Will’s study set

A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his right
ear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameter
and has a horny plug in the center.
The most likely diagnosis is
A) Bowen’s disease
B) basal cell carcinoma
C) keratoacanthoma
D) Kaposi’s sarcoma
E) seborrheic keratosis
Keratoacanthoma is a relatively common lesion in the elderly, but is difficult to distinguish from squamous
cell carcinoma. However, it is easily distinguished from Bowen’s disease, basal cell carcinoma, Kaposi’s
sarcoma, and seborrheic keratosis. Most keratoacanthomas undergo a benign self-healing course but may
leave a large, unsightly scar. Treatment is almost always preferred, both for cosmetic reasons and to
prevent the rare case of malignant transformation. Proper treatment for a lesion with this appearance is
excisional biopsy in order to distinguish between keratoacanthoma and squamous cell carcinoma.
An 8-year-old male is brought to the emergency department with an acute asthma attack that
began 48 hours earlier. His mother initiated his asthma action plan when the attack began,
starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with a
spacer every 3-4 hours. In the emergency department the child is alert, with a respiratory rate
of 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peak
flow is 40% of the predicted value.
Which one of the following should you do next?
A) Continue the current albuterol treatment but switch to a nebulizer
B) Administer high-dose albuterol via nebulizer every 20 minutes for 1 hour
C) Administer intravenous corticosteroids within the first hour
D) Administer magnesium sulfate intravenously
E) Prescribe high-dose mucolytics and chest physiotherapy
Repeated doses of a short-acting 2-agonist and correction of hypoxia are the main elements of initial
emergency department treatment for acute asthma exacerbations in children. Nebulizer treatments are no
better than a metered-dose inhaler with a spacer (SOR A). High-dose nebulized albuterol every 20 minutes
for 1 hour has not been shown to be beneficial. In children already receiving standard treatment with
albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve
lung function and reduce the need for hospitalization (SOR A). Oral administration of corticosteroids is
as effective as the intravenous route for reducing the need for hospital admission (SOR A). Mucolytics and
chest physiotherapy have not been shown to be effective in children with acute asthma attacks.
Ref: Pollart SM, Compton RM, Elward KS: Management of acute asthma exacerbations. Am Fam Physician 2011;84(
A 56-year-old male with type 2 diabetes mellitus has normal cardiac and renal function but has
failed to achieve adequate control of his diabetes with diet and multiple oral agents. His BMI is
30.1 kg/m2 and his hemoglobin A1c level is 9.1%.
Which one of the following is most likely to be beneficial in combination with insulin and diet
therapy in this patient?
A) Acarbose (Precose)
B) Glimepiride (Amaryl)
C) Metformin (Glucophage)
D) Pioglitazone (Actos)
E) Repaglinide (Prandin)
Metformin has been found to reduce cardiovascular risk in patients with type 2 diabetes mellitus. It also
decreases the risk of weight gain, and unlike some oral agents it does not significantly increase the risk of
hypoglycemia. It should be continued when insulin is initiated in patients with no renal impairment (SOR
You see a 78-year-old male in the hospital the day after his hip-replacement surgery. He has not
voided in the past 12 hours. A urethral catheter is placed and 500 mL of urine is removed from
his bladder.
Which one of the following is most likely to improve the success rate of a voiding trial?
A) Using a specialized catheter coudé instead of a standard catheter
B) Leaving the catheter in place for at least 2 weeks
C) Immediately removing the catheter to prevent a urinary tract infection
D) Starting tamsulosin (Flomax), 0.4 mg daily, at the time of catheter insertion
E) Starting antibiotic prophylaxis at the time of catheter insertion
Urinary retention is a common problem in hospitalized patients, especially following certain types of
surgery. Starting an -blocker at the time of insertion of the urethral catheter has been shown to increase
the success of a voiding trial (SOR A). Voiding trial success rates have not been shown to be improved
by leaving the catheter in for 2 weeks, immediate removal of the catheter, using a specialized catheter, or
antibiotic prophylaxis.
A 22-year-old college student comes to your office to discuss her several-year history of
abdominal pain and constipation. It has gotten worse since she returned to school this fall. She
describes crampy pain and bloating that eases after defecation. Her bowel movements are firm
and difficult to pass, and occur about every 3 days on average. Her symptoms have not included
vomiting, weight loss, blood in the stool, or melena. Her menses are regular and she is an
otherwise healthy young woman. Her family history is negative for any gastrointestinal or
genitourinary diseases. On examination you find her abdomen to be soft and without masses,
with no tenderness to palpation.
Which one of the following would be most appropriate at this time?
A) A therapeutic trial of increased soluble fiber intake
B) A therapeutic trial of lubiprostone (Amitiza)
C) Abdominal ultrasonography
D) Abdominal CT
E) Colonoscopy
ANSWER: A (Note: An article on this subject appeared in AFP after the exam was sent to the
printer, and came to our attention after the exam was scored. B is now considered a
better answer, and the critique and references have been updated to reflect this.)
This patient’s symptoms are consistent with irritable bowel syndrome (IBS). Her history, physical
examination, and laboratory evaluation did not show any evidence of peptic ulcer disease, celiac disease,
thyroid disease, or inflammatory bowel disease. Red flags include unintentional and unexplained weight
loss, rectal bleeding, a family history of bowel or ovarian cancer, and a change in bowel habits to looser
and/or more frequent stools persisting for more than 6 weeks in a person over 60. The patient does not
have any of these findings and therefore does not require any additional testing to confirm the diagnosis
of IBS.
Patients should be given information that explains the importance of self-help in effectively managing their
IBS. This should include information on general lifestyle, physical activity, and dietary intake. A Cochrane
review showed that soluble fiber such as psyllium is not effective for IBS. Lubiprostone is effective for
constipation-predominant IBS.
Which one of the following is a proven strategy to reduce anterior cruciate ligament tears in
high-school athletes?
A) The use of neoprene knee sleeves by all athletes competing in high-risk sports
B) Consistent inclusion of long-distance running in practice sessions
C) Structured exercises stressing balance, muscle strength, and proprioception
D) Prohibiting girls from playing on boys’ sports teams
E) Increased enforcement of penalties involving dangerous plays
Several prospective trials have shown significant benefits from the use of sports-specific training of the hips
and legs in preventing anterior cruciate ligament (ACL) injuries. These programs focus on plyometrics
(repetitive actions that rapidly load and contract a targeted muscle group), strength training, and balance
exercises, along with consistent feedback about proper landing technique. One such study was able to
reduce the frequency of ACL injuries in female high-school soccer players by 88%. Although the risk of
ACL injuries in female athletes is up to 10 times that of males, there is no data to show that restricting their
participation in male-dominated sports is a successful strategy to prevent injuries.
A 70-year-old female presents with recurrent episodes of cough, voluminous sputum, and
dyspnea. She is a nonsmoker and has never smoked, except for a few cigarettes in her teens.
Her past, family, and occupational histories do not suggest a cause for pulmonary or liver
disease. Her examination is within normal limits except for the lung examination, which reveals
crackles at both lung bases on auscultation. A chest radiograph shows nonspecific markings at
both bases.
The most appropriate next step in her workup would be
A) a PPD skin test
B) high-resolution CT
C) an a1-antitrypsin level
D) referral for bronchoscopy
The symptoms of this patient fit the criteria for bronchiectasis, and the gold standard for diagnosis is
high-resolution chest CT. The chest film does not suggest pulmonary tuberculosis, so a PPD would not
be appropriate initially (although tuberculosis can be a cause of bronchiectasis). Bronchoscopy may
eventually be necessary, but not at this point in the investigation. This patient’s age, the absence of findings
of emphysema, and the lack of a family history of emphysema or liver disease make the diagnosis of
a1-antitrypsin deficiency unlikely.
A previously healthy 24-year-old female presents with a 10-day history of facial pain and fever.
On examination she has tenderness over the maxillary sinus on the left.
Which one of the following would be most appropriate for treatment of this patient’s condition?
A) Intranasal saline flushes
B) Intranasal antihistamines
C) Oral antihistamines
D) Oral antibiotics
E) Reassurance only
While there are several guidelines for the clinical diagnosis of acute bacterial sinusitis (ABS), there is
general agreement that patients with a duration of symptoms of at least 10 days without improvement
should be treated with antibiotics, including both children and adults (SOR C). Signs and symptoms may
include nasal drainage and congestion, facial pressure and/or pain, sinus tenderness, and headache.
Recommendations for the duration of treatment vary.
One set of guidelines calls for empiric treatment with amoxicillin alone; another recommends going directly
to amoxicillin/clavulanate. Suggested alternatives include a “respiratory” quinolone or the combination of
a third-generation cephalosporin and clindamycin, particularly in patients with penicillin allergy. Due to
the increasing emergence of resistant Streptococcus and Haemophilus species, neither trimethoprim/sulfamethoxazole
nor macrolides are now recommended for empiric treatment of ABS.
Data regarding the efficacy of other measures such as nasal irrigation and the use of decongestants is
limited and variable. The most recent guidelines do not recommend the use of decongestants, whether oral
or topical.
A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized
by flat-topped violaceous papules 3-4 mm in size. The lesions are located primarily on the volar
wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared
she went to the emergency department and was treated for “possible scabies,” but the treatment
has made little or no difference.
Which one of the following treatments is indicated at this time?
A) Clobetasol (Cormax, Temovate) 0.05% ointment
B) Permethrin 5% cream
C) Tacrolimus (Protopic) 0.1% ointment
D) Triamcinolone 0.1% cream
This patient has classic lichen planus, with pruritic, symmetrically distributed papular lesions. The
violaceous flat-topped papules, usually 3-6 mm in size, are distinct and so characteristic in appearance that
a biopsy is usually not necessary to make the diagnosis. First-line treatment is with high-potency topical
corticosteroids such as clobetasol, as mid-potency topical agents such as triamcinolone are ineffective.
Topical calcineurin inhibitors, including tacrolimus, can be used in cases not responding to topical
corticosteroids. While scabies can masquerade as a variety of other dermatoses, retreatment with a
scabicide is not indicated in this patient.
Which one of the following children should be referred immediately for evaluation of speech
A) A 12-month-old who babbles but speaks no words
B) An 18-month-old who does not understand action words
C) A 2-year-old who has a vocabulary of 25 words
D) A 2-year-old who is unable to follow three-step directions
E) A 3-year-old who has a vocabulary of 50 words
Answer E: Because speech-language therapy is effective for primary expressive language disorders, referral as early
as possible is critical (SOR A). Red flags suggesting the need for immediate evaluation include no babbling
in a 12-month-old, not saying “mama” or “dada” at 18 months, a vocabulary of less than 25 words at age
2, and using less than 200 words at age 3. Children should be able to follow two-step commands by 2
years of age (SOR A).
A 23-year-old female presents with recurrent unprovoked epistaxis. The patient’s mother is
known to have hereditary hemorrhagic telangiectasia.
Contrast echocardiography is recommended to screen for which one of the following frequently
associated conditions?
A) Atrioseptal defect
B) Ventricular septal defect
C) Aortic root aneurysm
D) Pulmonary arteriovenous malformation
E) Myocardial perfusion defects
Answer D: Pulmonary arteriovenous malformations are found in 15%-30% of patients with hereditary hemorrhagic
telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. All patients with possible or
confirmed HHT should be screened for pulmonary arteriovenous malformations with contrast
echocardiography (SOR C). While contrast echocardiography is used to detect atrioseptal and ventricular
septal defects, neither of these conditions is particularly prevalent in HHT. Aortic aneurysms and
myocardial perfusion defects are also not associated with HHT.
