
disease
Which one of the following patients is
unlikely to benefit from vaccination against
hepatitis A? (check one)
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

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C. increase the risk of pneumonia. COPD


has several symptoms, including poor
exercise tolerance, chronic cough, sputum
production, dyspnea, and signs of rightsided heart failure. The most common
etiology is cigarette smoking. A patient
with any combination of two of these
findings, such as a 70-pack-year history of
smoking, decreased breath sounds, or a
history of COPD, likely has airflow
obstruction, defined as an FEV1 60% of
the predicted value. In stable COPD,
treatment is reserved for patients who
have symptoms and airflow obstruction.
Treatment options for monotherapy are all
similar in effectiveness and include longacting inhaled anticholinergics, long-acting
-agonists, and inhaled corticosteroids.
Inhaled corticosteroids will not reduce
mortality or affect long-term progression
of COPD. However, they do reduce the
number of exacerbations and the rate of
decline in the quality of life. There appears
to be no increase in cataract formation or
rate of fracture. These agents do have side
effects, including candidal infection of the
oropharynx, hoarseness, and an increased
risk of developing pneumonia.
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.
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============================
===========================
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

A 68-year-old male was seen in a local


urgent-care clinic 6 days ago for upper
respiratory symptoms and was started on
cefuroxime (Ceftin). He presents to your
office with a 2-day history of 4-5 watery
stools per day with no blood or mucus.
He is afebrile and has a normal abdominal
and rectal examination. A stool guaiac test
is negative, and a stool sample is sent for
further testing.
What is the best initial management for this
patient?
(check one)

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D. 400 IU. It is now recommended that all


infants and children, including adolescents,
have a minimum daily intake of 400 IU of
vitamin D, beginning soon after birth. The
current recommendation replaces the
previous recommendation of a minimum
daily intake of 200 IU/day of vitamin D
supplementation beginning in the first 2
months after birth and continuing through
adolescence. These revised guidelines for
vitamin D intake for healthy infants,
children, and adolescents are based on
evidence from new clinical trials and the
historical precedent of safely giving 400
IU of vitamin D per day in the pediatric
and adolescent population. New evidence
supports a potential role for vitamin D in
maintaining innate immunity and
preventing diseases such as diabetes
mellitus and cancer.
A. Stop the cefuroxime. This patient is at
high risk for Clostridium difficileassociated diarrhea, based on his age and
his recent broad-spectrum antibiotic use.
The initial management is to stop the
antibiotics. Treatment should not be
initiated unless the stool is positive for
toxins A and B. The recommended initial
treatment for C. difficileenteritis is oral
metronidazole. Probiotics may be useful
for prevention, but their use is
controversial. Loperamide should be
avoided, as it can slow down transit times
and worsen toxin-mediated diarrhea.

A. Stop the cefuroxime


B. Start ciprofloxacin (Cipro)
C. Start metronidazole (Flagyl)
D. Start loperamide (Imodium)
E. Recommend probiotics until he
completes the course of cefuroxime
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A 74-year-old female presents with a


several-month history of gradually
increasing dyspnea on exertion, swelling in
her feet and lower legs, and having to
sleep sitting up due to increased shortness
of breath while lying flat. She has been
healthy otherwise, with no known heart
disease or hypertension, and she has no
significant family history of heart disease.
An echocardiogram shows an ejection
fraction of 20% and a thin-walled,
diffusely enlarged left ventricle.
Which one of the following is the most
likely diagnosis?
(check one)
A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular
cardiomyopathy
E. Athlete's heart
Which one of the following is true
regarding treatment of pressure ulcers?
(check one)
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

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A. Dilated cardiomyopathy. This patient's


symptoms and echocardiographic findings
indicate a dilated cardiomyopathy. In
patients with hypertrophic cardiomyopathy
the echocardiogram shows left ventricular
hypertrophy and a reduction in chamber
size. In restrictive cardiomyopathy,
findings include reduced ventricular
volume, normal left ventricular wall
thickness, and normal systolic function
with impaired ventricular filling.
Arrhythmogenic right ventricular
cardiomyopathy usually presents with
syncope and without symptoms of heart
failure, and segmental wall abnormalities
would be seen on the echocardiogram.
Highly trained athletes may develop
echocardiographic evidence of eccentric
cardiac hypertrophy, but no symptoms of
heart failure would be present.

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).

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The "Get Up and Go Test" evaluates for


which one of the following? (check one)
A. Risk of falling
B. Effects of peripheral neuropathy
C. Kinetic tremor
D. Neurocardiogenic syncope
E. Central causes of vertigo

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


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

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A 20-year-old male presents with a


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

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C. Ceftriaxone (Rocephin) and


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

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An elevation of serum alkaline


phosphatase combined with an elevation
of 5'-nucleotidase is most suggestive of
conditions affecting (check one)
A. bone
B. the liver
C. the placenta
D. the small intestine

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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).