A 65-year-old male who has been in good health presents to your office with a 2-day history of
a sensation of pressure and hearing loss in his left ear. A physical examination and a thorough
neurologic examination are both unremarkable. Both tympanic membranes are normal. An
audiogram shows a 30-decibel hearing loss at three consecutive frequencies in the left ear, with
normal hearing on the right. Placing a vibrating tuning fork in the midline of the forehead
reveals sound lateralizing to the right ear.
Which one of the following would be most appropriate at this point?
B) A CBC, metabolic profile, and thyroid studies
C) Nifedipine (Procardia)
D) Acyclovir (Zovirax)
E) Oral corticosteroids
When a patient presents with sudden hearing loss it is important to distinguish between sensorineural and
conductive hearing loss. Patients should be asked about previous episodes, and the workup should include
both an assessment for bilateral hearing loss and a neurologic examination. Sudden sensorineural hearing
loss is diagnosed by audiometry demonstrating a 30-decibel hearing loss at three consecutive frequencies,
with no other cause indicated from the physical examination.
Evaluation for retrocochlear pathology may include auditory brainstem response, MRI, or follow-up
audiometry. Routinely prescribing antiviral agents, thrombolytics, vasodilators, vasoactive substances, or
antioxidants is not recommended. Oral corticosteroids may be offered as initial therapy, and hyperbaric
oxygen therapy may be helpful within 3 months of diagnosis. The guidelines also strongly recommend
against routine laboratory tests or CT of the head as part of the initial evaluation.
Which one of the following is true concerning the use of hemoglobin A1c levels to diagnose
diabetes mellitus?
A) A level >6.0% is diagnostic of diabetes mellitus
B) Results can be misleading in patients with sickle cell disease
C) The test is equally sensitive in African-Americans and whites
D) The test is useful to diagnose diabetes during pregnancy
Hemoglobin A1c (HbA1c) levels of 6.0%-6.5% indicate an increased risk for diabetes mellitus, and levels
>6.5% can be used to diagnose diabetes. Hemoglobinopathies and conditions causing hemolysis can cause
HbA1c measurements to be falsely low. The opposite effect is seen in African-Americans, who have higher
HbA1c levels than whites along the continuum of glycemia. Other tests should be used in patients with
conditions that affect HbA1c, including pregnancy.
A 50-year-old female presents for evaluation of dyspnea that tends to occur with exercise. She
has a 40-pack-year history of smoking and has been diagnosed with exercise-induced asthma.
She denies any other medical problems. You perform spirometry and find that the expiratory
loop is normal and that she has a flattened inspiratory loop.
What is the most likely diagnosis?
A) Vocal cord dysfunction
C) Asthma
D) Restrictive lung disease
Vocal cord dysfunction is a disorder in which the vocal cords move toward midline during inspiration or
expiration, leading to varying degrees of obstruction. It is commonly misdiagnosed as exercise-induced
asthma. There are a number of precipitating factors, including exercise, psychological conditions, irritants,
rhinosinusitis, and gastroesophageal reflux disease. Spirometry generally will show a normal expiratory
loop with a flattened inspiratory loop. In asthma and COPD the FEV1/FVC ratio is decreased, resulting
in a concave shape in the expiratory portion of the flow-volume curve. The inspiratory loops are generally
normal. Patients with restrictive lung disease have a normal FEV1/FVC ratio with a reduced FVC.
A previously healthy 27-year-old female presents with dysuria and urinary urgency and
frequency. She also complains of right flank pain, fevers and chills, and nausea without
vomiting. She has a decreased appetite, but has been able to drink liquids.
On examination she has a temperature of 38.4°C (101.2°F), a heart rate of 102 beats/min, and
a blood pressure of 126/82 mm Hg. She has mild suprapubic tenderness and right costovertebral
angle tenderness. A urinalysis shows microscopic pyuria, hematuria, and a positive leukocyte
esterase test. Additional laboratory studies are notable for leukocytosis with a left shift, but are
otherwise normal, including a negative pregnancy test. The patient does not have allergies to any
Which one of the following would be most appropriate for this patient?
A) Outpatient management with oral amoxicillin
B) Outpatient management with oral ciprofloxacin (Cipro)
C) Outpatient management with oral nitrofurantoin (Macrodantin)
D) Inpatient management with intravenous ceftriaxone (Rocephin)
E) Inpatient management with intravenous levofloxacin (Levaquin)
Most cases of uncomplicated acute pyelonephritis, including the one described here, can be managed in
the outpatient setting. Findings that might prompt consideration of inpatient management include comorbid
conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac
disease), hemodynamic instability, male sex, metabolic derangements, pregnancy, severe pain, a toxic
appearance, an inability to take liquids by mouth, or a temperature >39.4°C (103.0°F).
Nitrofurantoin for 5 days is an appropriate treatment for an uncomplicated urinary tract infection, but not
for pyelonephritis. Amoxicillin is generally not considered first-line treatment for pyelonephritis because
of a high prevalence of resistance to oral -lactam antibiotics, and it should only be chosen if susceptibility
results for the urinary isolate are known and indicate likely activity. Fluoroquinolones, such as
ciprofloxacin, are the preferred empiric antibiotic treatment for outpatient treatment of pyelonephritis, as
long as the local prevalence of resistance to community-acquired Escherichia coli is less than 10%.
An 82-year-old female is hospitalized for pneumonia and sepsis. She has advance directives in
Should it become necessary, the patient’s decision-making capacity is determined by
A) the spouse or next of kin
B) the attending physician
C) a consulting psychiatrist
D) the hospital ethics committee
E) a judge, at the request of hospital social services or the physician
The attending physician is responsible for determining capacity and incapacity for decision making. The
extent, cause, and probable duration of any incapacity should be documented in the clinical record.
A 67-year-old female presents with the inability to smell. She is in good health, and her only
medical problem is osteoporosis, treated with alendronate (Fosamax). She says she has no sinus
or nasal symptoms. A physical examination is normal including an ear, nose, and throat
Which one of the following would be most appropriate at this point?
A) Discontinuing the alendronate
B) An anti-tissue transglutaminase antibody test
C) A serum vitamin D level
D) MRI of the brain
Certain drugs can affect taste more than smell, but this does not include the bisphosphonates. Olfactory
disorders may be associated with deficiencies of vitamins A, B6, B12, and trace metals, but not with vitamin
D deficiency. Celiac disease is not known to cause a decreased ability to smell. Rare tumors involving the
olfactory region of the brain can affect smell, and are best detected by MRI.
The American Heart Association recommends a goal blood pressure of 130/80 mm Hg for
patients with
A) heart failure
B) pulmonary hypertension
C) atrial fibrillation
D) angina pectoris
E) chronic kidney disease
The American Heart Association recommends a goal blood pressure of 130/80 mm Hg or less for the
treatment of hypertension in patients with diabetes mellitus, chronic kidney disease, or coronary artery
A 78-year-old female has chronic symptomatic orthostatic hypotension, likely related to diabetic
autonomic dysfunction, which has failed to respond to nonpharmacologic treatment. Her current
medications include metformin (Glucophage), 1000 mg twice daily; atorvastatin (Lipitor), 40 mg
daily; aspirin, 81 mg daily; and insulin glargine (Lantus), 24 units at bedtime.
Which one of the following would be the most effective therapy for her orthostatic hypotension?
A) Clonidine (Catapres)
B) Midodrine
C) Pseudoephedrine
D) Terbutaline
E) Theophylline
Effective treatments for chronic orthostatic hypotension include fludrocortisone, midodrine, and
physostigmine (SOR B). Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate
A 34-year-old white female who works as an engineer for a major corporation complains of
fatigue, low energy, and a depressed mood. She states that she has felt this way for most of her
life. She feels depressed most of the time but denies any recent stresses or significant losses in
her life. She reports that she is doing well at work and that she recently received a promotion.
She has no interests other than her job and states that she has no happy thoughts and that her
self-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies.
She has had no sleep disturbance, change in appetite, or difficulty concentrating. She is taking
no medications and denies substance abuse. Results of a recent medical evaluation required by
her employer were all normal, including a physical examination, EKG, multiple chemical
profile, CBC, urinalysis, and TSH level.
Which one of the following is the most likely diagnosis?
A) Major depression
B) Dysthymic disorder
C) Bipolar disorder
D) Cyclothymia
E) Adjustment disorder with depressed mood
Dysthymic disorder is characterized by depressed mood for at least 2 years in addition to at least two of
the following: change in appetite, alteration in sleep, low energy, low self-esteem, poor concentration,
or feelings of hopelessness. There must be no history of a manic or hypomanic episode, substance abuse,
a chronic psychotic disorder, or an organic cause.
Symptoms of major depression are similar to those of dysthymia and can occasionally be difficult to
distinguish from dysthymia. This patient’s lifelong history of a depressed mood not triggered by any
particular depressing event, and the predominance of patient complaints as opposed to objective signs,
indicate that major depression is not the diagnosis in this case. Bipolar disorder is characterized by major depression with periods of mania. Cyclothymia is characterized
by dysthymia with periods of hypomania. Adjustment disorder with depressed mood is characterized by
impaired social or occupational functioning or abnormal symptoms within 3 months of a stressor.
A 35-year-old female immigrant from a rural village in Southeast Asia visits your clinic shortly
after arriving in the United States. She presents with a 1-week history of low-grade fever and
a nonproductive cough, and has crackles but no signs of consolidation or pleural effusion on
examination. You order a chest radiograph and see several oval infiltrates, 1-2 cm in size.
Which one of the following is the most likely cause of these symptoms?
A) Ascaris lumbricoides
B) Enterobius vermicularis (pinworm)
C) Taenia saginata
D) Taenia solium
E) Diphyllobothrium latum
This patient has the classic pulmonary manifestations of Ascaris infection, which develop during the
transpulmonary passage of Ascaris larvae (SOR C). The larvae produce a syndrome of transient
eosinophilic pulmonary infiltrates, commonly referred to as Löffler syndrome. Ascaris infection is the most
common worldwide cause of this syndrome. Symptoms develop when larvae are within the lungs,
approximately 9-12 days after ingestion of Ascaris eggs. Patients may develop the following symptoms
and signs:
• an irritating, nonproductive cough and burning substernal discomfort
• dyspnea and blood-tinged sputum
• urticaria during the first few days of the illness (15% of patients)
• fever, which infrequently exceeds 38.3°C (101.0°F)
• crackles and wheezing, with no signs of consolidation
• hepatomegaly
The acute symptoms generally subside within 5-10 days, depending upon the severity of the illness. The
chest radiograph may show round or oval infiltrates ranging in size from several millimeters to several
centimeters in both lung fields; these lesions are more likely to be present when blood eosinophilia exceeds
10%. The infiltrates are migratory and may become confluent in perihilar areas, and usually clear
completely after several weeks.
Taenia does not infiltrate the lungs, but forms cysts in the muscles. Diphyllobothrium latum, the fish
tapeworm, does not cause pulmonary problems. Enterobius (pinworm) does not migrate from the
gastrointestinal tract into other organs.
A new first-time mother calls for advice on nipple pain with breastfeeding. She is 6 days post
partum after an uncomplicated delivery.
Which one of the following would be most effective?
A) Lanolin cream
B) Expressed breast milk
C) Tea bag compresses
D) Hydrogel dressing
E) Education on positioning
Nipple pain with breastfeeding is extremely common, with some studies reporting a prevalence of up to
96%. Preventing or alleviating nipple pain is important for comfort, but also for promoting breastfeeding
in general. The best intervention for nipple pain is education on proper positioning and attachment of the
infant. Topical remedies may also be effective, although no one topical agent has been shown to be clearly
superior, and none is as effective as education on positioning and latch-on.
A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and
a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers
her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several
distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small
effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints
are affected.
The most likely cause of this problem is
A) varicella-zoster virus
B) measles (rubeola) virus
C) parvovirus B19
D) adenovirus
E) human immunodeficiency virus (HIV)
Also known as erythema infectiosum or fifth disease, parvovirus B19 infection is a fairly common cause
of an exanthematous rash and arthritis in younger women. This infection should be particularly suspected
in health-care workers who have frequent contact with children. The specific characteristics of the rash,
the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues
suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause
arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease.
Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.
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), his blood
pressure is 100/60 mm Hg, and his heart rate is 92 beats/min and regular. Examination of the
heart and lungs 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 the fluid for analysis. Which one of
the following findings would best support the suspected diagnosis of spontaneous bacterial
A) pH <7.2 B) Bloody appearance C) Neutrophil count >250/mL
D) Positive cytology
E) Total protein >1 g/dL
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 67-year-old female has a bone density study that indicates a T score of -3.5. You prescribe
alendronate (Fosamax) but at her next visit she says she cannot tolerate the side effects and asks
about other therapies.
Which one of the following has the best evidence for prevention of both vertebral fractures and
hip fractures?
A) Calcitonin-salmon (Miacalcin)
B) Raloxifene (Evista)
C) Teriparatide (Forteo)
D) Zoledronic acid (Reclast)
There are a number of alternatives to the bisphosphonates. Unfortunately, efficacy data is not encouraging
for most of them. Intravenous zoledronic acid has been shown to reduce both hip fracture risk and
vertebral fracture risk. Teriparatide reduces vertebral fracture risk but not hip fracture risk. The same is
true for raloxifene and calcitonin salmon.
A 65-year-old Asian male with a long history of cigarette smoking presents with weakness,
lethargy, and mental confusion. A physical examination is normal. There are no signs of
dehydration, edema, or pigmentary changes.
Laboratory Findings:
Serum sodium… 122 mEq/L (N 135-145)
Urine osmolality… 280 mOsm/kg H2O (N 50-1400)
Plasma osmolality…260 mOsm/kg H2O (N 285-295)
Urine sodium… 25 mEq/L
BUN…4 mg/dL (N 8-25)
Serum potassium…4.1 mEq/L (N 3.5-5.0)
The most likely diagnosis is
A) sodium depletion
B) syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
C) primary polydipsia
D) adrenal insufficiency
The syndrome of inappropriate secretion of antidiuretic hormone should be suspected in any patient who
has hyponatremia and excretes urine that is hypertonic relative to plasma. A urine sodium concentration
>20 mEq/L combined with a low BUN level provides further support for the diagnosis. Additional
findings may include weakness, lethargy, mental confusion, and weight gain.Sodium depletion usually causes clinical features of dehydration, an elevated BUN level, and a urine
sodium concentration <20 mEq/L. Primary polydipsia almost invariably results in dilute urine with low
osmolality when compared to serum. Renal failure is unlikely with a BUN level of 4 mg/dL. Adrenal
insufficiency is also unlikely, as most patients will have skin pigmentation, weight loss, and hypotension.
A normal serum potassium level is also inconsistent with the diagnosis of adrenal insufficiency.

A 38-year-old female has spontaneous rupture of the membranes with thick meconium just prior
to delivery of a male infant at 40 weeks gestation. Oropharyngeal suctioning of the infant is
performed prior to delivery of the shoulders. Upon delivery the infant is noted to have
spontaneous respirations, a heart rate of 120 beats/min, cyanosis of the hands and feet, and good
Which one of the following would be most appropriate in the immediate management of the
A) Intubation and tracheal suctioning below the vocal cords
B) Suctioning of the stomach to remove any swallowed meconium
C) Positive pressure ventilation
D) Expectant management only
Endotracheal suctioning of vigorous infants born through meconium-stained amniotic fluid is not
recommended (SOR C). Although infants born through thick meconium are more likely to develop
aspiration syndrome, endotracheal suctioning does not provide any benefit over expectant management in
preventing this condition or other respiratory problems. Endotracheal suctioning may be useful if the
infant is not vigorous or shows signs of respiratory depression.
Suctioning of the infant’s stomach can be done electively but is not required for immediate management.
Positive pressure ventilation is indicated for ventilatory support of newborns with respiratory depression
who are not born through meconium-stained amniotic fluid.
An 84-year-old female presents for follow-up of multiple chronic medical problems. She is
usually accompanied by her daughter, who lives nearby, but today is brought in by her son and
daughter-in-law, who live out of town. They are supportive, but are insistent that the patient see
a specialist for a problem that she has previously decided not to pursue further. The patient
wants to avoid conflict but does not want to see any other physicians.
Which one of the following is the most appropriate way to deal with this situation?
A) Speak with the son and daughter-in-law privately
B) Maintain neutrality and avoid triangulation
C) Call the daughter to discuss the situation
D) Try to talk your patient into seeing the specialist
E) Schedule the appointment to appease the family, then cancel it later
When family dynamics lead to conflict during an office visit, it is best for the physician to attempt to
remain neutral by avoiding triangulation, which occurs when the two sides in conflict each attempt to align
with a third party. Priority should be given to the patient’s right to privacy and confidentiality, and the
physician should ask permission from the patient to discuss his or her health issues with other people.
Physicians should always remember who they are primarily responsible to.
A 50-year-old male presents to your office with erythroderma and fever. He has not had a sore
throat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril
(Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has a
blood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6°C
(101.5°F). The skin is remarkable for marked erythema over 90% of the body, with tenderness
to touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted in
the neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.
A CBC shows a WBC count of 15,000/mm3 (N 4300-10,800) with 20% eosinophils. A
metabolic profile shows an AST (SGOT) level of 100 U/L (N 10-40) and an ALT (SGPT) level
of 110 U/L (N 10-55), but is otherwise normal.
Which one of the following is the most likely diagnosis?
A) Stevens-Johnson syndrome
B) Erysipelas
C) Red man syndrome
D) Toxic shock syndrome
E) Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
DRESS is an acronym for Drug Reaction with Eosinophilia and Systemic Symptoms. The hallmark of
DRESS syndrome is erythroderma accompanied by fever, lymphadenopathy, elevation of liver enzymes,
and eosinophilia. The offending medication should be discontinued immediately and treatment with
corticosteroids should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine,
and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS
syndrome has the highest mortality rate. Toxic shock syndrome should be suspected in patients with erythroderma, hypotension, and laboratory
evidence of end-organ involvement (elevated liver enzymes or kidney function studies, anemia,
thrombocytopenia, or elevation of creatine kinase). Treatment with intravenous clindamycin, which inhibits
toxin synthesis, should be undertaken immediately.
Stevens-Johnson syndrome is characterized by a vesiculobullous rash with mucocutaneous involvement,
and erysipelas is a painful localized rash with well-demarcated borders. Red man syndrome is associated
with vancomycin.
An unconscious 22-year-old male is brought into the emergency department. His respiratory
rate is 8/min, his pulse rate is 60 beats/min and regular, and his pupils are miotic.
The most likely cause of his condition is
A) organophosphate poisoning
B) scopolamine overdose
C) narcotics overdose
D) benzodiazepine overdose
In cases of drug overdose, several critical physical findings must be evaluated. The most important is the
size of the pupils. Tolerance rarely reduces the miotic effects of narcotic medications. A patient who is
comatose, with decreased breathing, a slow pulse, and small pupils should be strongly suspected of having
overdosed on a narcotic. Naloxone should be administered to reverse these effects. The response to
treatment with naloxone is irregular. Cerebral infarction in the pontine angle, organophosphate poisoning,
phenothiazine overdose, and treatment for glaucoma can also cause constricted pupils, but these
associations are seen much less frequently than narcotics overdose.
A 39-year-old male with a history of alcoholism presents to your office with complaints of
abdominal pain, vomiting, and nausea following a recent binge. He has eaten little since the
onset of his symptoms 3 days ago. Laboratory findings suggest alcoholic ketoacidosis. His serum
bicarbonate level is 16.3 mEq/L (N 22.0-26.0).
In addition to thiamine, what other treatment should be provided for this patient?
A) Bicarbonate and insulin
B) Glucagon (GlucaGen) and hydrocortisone
C) Normal saline and glucose
D) N-acetylcysteine and pyridoxine (vitamin B6)
Alcoholic ketoacidosis generally occurs in a patient who has been drinking heavily without eating. Blood
glucose levels are usually low or normal, and volume depletion associated with nausea, vomiting, and
abdominal pain is the norm. Patients typically have high osmolal and anion gaps. Treatment of alcoholic
ketoacidosis includes vigorous volume repletion with normal saline, along with administration of thiamine
and glucose. Only in the rare presence of marked acidemia (pH <7.10) is the administration of
bicarbonate thought to be necessary. Though insulin levels may be low, hyperglycemia is seldom found.
N-acetylcysteine and pyridoxine are not used for the treatment of alcoholic ketoacidosis. Levels of
glucagon and hydrocortisone are typically elevated in patients with alcoholic ketoacidosis.
A previously normotensive 20-year-old primigravida is admitted to the hospital at 39 weeks
gestation with a headache, a blood pressure of 170/110 mm Hg, and proteinuria. Which one of
the following is the most effective agent for preventing eclamptic seizure while preparing for
expedited delivery?
A) Benzodiazepines
B) Fosphenytoin (Cerebyx)
C) Magnesium sulfate
D) Nimodipine
Magnesium sulfate has a long history of use for preventing seizures in preeclampsia and eclampsia, and
a recent Cochrane review confirmed that it is the preferred agent. Benzodiazepines and fosphenytoin are
secondary agents that can be used if magnesium sulfate fails, but they are not as effective. Nimodipine was
also shown to be less effective than magnesium sulfate. Delivery is indicated, but magnesium sulfate must
also be administered (SOR A).
A 71-year-old white male with COPD and lung cancer is discharged from the hospital. In
addition to a medical diagnosis, which one of the following criteria is used to determine whether
Medicare will pay for his home oxygen therapy?
A) Oxygen saturation
D) The patient’s finances
Medicare eligibility for home oxygen therapy is based on oxygen saturation. To qualify for continuous
long-term oxygen therapy the patient must have a PaO2 less than or equal to 55 mm Hg or an SaO2 less than or equal to 88 mm Hg.
Which one of the following findings on examination of the head, oral cavity, and neck is
associated with diabetes mellitus?
A) Parotid enlargement
B) Tooth erosion
C) Diffuse melanin pigmentation
D) Cobblestone oral mucosa
E) Painful oral ulcers
Sialadenosis, bilateral noninflammatory enlargement of the parotid gland, is associated with diabetes
mellitus. Periodontal bleeding and inflammation, candidiasis, and delayed wound healing also are
associated with diabetes mellitus.
Tooth erosion can be an oral manifestation of gastroesophageal reflux disease or bulimia. Cobblestone oral
mucosa is seen in Crohn’s disease. Diffuse melanin pigmentation is an oral finding of Addison’s disease.
Painful oral ulcers occur in several conditions, including Behçet syndrome, aphthous ulcers, pemphigus,
and pemphigoid.
A 53-year-old female is concerned about a skin lesion that has recently been changing in size and
shape. On examination she is found to have a 7-mm, asymmetric, darkly pigmented lesion with
some color variegation and irregular borders.
Which one of the following skin biopsy techniques is most appropriate for confirming the
A) A shave biopsy
B) Electrodesiccation and curettage
C) Elliptical excision
D) Mohs surgery
This lesion is suspicious for melanoma, based on the asymmetry, irregular border, color variegation, and
size larger than 6 mm. In addition, a history of evolution of the lesion, with changes in size, shape, or
color, has been shown in some studies to be the most specific clinical finding for melanoma. The preferred
method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small
margin of normal-appearing skin. The depth of the lesion is crucial to staging and prognosis, so shave
biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location
or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely
to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an
appropriate treatment for melanoma. Mohs surgery is sometimes used to treat melanomas, but is not used
for the initial diagnosis.