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A 60-year-old right-handed white male


arrives in the emergency department with
symptoms and signs consistent with a
stroke. His past medical history is
significant for tobacco abuse and chronic
treated hypertension. He is alert and
afebrile. His pulse rate is 100 beats/min,
respirations 20/min, and blood pressure
190/95 mm Hg. He has a moderate rightsided hemiparesis and is aphasic. There
are no other significant physical findings.
While appropriate tests are being ordered,
immediate management in the emergency
department should include which one of
the following? (check one)
A. Monitoring oxygenation status with
pulse oximetry
B. Prompt lowering of systolic blood
pressure to <140 mm Hg
C. Beginning an intravenous heparin
infusion
D. Restricting fluid intake to 75 cc/hr
E. Giving parenteral corticosteroids

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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 48-72 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.

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Which one of the following is the most


common secondary cause of nephrotic
syndrome in adults? (check one)
A. Diabetes mellitus
B. Systemic lupus erythematosus
C. Hepatitis
D. NSAIDs
E. Multiple myeloma

A 19-year-old college student comes to


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

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

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

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============================
===========================
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)
A. A 1-day duration of illness
B. Ear pain
C. Difficulty opening his mouth
D. Hoarseness
E. Pain with swallowing
While playing basketball, a 29-year-old
male falls on his outstretched hand with his
wrist fully extended. He sees you the
following day because of diffuse wrist pain
and decreased range of motion. The point
of maximal tenderness is on the dorsal
aspect of the wrist between the extensor
pollicis brevis and extensor pollicis longus
tendons. There is no visible deformity.
Radiographs show no fracture.
Which one of the following is the most
appropriate initial treatment of this patient?
(check one)
A. A wrist extension splint
B. An ulnar gutter splint
C. A thumb spica splint
D. A short arm cast
E. Physical therapy

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C. Difficulty opening his mouth. Trismus is


almost universally present with peritonsillar
abscess, while voice changes, otalgia, and
odynophagia may or may not be present.
Pharyngotonsillitis and peritonsillar cellulitis
may also be associated with these
complaints. Otalgia is common with
peritonsillar abscess, otitis media,
temporomandibular joint disorders, and a
variety of other conditions. Peritonsillar
abscess is rarely found in patients who do
not have at least a 3-day history of
progressive sore throat.

C. A thumb spica splint. The scenario


described is suspicious for an occult
fracture of the scaphoid bone of the wrist.
The mechanism of injury, falling on an
outstretched hand with the wrist extended,
combined with tenderness in the anatomic
snuff box (between the extensor pollicis
longus and extensor pollicis brevis
tendons) raises the possibility of a
scaphoid fracture even if initial radiographs
are negative. In order to reduce the
potential for serious complications,
including vascular necrosis and non-union,
it is imperative that both the wrist and the
thumb be immobilized. In the case
described, a thumb spica splint is the best
option initially. It should be worn
continuously until a follow-up evaluation,
including radiographs, in 1-2 weeks.

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A 42-year-old male seeks your advice


regarding smoking cessation. You
recommend a smoking cessation class, as
well as varenicline (Chantix).
You caution him that the most common
side effect is: (check one)

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E. nausea. The most common adverse


event attributed to varenicline at a dosage
of 1 mg twice a day is nausea, occurring in
approximately 30%-50% of patients.
Taking the drug with food lessens the
nausea.

A. dermatitis
B. diarrhea
C. edema
D. hirsutism
E. nausea
Occlusion of the circumflex artery is most
likely to cause EKG changes in: (check
one)
A. V1 and V2
B. V3 and V4
C. II, III, and AVF
D. I and AVL
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

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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.
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.

410/870

5/17/2014

A 6-month-old white male is brought to


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

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

411/870

5/17/2014

Patients with which rheumatologic


condition have the highest relative risk of
internal malignancy compared to the
general population? (check one)
A. Systemic scleroderma
B. Systemic lupus erythematosus
C. Sjgren's syndrome
D. Rheumatoid arthritis
E. Dermatomyositis

A 36-year-old white male complains of


episodic pain in the rectum over the past
several years. The pain occurs every 3-6
weeks and is sharp, cramp-like, and
severe. It lasts from 1 to 15 minutes. He
has no other gastrointestinal complaints. A
physical examination, including a digital
rectal examination and anoscopy, is
normal.
The most likely diagnosis is:
(check one)
A. fecal impaction
B. coccygodynia
C. anal fissure
D. proctalgia fugax
E. sacral nerve neuralgia

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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 nonHodgkin's lymphoma is 44 times higher
than in the general population, with an
individual lifetime risk of 6%-10%.
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.