A 22-year-old female in her second trimester of pregnancy presents with a 48-hour history of
a sore throat. She has also had coryza and a nonproductive cough. A physical examination
reveals a temperature of 37.3°C (99.2°F) and a blood pressure of 110/70 mm Hg. A HEENT
examination reveals tonsillar and pharyngeal erythema with no exudate. There is no adenopathy.
Her chest is clear.
Which one of the following would be most appropriate for this patient?
A) Reassurance and symptomatic treatment only
B) A routine throat culture
C) A rapid antigen detection test for Streptococcus
D) Azithromycin (Zithromax) for 5 days
E) Penicillin V for 10 days
Most episodes of pharyngitis are caused by viral rather than bacterial infections. The use of clinical
decision rules for diagnosing group A -hemolytic streptococcal pharyngitis improves quality of care while
reducing unwarranted treatment and overall cost (SOR A). The original Centor score used four signs and
symptoms to estimate the probability of acute streptococcal pharyngitis in adults with a sore throat, and
was later modified by adding age as a fifth criterion. One point each is assigned for (1) absence of cough,
(2) swollen, tender anterior cervical nodes, (3) temperature >38.0°C (100.4°F), and (4) a tonsillar
exudate and swelling. One point is added for patients between the ages of 3 and 14 years, and a point is
subtracted for patients over the age of 45. The cumulative score determines the likelihood of streptococcal
pharyngitis and the need for antibiotics, and guides testing strategies. Patients with a score of zero or 1 are
at very low risk for streptococcal pharyngitis and do not require testing or antibiotic therapy. Patients with
a score of 2-3 should be tested using a rapid antigen test or throat culture, and a positive result warrants
antibiotic therapy. Patients with a score of 4 or higher are at high risk for streptococcal pharyngitis, and
empiric treatment may be considered. This patient’s score is zero, and no testing or treatment is warranted.
A 34-year-old female has a history of many years of diffuse pain, debilitating fatigue, and
disrupted sleep. You suspect she may have fibromyalgia. Laboratory tests and imaging studies
have been negative. She is confused about why she is in so much pain even though “everything
is normal.”
What do you tell her is currently thought to be the etiology of fibromyalgia?
A) Diffuse inflammation of soft tissues
B) A chronic viral infection
C) An exaggerated response to tactile stimuli by the central nervous system
D) A malfunction of pain receptors in the dermis, causing excess sensitivity
E) A psychological disorder in which the patient imagines the pain
The understanding of fibromyalgia has been rapidly expanding in recent years, primarily due to the use
of functional magnetic resonance imaging (fMRI). The hallmark of fibromyalgia is an exaggerated
response to painful stimuli, or an attribution of pain to a stimulus that is normally not painful. Early
research focused on peripheral tissues as the source of this condition. However, the cause has now been
recognized as an abnormality in the central nervous system, which can be seen on fMRI. This physical
brain abnormality differentiates fibromyalgia from psychogenic conditions such as conversion disorder and
malingering. Any evidence of an actual abnormality of the peripheral tissue on physical examination, blood tests, or an
imaging study in a patient suspected to have fibromyalgia should raise the suspicion that another diagnosis
is also present. It is estimated that up to 25% of patients who have a definable rheumatologic condition
such as lupus or rheumatoid arthritis also suffer from fibromyalgia. Many patients who develop
fibromyalgia started having symptoms in the wake of a viral infection (especially Epstein-Barr virus).
However, these viral illnesses are believed to trigger a genetic predisposition rather than being a necessary
cause of this condition.
A 12-year-old African-American male is brought to your office by his parents because he has
been limping for the past month. He says he has pain in the groin and knee, but the pain is
poorly localized. On examination he is noted to be obese, with normal findings on examination
of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait
is antalgic.
The most likely cause of this problem is
A) unreported trauma
B) aseptic necrosis of the femoral head
C) reactive arthritis
D) juvenile rheumatoid arthritis
E) slipped capital femoral epiphysis
Slipped capital femoral epiphysis is often misdiagnosed, as the symptoms are frequently vague. It is the
most common hip disorder in adolescents, with the age range being 9 to 15 years. It occurs when the
proximal femoral epiphysis slips posteriorly and inferiorly on the femoral neck through the growth plate.
The typical presentation is a limping child who may have pain in the groin, hip, thigh, or knee. Very often
the pain is vague and poorly localized. It occurs more often in boys, with African-Americans and Pacific
Islanders having a higher rate of involvement, possibly due to increased levels of obesity in these
population groups.
Physical findings vary, depending on the severity of the slippage. A child with a severe slip may not be
able to bear weight. Obligatory external rotation of the involved hip is noted when the hip is passively
flexed to 90°. Radiographs are needed to diagnose unstable slipped capital epiphysis, and should include
frog-leg lateral views and anteroposterior views of both hips.
Another cause of hip pain in adolescent patients is apophyseal avulsion fractures. Clinical features include
pain after a sudden, forceful movement. Hip apophysitis presents as activity-related hip pain with a history
of overuse and negative radiographs. In children under the age of 10 years, transient synovitis is also a
common cause of hip pain. It occurs after a viral illness and is associated with negative radiographs but
positive laboratory tests. Fractures may be seen in children on occasion, but there will be a history of
trauma. Septic arthritis is an infrequent cause of hip pain in children, but patients have a history of fever
with elevation of the WBC count and inflammatory joints. The diagnosis would be confirmed by joint
aspiration. Legg-Calvé-Perthes disease is also infrequent, and features include vague hip pain with
decreased internal rotation of the hip. The diagnosis is based on findings from radiographs or MRI.
Of the following cardiovascular parameters, which one increases with normal aging?
A) Maximum heart rate
B) Heart rate variability
C) Left ventricular ejection fraction
D) Arterial wall elasticity
E) Blood pressure
It can be difficult to determine the point at which changes of normal aging are more appropriately
considered disease processes. Although the direction of expected change is generally well understood,
variables such as the level of fitness and overall health of an individual affect the degree of change. As the
body ages, the measured left ventricular ejection fraction, heart rate variability, and maximum heart rate
trend downward, the walls of the major aorta and major arteries stiffen, and the vasodilator capacity of
most smaller vessels is reduced (SOR A). The arterial wall changes increase peripheral resistance and
result in an increase in blood pressure. Positive adaptive changes have been shown in older adults who
engage in regular aerobic exercise, however, and these changes can be measured after only 3 months of
moderate-intensity exercise (SOR A).
A 68-year-old male with type 2 diabetes mellitus has failed to control his diabetes with diet and
exercise. His most recent serum creatinine level was 1.9 mg/dL (N 0.6-1.5).
Which one of the following agents is most likely to cause symptomatic hypoglycemia in this
A) Glimepiride (Amaryl)
B) Glipizide (Glucotrol)
C) Glyburide (DiaBeta)
D) Metformin (Glucophage)
E) Repaglinide (Prandin)
Older patients are at higher risk for hypoglycemia caused by oral antidiabetic agents. Glyburide is
associated with a significantly greater risk of symptomatic hypoglycemia than other second-generation
sulfonylurea hypoglycemic agents.
Metformin decreases liver production of glucose and is not associated with hypoglycemia. Even so, this
patient’s creatinine elevation is a contraindication to metformin use, as it increases the risk of lactic
Glimepiride, glipizide, and repaglinide stimulate insulin release and increase the risk of hypoglycemia.
However, the risk of symptomatic hypoglycemia is substantially lower compared to the risk associated with
glyburide in patients with similar hemoglobin A1c values (SOR B).
A healthy 47-year-old female presents with a 3-day history of moderately severe low back pain
after attempting to lift a heavy container of potting soil in her garden. She has no history of back
problems. Her pain is in the right lower back with radiation to the buttock. She denies urinary
or bowel incontinence, urinary retention, and numbness or tingling. A physical examination
confirms low back muscular strain.
Which one of the following interventions has been shown to be beneficial in this situation?
A) Bed rest
B) Massage therapy
C) Lumbar traction
D) Prednisone
E) Cyclobenzaprine (Flexeril)
Acute low back pain is one of the most common presenting symptoms in family medicine practices. In the
absence of red flags such as fever, a history of cancer, or neurologic deficits, patients can be successfully
treated with conservative therapy. Interventions that have been shown to be beneficial include
non-benzodiazepine muscle relaxers (SOR A). They are most effective in the first 1-2 weeks but can be
used for up to 4 weeks. Additional beneficial treatments include physical therapy, acetaminophen, and
NSAIDs. Bed rest is inadvisable for patients with low back pain (SOR A). Patients who stay active have
better outcomes than those who stay at rest. There is no good evidence that oral corticosteroids are beneficial for acute back pain, and insufficient
evidence that massage therapy is effective. Lumbar traction provides no benefit in acute low back pain
(SOR B).
A 40-year-old male complains of a cough that has persisted for more than 3 months. He is
otherwise asymptomatic. A chest radiograph and pulmonary function tests are normal.
Which one of the following is the most likely cause?
A) Bronchiectasis
B) Tuberculosis
C) Sarcoidosis
D) Asthma
E) Gastroesophageal reflux disease
Gastroesophageal reflux disease is one of the most common causes of chronic cough. Patients with “silent”
gastroesophageal reflux may not have the classic symptoms of heartburn and regurgitation. The diagnosis
is based on resolution of the cough with an empiric trial of a proton pump inhibitor, although a chest
radiograph should be obtained in all patients with a chronic cough to exclude bronchiectasis, tuberculosis,
and sarcoidosis. Asthma is another frequent cause of chronic cough, but it can be ruled out with normal
pulmonary function tests.
A 45-year-old male asks you to evaluate his cardiovascular health status. He is currently
asymptomatic, but wants to do everything he can to prevent heart disease and to understand his
potential cardiovascular risk. His Framingham score indicates that he is at low risk (10-year risk
<6%), and his physical examination is normal.
He asks which laboratory and imaging tests he should have, and you recommend a lipid profile.
According to the American College of Cardiology Foundation and the American Heart
Association, which one of the following should also be recommended for this patient at this
A) Lipoprotein and apolipoprotein levels
B) A C-reactive protein level
C) Measurement of cardiac calcium
D) An ankle-brachial index
E) No further testing
The American College of Cardiology Foundation/American Heart Association guidelines for early
cardiovascular assessment do not recommend lipoprotein and apolipoprotein levels. A C-reactive protein
level can help to determine the need for statin therapy in men 50 and older and women 60 and older whose
LDL-cholesterol levels are <130 mg/dL and who are not on lipid-lowering medication, hormone therapy,
or immunosuppressive therapy, and who do not have clinical coronary heart disease, diabetes mellitus,
chronic kidney disease, severe inflammatory disease, or contraindications to statins. A C-reactive protein
level may also be reasonable in younger patients with intermediate, but not low, cardiovascular risk.
Measurement of cardiac calcium levels is reasonable in patients whose cardiovascular risk is intermediate
(10-year risk 10%-20%) or low-to-intermediate (10-year risk 6%-10%). An ankle-brachial index is
reasonable for intermediate-risk, but not low-risk, patients. At this point in time, the patient described here
does not meet any recommended criteria for further testing.
In an adult who has a critical illness but no history of cardiac disease, the threshold for
transfusion of red blood cells should be a hemoglobin level of
A) 6 g/dL
B) 7 g/dL
C) 8 g/dL
D) 9 g/dL
E) 10 g/dL
The threshold for transfusion of red blood cells should be a hemoglobin level of 7 g/dL in adults and most
A 67-year-old female hospitalized with pneumonia develops the rapid onset of dyspnea, pleuritic
chest pain, tachypnea, and hypoxemia not responding to oxygen and requiring intubation. A
physical examination is notable for rales throughout both lung fields with no peripheral edema
noted. A chest radiograph shows bilateral pulmonary infiltrates. Her BNP level is 90 ng/L.
Which one of the following is the most likely reason for her worsening clinical situation?
A) Heart failure
B) Hypersensitivity pneumonitis
C) Acute respiratory distress syndrome
D) Pulmonary embolus
E) Pneumothorax
This patient demonstrates classic findings for acute respiratory distress syndrome (ARDS). In many cases
ARDS must be differentiated from heart failure. Heart failure is characterized by fluid overload (edema),
jugular venous distention, a third heart sound, an elevated BNP level, and a salutary response to diuretics.
A BNP level <100 pg/mL can help rule out heart failure (SOR A). In addition, a patient with ARDS
would not have signs of left atrial hypertension and overt volume overload.
Hypersensitivity pneumonitis is usually preceded by exposure to an inciting organic antigen such as bird
feathers, mold, or dust. Pulmonary embolus, while certainly in the differential, is unlikely to cause such
dramatic radiographic findings. Pneumothorax would be seen on the chest radiograph.
A 64-year-old male with a previous history of hypertension and atrial fibrillation presents with
an acute onset of ataxia, headache, mild confusion, and restlessness. His only current
medications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his blood
pressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature
36.7°C (98.1°F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. His
INR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.
Which one of the following should be performed urgently?
A) Neurosurgical consultation for posterior cerebellar hematoma decompression
B) A reduction in blood pressure to 140/90 mm Hg
C) Administration of vitamin K, 10 mg intravenously
D) Administration of mannitol (Osmitrol), 0.5-1.0 mg/kg intravenously
E) Induction of hypothermia to achieve a body temperature of 34.4°C (94.0°F)
Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral
hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical
consultation. Guidelines have been developed by the American Heart Association for lowering blood
pressure in patients with a systolic blood pressure >180 mm Hg, or a mean arterial pressure >130 mm
Hg. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral
edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear.
Patients with an INR >1.5 should receive therapy to replace vitamin K-dependent factors and have their
warfarin withheld.
You prescribe enalapril (Vasotec) for a 68-year-old male with heart failure. At a follow-up visit
6 weeks later the patient’s serum creatinine level is 2.5 mg/dL (N 0.6-1.5) and his serum
potassium level is 5.7 mEq/L (N 3.4-4.8). His baseline values were normal.
Which one of the following is a side effect of ACE inhibitors that is the most likely cause of
these changes in renal function?
A) Toxicity to the proximal renal tubules
B) Impaired autoregulation of glomerular blood flow
C) Microangiopathic arteriolar thrombosis
D) Rhabdomyolysis
E) Interstitial nephritis
Blood flow to the kidney is autoregulated so as to sustain pressure within the glomerulus. This is influenced
by angiotensin II-related vasoconstriction. ACE inhibitors can impair the kidney’s autoregulatory function,
resulting in a decreased glomerular filtration rate and possibly acute renal injury. This is usually reversible
if it is recognized and the offending agent stopped. NSAIDs can exert a similar effect, but they can also
cause glomerulonephritis and interstitial nephritis. Statins, haloperidol, and drugs of abuse (cocaine,
heroin) can cause rhabdomyolysis with the release of myoglobin, which causes acute renal injury.
Thrombotic microangiopathy is a rare mechanism of injury to the kidney, and may be caused by
clopidogrel, quinine, or certain chemotherapeutic agents.
A 46-year-old African-American female sees you because of a history of excessive uterine
bleeding and irregularity in her menstrual cycle. She has three children and had a tubal ligation
after her last delivery. A pelvic examination does not reveal any pathology to explain her
symptoms. Further laboratory evaluation indicates that she is mildly anemic. You perform an
endometrial biopsy in the office that confirms your suspicion of endometrial hyperplasia without
Which one of the following is the treatment of choice for this patient?
A) Elective hysterectomy
B) Hysteroscopic endometrial laser ablation
C) High-dose oral estrogen supplementation
D) Antifibrinolytic therapy
E) Progestational drugs
Medical therapy with progestational drugs is the treatment of choice for menorrhagia due to endometrial
hyperplasia without atypia. Progestins convert the proliferative endometrium to a secretory one, causing
withdrawal bleeding and the regression of hyperplasia. The most commonly used form is cyclic oral
medroxyprogesterone, given 14 days per month, but implanted intrauterine levonorgestrel is the most
effective (SOR A) and also provides contraception.
High-dose estrogen supplementation would further stimulate the endometrium. Estrogen is useful in cases
where minimal estrogen stimulation is associated with breakthrough bleeding. The anti-fibrinolytic agent
tranexamic acid prevents the activation of plasminogen and is given at the beginning of the cycle to
decrease bleeding. Side effects and cost limit this treatment option, however. It may be most useful in
women with bleeding disorders or with contraindications to hormonal therapy.
NSAIDs, which decrease prostaglandin levels, reduce menstrual bleeding but not as effectively as
progestins. While mefenamic acid is marketed for menstrual cramps and bleeding, all NSAIDs have a
similar effect in this regard.
If medical management fails, hysteroscopic endometrial ablation is an option for reducing uterine bleeding
but is considered permanent and obviously will impair fertility. Hysterectomy is reserved for severe and
chronic bleeding that is not relieved by other measures.
The diagnosis of Osgood-Schlatter disease (osteochondritis of the tibial tubercle apophysis) is
best made on the basis of findings from
A) the history and examination
B) evaluation by an orthopedic specialist
C) radiographs
D) ultrasonography
Osgood-Schlatter disease is an inflammatory condition that is a common cause of knee pain in children and
adolescents. The diagnosis is usually based on clinical findings, although radiographs may be necessary
to rule out fractures or other problems if findings are not typical. MRI, ultrasonography, and orthopedic
referral are not usually needed. The problem is typically self-limited and responds to activity modification,
over-the-counter analgesics, stretching, and physical therapy.
A 35-year-old primigravid schoolteacher awakens with a rash clinically consistent with varicella
early in the 38th week of her pregnancy. She had a negative varicella titer early in her
pregnancy. The clinical course is mild and all vesicles have either crusted over or healed 1 week
later. She has an uncomplicated labor and vaginal delivery at 40 weeks gestation, and delivers
a healthy-appearing male.
Of the following options, which one is the most appropriate initial management for the newborn?
A) Intravenously administered varicella immune globulin
B) A weight-appropriate dose of intravenous acyclovir (Zovirax)
C) Varicella vaccine
D) Combination treatment with varicella vaccine, intravenous acyclovir, and varicella
immune globulin
E) Close observation only
The result of neonatal varicella infection can be catastrophic, with a fatality rate approaching 30%.
Maternal immunity is ideal, but since varicella vaccination is contraindicated during pregnancy the best
alternative is advising the patient to avoid contact with infected individuals until safe postpartum
immunization is possible. Maternal varicella infection is particularly problematic during weeks 13-20 of
pregnancy (resulting in a 2% risk of congenital varicella in the newborn) and when the onset of maternal
symptoms occurs from 5 days before until 2 days after delivery. Administration of varicella immune globulin to the expectant mother has not been shown to benefit the
fetus or infant, but because pregnancy can increase the risk of serious complications in the mother the
Advisory Committee on Immunization Practices (ACIP) recommends that administration to pregnant
women be considered following known exposure. The ACIP also recommends that term infants born within
the 7-day window described above, as well as all preterm infants, receive varicella immune globulin, and
that those who develop any signs of varicella infection also be given intravenous acyclovir. Term infants
delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive
immunity for protection and the expected benign course generally requires only observation.
Traveler’s diarrhea can be effectively treated in the great majority of cases with which one of
the following?
A) Erythromycin
B) Penicillin V
C) Sulfacetamide
D) Ciprofloxacin (Cipro)
Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity
of traveler’s diarrhea when given for 1-3 days. Sulfacetamide is available only in a topical form for use
in the eye. Penicillin and erythromycin are not effective against the most common cause of traveler’s
diarrhea, enterotoxigenic Escherichia coli.
The primary indication for joint replacement surgery in patients with osteoarthritis is
A) intractable pain
B) joint laxity
C) limited range of motion
D) recurrent subluxation
The primary indication for joint replacement surgery in patients with osteoarthritis is intractable pain,
which is almost always relieved by the surgery. Joint replacement may also be appropriate for patients
with significant limitations of joint function or with altered limb alignment. Range of motion, joint laxity,
and recurrent subluxation relate to musculotendinous function, and are not reliably improved by joint
In a child, which one of the following findings on cardiac auscultation is most likely to be
associated with structural heart disease?
A) Increased murmur intensity with standing
B) An early systolic murmur
C) A murmur limited to a small area
D) An S2 with a variable split duration
E) A musical or low pitch
Heart murmurs are common in children and adolescents. Often the murmur is innocent, but it may also
be the only finding in an asymptomatic child with structural heart disease. Physical findings that should
lead one to consider evaluation for structural heart disease include increased intensity with standing, a
holosystolic murmur, a grade of 3 or higher, a harsh quality, an abnormal S2, maximal intensity at the
upper left sternal border, a diastolic murmur, or a systolic click. Characteristics that are more likely to be associated with innocent murmurs include a systolic murmur, a
soft sound, a short duration, a musical or low pitch, intensity that varies with phases of respiration,
increased loudness in the supine position, and increased loudness with exercise, anxiety, or fear. If the
diagnosis of an innocent murmur cannot be made from physical findings, an echocardiogram is the most
appropriate study. A chest radiograph and EKG rarely assist in the diagnosis of heart murmurs in children
(SOR B) and should not routinely be ordered.
A 7-year-old white male is brought to your office about 5 hours after a dog bit him on the
forearm. You examine the wound and decide not to suture it. His last tetanus immunization
brought him up to date at 4 years of age.
Which one of the following is most appropriate?
A) Culture the wound
B) Scrub the wound with povidone-iodine (Betadine) surgical scrub
C) Irrigate the wound
D) Administer tetanus immune globulin and DTaP immunization
Dog and cat bite wounds may appear trivial, but if they are not managed appropriately they can become
infected and may result in functional impairment. Cultures are recommended for wounds that are clinically
infected. Because it can be toxic to tissue, povidone-iodine surgical scrub should not be used. Irrigation
with either normal saline or Ringer’s lactate solution may reduce the rate of infection by up to twentyfold.
Tetanus immune globulin is not needed, and DTaP is not given to children 7 years of age or older.
A 50-year-old female is hospitalized with severe, diffuse abdominal pain without nausea or
vomiting. Vital signs on admission include a pulse rate of 110 beats/min, a respiratory rate of
35/min, and a temperature of 38.2°C (100.8°F). Laboratory findings include a WBC count of
21,000/mm3 (N 4300-10,800) with 80% segmented neutrophils, and a serum amylase level of
4000 U/L (N 53-123). CT of the abdomen is consistent with cholelithiasis and necrotizing
pancreatitis without an abscess.
Which one of the following measures is best supported by evidence?
A) Corticosteroids
B) Placement of a nasogastric tube
C) Intravenous antibiotics
D) Surgery if repeat CT shows development of a pseudocyst
Intravenous antibiotics, especially imipenem, have been shown to be beneficial in patients with pancreatitis.
Patients with pancreatitis who are not vomiting do not require nasogastric tube placement. Corticosteroids
are not indicated in the management of acute pancreatitis, and pseudocysts can be managed initially with
percutaneous aspiration.
In your role as team physician, you are attending a high-school basketball game. A player
suffers an inversion injury of her ankle while coming down after reaching for a rebound. You
examine her immediately and diagnose a grade 2 ankle sprain.
Which one of the following is the most successful treatment for this injury?