412/870

5/17/2014

The most common cause of acute


interstitial nephritis is: (check one)
A. hypertension
B. pyelonephritis
C. collagen vascular disease
D. dehydration
E. hypersensitivity to medications

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E. hypersensitivity to medications.
Approximately 85% of cases of acute
interstitial nephritis result from a drugrelated hypersensitivity reaction; other
cases are due to mechanisms such as an
immunologic response to infection or an
idiopathic immune syndrome.
Hypertension and dehydration do not
cause interstitial nephritis. Medications that
most commonly cause acute interstitial
nephritis through hypersensitivity reactions
include penicillins, sulfa drugs, and
NSAIDs.
Urinalysis typically reveals moderate to
minimal proteinuria, except in NSAIDinduced acute interstitial nephritis, in which
proteinuria may reach the nephrotic range.
Other typical findings include sterile
pyuria, the absence of red blood cell
casts, and frequently eosinophiluria, but
none of these findings is pathognomonic.
Withdrawal of the causative agent leads to
resolution of the problem within 7-10 days
in the majority of cases, and most patients
have a good recovery.

413/870

5/17/2014

A 24-year-old female has noted excessive


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

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A. Telogen effluvium. The recycling of


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

414/870

5/17/2014

============================
===========================
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 .

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A. A central DXA scan of the lumbar


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

Which one of the following tests would be


best to determine whether this patient has
osteoporosis? (check one)
A. A central DXA scan of the lumbar
spine and hips
B. A forearm DXA scan
C. Quantitative CT of the lumbar spine
D. Quantitative calcaneal ultrasonography
E. Measurement of biochemical markers
of bone turnover in the urine

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415/870

5/17/2014

A 56-year-old female has a 35-pack-year


smoking history. She is concerned that she
may have COPD, although she has no
history of chronic cough, chest pain, or
other pulmonary symptoms. Her family
history is remarkable for a mother with
COPD who was a smoker, but there is no
family history of 1-antitrypsin disease.
Which one of the following would you
recommend with regard to screening
spirometry?
(check one)
A. Screening, based on her age
B. Screening, based on her family history
C. Screening, based on her smoking
history
D. No screening, based on lack of benefit
An 8-year-old white male presents with a
4-day history of erythematous cheeks,
giving him a "slapped-cheek" appearance.
Examination of the extremities reveals a
mildly pruritic, reticulated, erythematous,
maculopapular rash (see Figure 1). He is
afebrile and no other constitutional
symptoms are present.

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D. No screening, based on lack of benefit.


COPD is the fourth leading cause of death
in the United States. The diagnosis is
made by documenting airflow obstruction
in the presence of symptoms and/or risk
factors. Airflow limitation cannot be
accurately predicted by the history and
examination.
The U.S. Preventive Services Task Force
recently concluded that there is "moderate
certainty" that screening asymptomatic
patients for COPD using spirometry has
little or no benefit and is not
recommended. This recommendation
applies to otherwise healthy individuals
without a family history of 1-antitrypsin
disease.
...

416/870

5/17/2014

The most likely etiologic agent is


(check one)
A. human parvovirus
B. adenovirus
C. cytomegalovirus
D. coxsackievirus

A 35-year-old right-handed softball player


injures his left wrist when sliding into
second base. When he sees you the next
day his description of the injury indicates
that he hyperextended his wrist while
sliding, and the pain was later
accompanied by swelling. Your
examination is remarkable only for mild
swelling and tenderness of the dorsal
wrist, distal to the ulnar styloid. A
radiograph of the wrist is shown in Figure
2.

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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 1-3 weeks but can recur with
heat, stress, and exposure to sunlight.
...

417/870

5/17/2014

Which one of the following best describes


this injury? (check one)
A. Triquetral fracture
B. Scaphoid (navicular) fracture
C. Lunate fracture
D. Lunate dislocation
E. Wrist sprain

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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.

418/870

5/17/2014

Which one of the following medications is


most effective for treating the arrhythmia
shown in Figure 3?
(check one)
A. Atropine
B. Bretylium tosylate (Bretylol)
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl)
E. Adenosine (Adenocard)

The condition shown in Figure 4 occurred


in a 31-year-old sexually active male.
Which one of the following is true
regarding this problem?
(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

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E. Adenosine (Adenocard). Adenosine,


an expensive intravenous drug, is highly
effective in terminating many resultant
supraventricular arrhythmias. Although it
can cause hypotension or transient atrial
fibrillation, adenosine is probably safer
than verapamil because it disappears from
the circulation within seconds. Because of
its safety, many cardiologists now prefer
adenosine over verapamil for treatment of
hypotensive supraventricular tachycardia.
Bretylium tosylate, procainamide, and
lidocaine are used to treat ventricular
arrhythmias. Atropine is indicated in the
treatment of sinus bradycardia.
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 HPV-associated
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.