A) Use of a weight-bearing short leg cast for 2 weeks, then progressively increased activity
B) Non-weight bearing, with crutches and an elastic wrap for 2 weeks
C) Ankle taping, an elastic wrap, and partial weight bearing for 6 weeks
D) Icing, a gel or air splint, and mobilization within 48 hours
Conservative treatment of grade 1 and 2 ankle sprains in athletes, consisting of the use of leg casts for 2
weeks followed by progressive increases in activity, has been found to lead to a loss of playing time of 4-6
weeks. Treatment consisting of an elastic wrap and use of a crutch until pain resolves produces similar
results. Early mobilization after aggressive control of inflammation is recommended. Typical treatment
includes extensive icing, compression, and elevation, followed by the application of air or gel splints. In
the first 48 hours, physical therapy begins with early mobilization, strengthening, and proprioception
retraining. In one study utilizing this more aggressive approach, athletes were able to return to functional
status in 9 days after grade 1 sprains and in 12 days after grade 2 injuries.
Which one of the following features in an elderly patient with cognitive problems is more
suggestive of depression than of Alzheimer’s disease?
A) A long duration of cognitive problems
B) A slow progression of cognitive problems
C) Delusions that are congruent with mood
D) No past history of psychiatric problems
Cognitive problems are often a feature of depression in older patients, which can make it difficult to
distinguish depression from dementia. Congruence of mood with delusions is more typical of depression.
A longer duration of cognitive problems, slow progression of cognitive problems, and no past history of
psychiatric problems are more typical of dementia.
You are considering adding sitagliptin (Januvia) to the regimen of a patient with type 2 diabetes
mellitus. Which one of the following best describes the mechanism of action of this drug?
A) It increases glucagon levels
B) It slows inactivation of incretin hormones
C) It reduces the absorption of glucose in the gastrointestinal tract
D) It reduces insulin resistance in skeletal muscle
E) It reduces insulin resistance in the liver
Sitagliptin is a DPP-4 inhibitor. These agents slow the inactivation of incretin hormones, prolonging their
action and thereby increasing insulin release and decreasing glucagon. Sitagliptin decreases hemoglobin
A1c levels by 0.7%, but there is no data on patient-oriented outcomes or long-term safety with this
Examination of a patient with COPD and a complaint of increased shortness of breath reveals
dullness to percussion in the left lower lung field, with decreased fremitus and decreased breath
sounds. This is most compatible with
A) pulmonary consolidation
B) pleural effusion
C) emphysematous bleb formation
D) pneumothorax
Pleural fluid is associated with a dull-to-flat percussion note, decreased-to-absent tactile fremitus, and
decreased-to-absent breath sounds. A consolidation would be indicated by bronchial breath sounds and
increased fremitus. Emphysematous blebs and pneumothorax are hyperresonant to percussion.
In patients with mild to moderate allergic rhinitis, which one of the following is the most
effective treatment?
A) First-generation antihistamines such as diphenhydramine (Benadryl)
B) Second-generation antihistamines such as fexofenadine (Allegra)
C) Montelukast (Singulair)
D) Intranasal corticosteroids
E) Prednisone
Intranasal corticosteroids are the most effective treatment for mild to moderate allergic rhinitis and should
be first-line therapy. Second-line therapies that can be used for symptoms that do not respond to initial
treatment include antihistamines, decongestants, cromolyn, and leukotriene receptor antagonists.
Nonpharmacologic measures that may be helpful include nasal irrigation and avoiding irritants.
A 58-year-old female presents with significant nausea and abdominal cramping 1 month after
beginning lithium carbonate. Her symptoms have not been relieved by multiple doses of
antacids. A physical examination is remarkable only for the appearance of discomfort and a
resting pulse rate of 92 beats/min.
You suspect lithium toxicity and advise her to discontinue the lithium immediately and submit
blood samples for a lithium level and complete metabolic panel. When you review her results
that afternoon you find that her lithium level is in the mid-therapeutic range and the only
abnormal laboratory findings are a calcium level of 13.0 mg/dL (N 8.8-10.0), an albumin level
of 3.0 g/dL (N 3.8-5.0), a BUN level of 35 mg/dL (N 7-18), and a creatinine level of 1.6
mg/dL (N 0.6-1.2).
Of the options listed below, the best immediate intervention is
A) cinacalcet (Sensipar)
B) furosemide (Lasix)
C) glucocorticoids
D) intravenous saline infusion
E) intravenous zoledronic acid (Zometa)
Drugs such as lithium, thiazide diuretics, sex hormones, and vitamins A and D can increase the serum
ionized calcium level. The gastrointestinal symptoms associated with lithium toxicity are also the most
common presenting symptoms of hypercalcemia. Hypercalcemic patients may also complain of
constipation, fatigue, lethargy, polyuria, and weakness, all the result of an increased serum level of ionized
calcium (roughly calculated to be 40% of the total serum calcium level plus 0.8 g/dL for each 1 g/dL
decrease in serum albumin below 4 g/dL). The most common causes of hypercalcemia are malignancy and
hyperparathyroidism, together accounting for over 80% of all cases. Excessive ingestion of antacids can
result in milk-alkali syndrome, another cause of hypercalcemia. Granulomatous disease and renal diseases
are other possible causes.
Although additional details are required in this case to determine the cause, primary hyperparathyroidism
augmented by medications is highly likely given the patient’s age and sex, and measurement of her
parathyroid hormone level must be included in the workup. No matter the cause, the treatment of
symptomatic hypercalcemia should be immediate and directed at lowering the serum calcium level. The
safest and most effective way to accomplish this is with intravenous normal saline volume replacement,
reducing the need for reabsorption of salt, water, and, coincidentally, calcium in the proximal tubules.
Because hypercalcemia often results in volume depletion, aggressive fluid replacement is often ideal,
provided there is no contraindication to doing so. Once the volume depletion is corrected the addition of
loop diuretics such as furosemide can facilitate excretion of calcium. Each of the other options has a place
in the longer term treatment of hypercalcemia in appropriate situations: bisphosphonates for malignancy,
glucocorticoids for granulomatous disease, and cinacalcet for hyperparathyroidism.
A 57-year-old male with a BMI of 37.1 kg/m2 was found to have a fasting blood glucose level
of 115 mg/dL on a screening test. His mother and three siblings have type 2 diabetes mellitus.
A follow-up hemoglobin A1c (HbA1c) level is 6.2%. Six months later, after lifestyle
interventions, the patient’s BMI is 35.5 kg/m2 and his HbA1c is 6.1%. On a lipid panel, his
triglyceride level is 457 mg/dL and his HDL-cholesterol level is 32 mg/dL. His serum creatinine
level is 1.0 mg/dL (N 0.6-1.2). You consider the use of pharmacologic therapy.
Which one of the following would be the best initial medication?
A) Acarbose (Precose)
B) Exenatide (Byetta)
C) Glipizide (Glucotrol)
D) Metformin (Glucophage)
E) Pioglitazone (Actos)
Metformin is well tolerated and there is good data to show it helps prevent type 2 diabetes mellitus in
high-risk patients. Pioglitazone has been shown to slow the progression from prediabetes to diabetes, but
it has more side effects and is more expensive than metformin. Neither glipizide nor exenatide is currently
recommended as a treatment for prediabetes. Acarbose has a high discontinuation rate due to side effects.
A 16-year-old male comes to your office with a 1-month history of increasingly severe lower
back pain. He plays on his school’s soccer team, but denies any history of injury.
Hyperextension is particularly painful, and now the pain occurs during normal daily activities.
Examination reveals a hyperlordotic posture, limited range of motion, and tight hamstrings. The
remainder of the examination is unremarkable.
Which one of the following should be done initially?
A) A complete blood profile
B) Rheumatoid factor and HLA-B27 testing
C) Plain radiography
E) A radionuclide bone scan
While spondylolysis occurs in 6% of the general population, it may be the cause of 50% of back pain in
young adults. This unilateral or bilateral vertebral defect of the pars interarticularis is likely due to
repetitive hyperextension of the posterior spine that results in a fracture or stress injury. This usually
occurs at L4-L5. Sports that put increased demands on the spine include football, gymnastics,
weightlifting, soccer, volleyball, and ballet.
The recommended initial study for athletes with back pain of more than 3 weeks’ duration is lumbar spine
radiographs, including anterior/posterior, lateral, and oblique views bilaterally. The “Scotty dog with a
collar” sign can be noted on the oblique view. This may not be present in early spondylolysis, so a SPECT
scan may be appropriate.
Treatment for spondylolysis consists of discontinuing the offending activity, medication for pain, physical
therapy, and possibly bracing. Healing may take 9-12 months.
A 2-year-old female visiting with her parents from Mexico presents with a 1-week history of
repeated episodes of forceful coughing followed by emesis. Her immunization status is
unknown. Her mother reports that a runny nose and “cold” preceded the onset of the cough. The
child is currently afebrile and appears mildly ill; her lungs are clear.
Your management would include which one of the following?
A) Hospitalization for ribavirin aerosol therapy
B) Reassurance that the cough will abate over the next week
C) Oral erythromycin therapy for 2 weeks
D) Administration of immune serum globulin intramuscularly
This child’s presentation is highly suspicious for pertussis, given the severe coughing paroxysms and the
possibility of inadequate immunization. Two weeks of oral erythromycin is recommended for children with
mild to moderate illness, principally to halt the spread of the infection. Ribavirin is used for respiratory
syncytial virus infection, which is generally seen in much younger children with more respiratory distress.
The cough of pertussis often lasts several weeks. Immune globulin is not recommended.
The fluid of choice for resuscitation after a significant burn injury is
A) lactated Ringer’s solution
B) hypertonic saline
C) packed RBCs
D) whole blood
E) 5% albumin
Crystalloids are the essential component of fluid resuscitation in patients with severe burn injuries, with
lactated Ringer’s solution being the most commonly used. Substantial early loss of blood is unusual, and
transfusions are not often required. The use of colloids in these patients has not been shown to be helpful
and may be harmful. Hypertonic saline solution may be useful in selected patients but requires careful
monitoring and may be detrimental.
A 52-year-old male comes to your office with a 2-month history of hoarseness that began with
the onset of a head cold. His other symptoms resolved but the hoarseness has continued. He has
smoked for 32 years and drinks 4 beers per day, and has had gastroesophageal reflux disease
(GERD) for several years.
Which one of the following would be most appropriate at this point?
A) Voice rest
B) Laryngoscopy
C) Upper endoscopy
D) Inhaled corticosteroids
E) High doses of a proton pump inhibitor
Patients with hoarseness lasting longer than 2 weeks with risk factors for dysplasia or carcinoma, such as
smoking, heavy alcohol use, or long-standing gastroesophageal reflux disease, should be evaluated with
laryngoscopy. Inhaled corticosteroids can contribute to hoarseness.
Four weeks after successful initial treatment of unilateral otitis media in a 2-year-old white male
enrolled in a local day-care center, you reevaluate the child. He is asymptomatic, but you detect
a middle ear effusion in the affected ear. The tympanic membrane is otherwise normal.
The best management at this time would be
A) inflation of the eustachian tube by the Valsalva maneuver
B) an antihistamine daily for 30 days
C) low-dose corticosteroids for 30 days
D) referral to an ENT specialist
E) no further treatment, with reevaluation in 2 months
Otitis media is a major health problem in the United States; it is the number one reason children visit
doctors and accounts for one-fourth of all antibiotic prescriptions. With appropriate antibiotics most
patients will improve in 2-3 days. Persistence or worsening of symptoms requires immediate reevaluation,
since complications such as bacterial resistance or meningitis may be developing. Occasionally a persistent
middle ear effusion will be found on reexamination 10-14 days after initial treatment. Inflation of the
eustachian tube using the method of Politzer or employing the Valsalva maneuver has been shown to be
ineffective, as have antihistamines and systemic steroids. Most asymptomatic effusions with mild hearing
loss will clear in 90 days if left alone.
A previously healthy 26-year-old white male carpenter reports episodes of chest tightness and
dyspnea. He states that he feels better on weekends.
He most likely has
A) hypersensitivity pneumonitis
B) toxic pneumonitis
C) byssinosis
D) benign pleural effusion
E) occupational asthma
The diagnosis of occupational asthma can be made when both bronchospasm and its relationship to the
work environment can be demonstrated. A history of cough, wheezing, chest tightness, or episodic
dyspnea in varying combinations or singly should lead one to suspect bronchospasm. Relating
bronchospasm to the work environment can be done in several ways. A history of exposure to a known
sensitizer is helpful, as is a pattern of symptoms occurring after exposure. With many agents the onset of
symptoms may be delayed up to several hours. A 10% decrease in FEV1 measured before and after a work
shift supports the diagnosis. Improvement of bronchospasm with removal from exposure also suggests the
diagnosis. Treatment includes both standard pharmacologic therapy and removal from exposure as soon
as possible.
Hypersensitivity pneumonitis is an immune-mediated syndrome that is not as common as occupational
asthma. It begins with malaise, fever, and myalgias 4-6 hours after exposure to an antigen to which the
person has become sensitized. Byssinosis is due to exposure to the dust of hemp, flax, or cotton.
Symptoms vary from reversible chest tightness on one or more days early in the work week to chronic
bronchitis and permanent obstructive lung disease. Toxic pneumonitis or pulmonary edema is the result
of very high exposure to irritant gases, metal dust, or metal fumes, usually associated with unusual
circumstances such as a fire, explosion, or spill. Benign pleural effusions are the most common sequela
during the first 20 years after asbestos exposure. The diagnosis is one of exclusion, made by ruling out
other causes of exudative effusions in workers with known asbestos exposure.
A 67-year-old female who is a recently retired college professor takes warfarin (Coumadin)
because of chronic atrial fibrillation. She asks you about the possibility for self-management of
her anticoagulation using a portable monitor at home.
Which one of the following is true regarding self-management of anticoagulation therapy
compared to standard monitoring?
A) It decreases the number of thromboembolic events
B) It increases the number of bleeding events
C) It increases all-cause mortality
D) It increases the patient’s level of anxiety
E) When cost, complication rates, and mortality rates are considered, it is inferior to
standard monitoring
When self-management and standard management of anticoagulation therapy are compared,
self-management improves the rate of minor hemorrhage, with no difference in the rate of major
hemorrhage. Self-monitoring also improves the rate of thromboembolism. Both self-monitoring and
self-management improve the rate of all-cause mortality. When studied, patients who self-managed their
anticoagulation therapy perceived greater self-efficacy compared to patients receiving standard care, and
self-management did not increase their levels of anxiety. When all factors are considered, self-monitoring
and self-management have outcomes superior to those of standard monitoring and management.
You are following a 60-year-old female for osteopenia. Which one of the following tests is best
for assessing her vitamin D status?
A) 1,25-Dihydroxyvitamin D
B) 24,25-Dihydroxyvitamin D
C) 25-Hydroxyvitamin D
D) Parathyroid hormone
E) Phosphate
The serum 25-hydroxyvitamin D level is the best indicator of overall vitamin D status because it reflects
total vitamin D from dietary intake and sunlight, as well as conversion from adipose stores in the liver.
Measurement of 1,25-dihydroxyvitamin D, the active form of vitamin D formed in the kidney, may be
necessary in advanced chronic kidney disease. 24,25-Dihydroxyvitamin D is not biologically active.
Phosphate and parathyroid hormone are involved in the regulation of vitamin D levels, but are not helpful
in determining overall vitamin D status.
A 45-year-old male presents to your office for a health maintenance visit. Other than mild
fatigue, which he attributes to long hours at work and lack of exercise, he has no complaints.
He is married, and says he takes no routine medications and does not smoke or drink. His
examination is unremarkable except for a BMI of 32.3 kg/m2. A CBC is unremarkable, but a
fasting metabolic profile shows a glucose level of 115 mg/dL, an AST (SGOT) level of 100 U/L
(N 5-40), and an ALT (SGPT) level of 112 U/L (N 7-56). The remainder of the profile is
Which one of the following is the most likely cause of the abnormal laboratory findings?
A) Acetaminophen toxicity
B) Hepatitis B or C
C) Herbal preparations containing kava
D) Alcohol use
E) Nonalcoholic fatty liver disease
Currently, nonalcoholic fatty liver disease is the leading cause of transaminase elevations, and is becoming
increasingly common as obesity becomes more prevalent. It is estimated that some 30% of adults in the
United States have this disease. Patients with metabolic syndrome, diabetes mellitus, or elevated
triglycerides are at the highest risk. If the AST/ALT ratio is >2, especially if -glutamyl transpeptidase
is elevated, alcoholic liver disease should be suspected.
It is well known that severe hepatotoxicity can occur with acetaminophen overdoses, and dosages of even
4 g/day for 5-10 days will cause enzyme elevations in more than half of healthy nondrinkers. Herbal
preparations associated with elevated liver enzymes include kava and germander. Hepatitis C can cause
transient enzyme elevations, typically of ALT.
If liver enzymes remain elevated on a repeat test 2-4 weeks later, the patient should be tested for hepatitis
B and C, and iron, iron binding capacity, and ferritin levels should be ordered to check for
hemochromatosis. A lipid profile and glucose level should be ordered as well, and abdominal
ultrasonography considered to look for evidence of fatty infiltration of the liver.
A 60-year-old male is started on simvastatin (Zocor) for elevated cholesterol. He mentions that
he takes several herbal and dietary supplements.
Which one of the following should this patient be advised to avoid?
A) Ginkgo biloba
B) Ginseng
C) Garlic
D) St. John’s wort
Of the common herbal supplements, St. John’s wort interacts with the most drugs, including statins,
warfarin, and antidepressants. The other herbal supplements listed do not interact with statins. Ginkgo
biloba and ginseng may interact with warfarin.
Treatment with which one of the following antihypertensive medications may mimic the effects
of primary hyperparathyroidism?
A) Amlodipine (Norvasc)
B) Doxazosin (Cardura)
C) Hydrochlorothiazide
D) Lisinopril (Prinivil, Zestril)
E) Metoprolol (Lopressor, Toprol-XL)
An elevated level of parathyroid hormone (or a level that is in an unexpected “normal” range) in a patient
with an elevated calcium level generally indicates a diagnosis of primary hyperparathyroidism. However,
these laboratory findings may also occur with lithium or thiazide use, tertiary hyperparathyroidism
associated with end-stage renal failure, or familial hypocalciuric hypercalcemia, and a medical and family
history should be obtained to assess these possibilities. The other medications listed do not cause
A 67-year-old female comes to your office to establish care after recently moving to your
community. Her medical history includes hypertension, nonobstructive coronary artery disease,
and heart failure, with an ejection fraction of 35% on an echocardiogram done last year. She
does not have diabetes mellitus or lung disease and she has never had a myocardial infarction.
She tolerates her medications well and is active, walking about 2 miles daily. Her medications
include aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; and simvastatin (Zocor),
40 mg daily.
Which one of the following possible additions to her medication regimen has the best evidence
for reducing mortality?
A) Clopidogrel (Plavix)
B) Ezetimibe (Zetia)
C) Losartan (Cozaar)
D) Metoprolol succinate (Toprol-XL)
E) Spironolactone (Aldactone)
According to the 2011 update of the American Heart Association/American College of Cardiology
Foundation guidelines on secondary prevention of coronary artery disease, metoprolol succinate has the
best evidence for mortality reduction when compared to the other medications listed. The other medications
have utility, but in more specialized circumstances: losartan for those intolerant of ACE inhibitors,
clopidogrel for those intolerant of aspirin, and ezetimibe for those intolerant of statins. Spironolactone has
evidence of benefit post myocardial infarction when added to a regimen that includes an ACE inhibitor and
a beta-blocker.
An 85-year-old male is brought to your office by his family for a follow-up visit for Alzheimer’s
dementia. His dementia has been present for 4 years. He has been experiencing increasing
agitation and delusions over the past several weeks, and the family requests a medication to
“calm him down.”
Which one of the following is indicated in this situation according to FDA guidelines?
A) Aripiprazole (Abilify)
B) Haloperidol
C) Olanzapine (Zyprexa)
D) Risperidone (Risperdal)
E) No antipsychotic drugs
The FDA states that antipsychotics are not indicated for treating dementia-related psychosis. The reason
for this is that the efficacy for antipsychotics has not been consistently shown in clinical trials and, in fact,
patients treated with olanzapine functioned worse after treatment than did those who received a placebo.
There is also evidence that these drugs may increase mortality from infection or heart-related conditions.
Practice guidelines recommend the use of antipsychotics only after other options have been exhausted and
symptoms are severe, persistent, and not responsive to nonpharmacologic interventions (SOR B).
Physicians are more likely than the general population to suffer from which one of the
A) Depression
B) Alcoholism
C) Prescription drug abuse
D) Illicit drug abuse
It is thought that easier access to prescription medications leads to a higher incidence of misuse by
physicians. The drugs most commonly abused are benzodiazepines and opioids. Most studies suggest that
alcoholism rates among physicians approximate those of the general population when adjusted for
socioeconomic status. The lifetime prevalence of depression also is similar for physicians and the general
population (12.8% for men and 19.5% for women). Physicians are less likely to abuse illicit drugs,
probably because of their access to prescription drugs.
In symptomatic young children with Campylobacter enterocolitis that is refractory to
conservative management, the preferred treatment is
A) erythromycin
B) ciprofloxacin (Cipro)
C) ampicillin
D) trimethoprim (Primsol)
E) metronidazole (Flagyl)
Campylobacter enterocolitis in children is generally a mild, self-limiting disease. However, in patients who
are sick enough to require hospitalization or who remain symptomatic by the time a bacteriologic diagnosis
has been made, antibiotic therapy is indicated. The preferred drug is oral erythromycin, which clinical
trials indicate may produce clinical improvement. Ciprofloxacin may be an effective alternative to
erythromycin in the treatment of Campylobacter, but it is contraindicated in young children. There is no
evidence that ampicillin, trimethoprim, or metronidazole is effective for this disease.
A 42-year-old male was admitted to the hospital yesterday for an extensive deep-vein thrombosis
and treated with unfractionated heparin anticoagulation. The nurse alerts you that the patient has
had multiple episodes of passing moderate amounts of maroon blood per rectum. He has a
previous history of diverticulosis. He is hemodynamically stable.
The initial treatment of choice for this patient is
A) cryoprecipitate
B) dabigatran (Pradaxa)
C) protamine sulfate
D) vasopressin (Pitressin)
E) vitamin K
Protamine sulfate is the treatment of choice for heparin overdose or significant bleeding secondary to
heparin therapy. Vitamin K is used for reversal of anticoagulation from warfarin. Vasopressin is a pressor
agent used to treat hypotensive episodes. Dabigatran is an anticoagulant used in nonvalvular atrial
fibrillation. Cryoprecipitate is a blood product used for replacement of von Willebrand’s factor, factor
XIII, fibrinogen, and fibronectin.
A 55-year-old nonsmoking male presents with a 2-month history of a nonproductive cough. He
has no other respiratory tract symptoms, including dyspnea, and no history of fever. He takes
hydrochlorothiazide and metoprolol succinate (Toprol-XL) for hypertension, and is otherwise
healthy. A physical examination, including vital signs with pulse oximetry, is unremarkable.
Which one of the following should you do next?
A) Discontinue metoprolol
B) Begin empiric antibiotic treatment for atypical pathogens
C) Perform a complete spirometry evaluation
D) Order a chest radiograph
E) Order CT of the chest with contrast
Adults with a chronic cough lasting 2 months or longer who are nonsmokers and are not taking ACE
inhibitors should have plain radiographs to rule out specific causes prior to initiating empiric therapy (SOR
C). Any treatment should be targeted to the most likely cause. The three most common causes of chronic
cough in adults, other than ACE inhibitors, are gastroesophageal reflux disease, asthma, and upper airway
cough syndrome.