419/870

5/17/2014

Which one of the following interpretations


of Figure 5 is most accurate?
(check one)
A. Surgical menopause is on the increase
B. Menopause is occurring at an earlier
age
C. The mean age for reaching menopause
is 50
D. One hundred percent of this sample
reached menopause by age 60
E. Menopause is the result of relative
estrogen deficiency

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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.

420/870

5/17/2014

Which one of the following best describes


the condition seen in the radiograph in
Figure 6?
(check one)
A. Osgood-Schlatter disease
B. Legg-Calv-Perthes disease
C. Blount's disease
D. Slipped capital femoral epiphysis
E. A normal hip
A cement plant worker presents to your
office with the recurrent acute skin
eruption on his legs shown in Figure 7.
It extends proximally from the dorsum of
the feet to just below the knees. This is the
third eruption in 2 years.This patient most
likely has: (check one)
A. tinea with a secondary id reaction
B. rhus dermatitis
C. methicillin-resistant Staphylococcus
aureus (MRSA) cellulitis
D. contact dermatitis related to his
occupation

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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. LeggCalv-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.
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.

421/870

5/17/2014

At a routine annual visit, a 31-year-old


inner-city 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. A paronychial fungal infection
B. Psoriasis
C. Iron deficiency
D. Lead exposure
E. A traumatic/metabolic event
============================
===========================
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)

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E. A traumatic/metabolic event.
Fingernails and toenails are often
overlooked as clues to systemic illness.
Like hair shafts, they document a history
of the body during the past several
months. The symmetric depression across
the nail plate growing toward the distal
edge of the nail shown here represents
significant trauma to the body some weeks
ago. These classic lines are called Beau's
lines. No treatment is required. The other
options listed involve the nails, but cause
different and characteristic types of nail
changes.

A. Aspirin. A number of drugs inhibit


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

422/870

5/17/2014

An otherwise healthy 10-year-old female


presents with a papulovesicular eruption
on one leg.It extends from the lateral
buttock, down the posterolateral thigh, to
the lateral calf. It is mildly painful. The
patient's immunizations are up to date,
including varicella and MMR. Her family
has a pet cat at home, and another child at
her school was sent home with a rash
earlier in the week.
Which one of the following is the most
likely diagnosis?
(check one)

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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.

A. Contact dermatitis
B. Herpes zoster dermatitis
C. Tinea corporis
D. Scabies
A 7-year-old male with recurrent sinusitis
has difficulty breathing through his nose.
He has had chronic diarrhea and his
weight is at the 5th percentile. Nasal
polyps are noted on examination, in the
form of grayish pale masses in both nares.
No nasal purulence or odor is present.
Which one of the following tests should
you order? (check one)
A. A serum angiotensin-converting
enzyme level
B. A serum alpha1-antitrypsin level
C. A serum ceruloplasmin level
D. An erythrocyte sedimentation rate
E. A sweat chloride test

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E. A sweat chloride test. This child has


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

423/870

5/17/2014

A 30-year-old female with dysfunctional


uterine bleeding asks about treatment
options. An examination is normal and
blood testing is negative. She is unmarried
and is undecided about having children.
Which one of the following would be the
most appropriate treatment for this
patient? (check one)
A. A levonorgestrel-releasing intrauterine
device
B. Endometrial ablation
C. Hysterectomy
D. Oral progestin during the luteal phase
You are treating an 18-year-old white
male college freshman for allergic rhinitis.
It is September, and he tells you that he
has severe symptoms every autumn that
impair his academic performance. He has
a strongly positive family history of atopic
dermatitis.
Which one of the following medications is
considered optimal treatment for this
condition? (check one)
A. Intranasal glucocorticoids
B. Intranasal cromolyn sodium
C. Intranasal decongestants
D. Intranasal antihistamines

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

A. Intranasal glucocorticoids. Topical


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

424/870

5/17/2014

You are treating a 53-year-old female for


a deep-vein thrombosis in her left leg. The
use of compression stockings for this
problem has been shown to: (check one)
A. increase the risk of pulmonary
embolism
B. increase the level of pain
C. increase complications if used prior to
completion of a course of anticoagulation
therapy
D. decrease the risk of post-thrombotic
syndrome

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D. decrease the risk of post-thrombotic


syndrome. Post-thromb