Patients who are taking an ACE inhibitor should be switched to another class of antihypertensive drugs.
Metoprolol does not cause a cough per se, although it may unmask preexisting asthma or COPD, resulting
in a cough. -Blockers should not be discontinued abruptly, however. Formal spirometry and advanced
radiographic imaging have eventual roles in the evaluation of chronic cough but are expensive tests and
are not the best initial steps for evaluating a chronic cough.
In neonatal resuscitation, chest compressions should begin if the heart rate drops below a
threshold of
A) 120 beats/min
B) 100 beats/min
C) 80 beats/min
D) 60 beats/min
E) 40 beats/min
Chest compressions are recommended for a heart rate below 60 beats/min in a neonate.
According to the most recent American Diabetes Association guidelines, which one of the
following groups of patients with diabetes mellitus should take aspirin for primary prevention
of cardiovascular events?
A) All patients
B) All patients over the age of 55
C) Only those whose risk for cardiovascular disease events is >10%
D) Only those whose risk for cardiovascular disease events is >20%
At one point, the American Diabetes Association (ADA) recommended aspirin for all patients with diabetes
mellitus. They have since revised their guidelines and advise that aspirin not be used for primary
prevention of cardiovascular events unless a patient’s cardiovascular risk is >10% over 10 years. The
reason the ADA revised their guidelines on use of low-dose aspirin is because of the results from two
studies: the Prevention of Progression of Arterial Disease and Diabetes (POPADAD) study and the
Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) study.
The POPADAD study compared aspirin versus placebo in patients with diabetes and found that death rates
from coronary heart disease and stroke were similar for the two groups, as were rates of nonfatal
myocardial infarction and nonfatal stroke. The JPAD study also compared aspirin vs. placebo in diabetic
patients, with similar rates of sudden death, nonfatal myocardial infarction, nonfatal stroke, unstable
angina, TIA, and peripheral vascular disease. Rates of fatal myocardial infarction and fatal stroke were
lower in the aspirin group.
Which one of the following has the highest sensitivity and specificity for carpal tunnel
A) A positive Phalen maneuver
B) Distal tingling with percussion (Tinel’s sign)
C) A history of shaking the hand or flicking the wrist to alleviate nighttime pain (the flick
D) Thenar atrophy
The flick sign has the highest sensitivity (93%) and specificity (96%) among the clinical findings of carpal
tunnel syndrome. This sign is defined as a history of shaking the hand or flicking the wrist in an attempt
to alleviate discomfort after being awakened with nighttime pain. Tinel’s sign and the Phalen maneuver
have a sensitivity of 36% and 57%, and a specificity of 75% and 58%, respectively. Thenar atrophy is
usually seen in severe and chronic cases of carpal tunnel syndrome and has a sensitivity of 16% and a
specificity of 90% (SOR B).
In patients with systolic heart failure, which one of the following -blockers is best for reducing
mortality and hospitalization rates?
A) Atenolol (Tenormin)
B) Carvedilol (Coreg)
C) Labetalol (Trandate)
D) Nebivolol (Bystolic)
Evidence shows that -blockers reduce mortality and hospitalization rates for patients with systolic heart
failure (SOR A). They should be started at a low dosage and increased to target dosages (SOR A).
-Blockers should be considered even in patients with COPD and asthma, given their benefits. The benefit
of -blockers is proportional to the degree of reduction in heart rate (SOR A).
Of the listed -blockers, carvedilol has been shown to reduce the rates of death and hospitalization in heart
failure patients. Other beta-blockers that have been established through randomized, controlled trials to
benefit heart failure patients are bisoprolol and metoprolol succinate. The effect of nebivolol on mortality
has not been adequately studied.
An 80-year-old male comes to your office for evaluation of neck stiffness with a sensation of
grinding when turning his head. He has had this for several years, and has now developed dull
aching in his arms and numbness in his fingers. He also has noted stiffness in his legs.
Examination reveals that flexion of the neck results in a sensation that the patient says feels like
an electric shock going down his back. You note some wasting of the intrinsic musculature of
the hands, as well as hyperreflexia.
Which one of the following should you do now?
A) Order EMG of both upper extremities
B) Order plain films of the cervical spine
C) Order MRI of the cervical spine
D) Refer for cervical corticosteroid injections
E) Reevaluate the patient after 4 weeks of cervical bracing
Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the
elderly. Degenerative changes in the cervical spine, such as osteophyte formation, stiffened and
hypertrophied ligamentum flava, and spinal stenosis, can result in spinal cord compression. Symptoms
usually develop insidiously and may include neck stiffness, pain in the arm(s), tingling or numbness in the
hands, and weakness of the hands or legs. Flexion of the neck may produce a shock-like sensation down
the back, known as Lhermitte’s sign.
Sensory abnormalities may vary. Hyperreflexia is a characteristic physical finding. The gait may be stiff
or spastic, and atrophy of the intrinsic muscles of the hands is common. CSM can be differentiated from
amyotrophic lateral sclerosis (ALS) by the fasciculations and leg atrophy seen in ALS. Other conditions
that produce similar findings include multiple sclerosis and masses such as a metastatic tumor.
The primary diagnostic test is MRI of the cervical spine. Plain films are of little use as an initial diagnostic
procedure. Electromyography is usually not helpful, although it is occasionally needed to exclude
peripheral neuropathy.
Nonsurgical treatment such as cervical bracing may be used in mild cases of CSM, but once a frank
myelopathy occurs surgical intervention is the only option. Studies on bracing show variable results,
although it is reported that symptomatic patients may deteriorate neurologically during bracing.
A full-term infant weighing 6 lb 8 oz at birth will typically weigh 20 lb at what age?
A) 6 months
B) 9 months
C) 12 months
D) 15 months
E) 18 months
Normal newborns may lose up to 10% of their weight following birth, and should return to their birth
weight by the end of the first week of life. The steady addition of 4-7 oz of weight per week should result
in a doubling of birth weight by 4-6 months of age. During the second half of the first year of life an
addition of 3-5 oz/week is more the norm, resulting in a tripling of the birth weight by 1 year of age.
Breastfed infants tend to gain weight more quickly during the first 6 months of life, while formula-fed
infants do so from 6-12 months, with both groups having virtually equal weight gains by the end of the
first year.
One of your patients is planning to fly from Nebraska to Israel and asks about measures to
prevent or reduce jet lag. Which one of the following is supported by the best evidence?
A) Melatonin should be started on the morning of departure and taken every morning for
1 week
B) Melatonin should be taken nightly for 2-5 nights, beginning on the first night at the
C) Melatonin will help only on the return flight
D) A dose of caffeine equivalent to 3 cups of coffee should be taken every morning,
beginning on the morning of departure
A Cochrane review found that melatonin was effective for reducing jet lag, especially when crossing 5 or
more time zones in an easterly direction. The drug can also be effective when crossing 2-4 time zones.
The most effective dosage seems to be 0.5-5 mg taken at bedtime starting on the day of arrival, with
higher doses being more effective. Taking it before departure does not help, and taking it earlier in the day
could make jet lag worse. There does not seem to be any benefit from taking melatonin prior to departure,
and melatonin is not recommended when flying westward.
A 13-year-old male with a history of mild intermittent asthma reports escalating use of his
short-acting -agonist inhaler. He routinely uses it at least 5-10 times per week for symptom
relief. He has been experiencing wheezing and chest tightness with only minimal exertion, and
sometimes at rest, which is a new problem for him.
You recommend that he add which one of the following to his asthma medication regimen?
A) Intermittent use of an inhaled long-acting -agonist
B) Daily use of an inhaled long-acting -agonist
C) Daily use of an inhaled corticosteroid
D) Daily use of an oral corticosteroid
E) Daily use of an oral immunomodulator
Inhaled corticosteroids are the most potent and consistently effective long-term daily controller medications
for monotherapy of mild persistent asthma (SOR A). They can be successfully used in combination with
intermittent short-acting -agonists. Oral systemic corticosteroids are recommended for moderate to severe
asthma exacerbations and usually for a very limited time period (SOR A). Daily long-acting -agonists are
often used in combination with inhaled corticosteroids; however, long-acting -agonists are not
recommended for use as daily monotherapy for long-term control of persistent asthma, or for intermittent
use (SOR A). Immunomodulators such as omalizumab prevent binding of immunoglobulin E to the
high-affinity receptors on basophils and mast cells. These are used as an additive therapy for patients age
12 years and older with severe persistent asthma, and are not recommended for routine use as
monotherapeutic agents.
A 14-year-old female is concerned because she is unable to gain weight. A review of systems
reveals intermittent diarrhea and chronic dermatitis previously diagnosed as eczema. Her past
and family histories are unremarkable. A laboratory workup is negative, including a complete
metabolic profile, a TSH level, and a sweat chloride test. A stool sample is negative for WBCs,
ova, and parasites.
Which one of the following is true regarding this patient?
A) She should be tested for IgA anti-tissue transglutaminase
B) She should be placed on a lactose-free diet
C) She should be referred to an eating disorders specialist
D) She should have a colonic mucosal biopsy
Celiac sprue (gluten-sensitive enteropathy) classically presents as a malabsorption syndrome associated
with dermatitis herpetiformis. This dermatitis usually appears as excoriated papules, as it is extremely
pruritic. The rash may be misdiagnosed as atypical psoriasis or nonspecific dermatitis. With the
development and use of better diagnostic tests, it now appears that this disorder has been underdiagnosed.
Symptoms include fatigue, weight loss, diarrhea, abdominal pain, anemia, bone pain, aphthous ulcers,
stomatitis, infertility, impotence, alopecia areata, dental enamel defects, seizures, ataxia, and dermatitis.
Serologic tests are now available to aid in confirming the diagnosis of celiac sprue, including IgA
antigliadin antibody, IgG antigliadin antibody, IgA antiendomysial antibody, and IgA antitransglutaminase.
Cystic fibrosis, Crohn’s disease, and anorexia nervosa can cause weight loss but not dermatitis. Sprue
affects the small intestine; a biopsy of the colon would be inappropriate given this presentation.
A 48-year-old white male has experienced five episodes of right upper quadrant pain during the
past year. The most recent episode occurred 2 weeks ago. The episodes last 2-4 hours and are
associated with nausea and vomiting.
Which one of the following is most likely to provide an explanation for the patient’s symptoms?
A) A serum bilirubin level
B) An AST (SGOT) level
C) A plain film of the abdomen
D) A HIDA scan
E) Abdominal ultrasonography
The patient described has a history compatible with gallbladder disease. In a patient with such a typical
history, abdominal ultrasonography is likely to show gallstones and thus provide support for the diagnosis.
Serum bilirubin and AST levels are usually normal except at the time of an attack. A HIDA scan may be
useful if performed during an attack, since the scan assesses the patency of the cystic duct. A plain
abdominal film will detect only 10%-15% of cases of cholelithiasis.
A 4-year-old female is brought to your office with a 5-day history of a cough and low-grade
fever. She appears mildly anxious but in no respiratory distress, and the physical examination
is notable for a temperature of 38.1°C (100.6°F), a respiratory rate of 44/min, and a spot O2
saturation of 94% with decreased breath sounds and fine crackles in the left lower lobe. You
decide to prescribe amoxicillin. When you give the prescription to the mother she mentions that
her 12-year-old son was given azithromycin (Zithromax) for pneumonia last year when he had
similar symptoms and findings, and she asks why the children were given different antibiotics.
What explanation would you give the mother for choosing amoxicillin?
A) Younger children are more likely to have gram-negative pathogens
B) Younger children usually have more virulent bacteria
C) Younger children are less likely to have infections caused by atypical bacteria such as
D) The half-life of azithromycin is shortened in children younger than 5 years
In preschool-age children, lower respiratory infections such as pneumonia are most commonly viral
illnesses. Antibiotics may be withheld in young children who are mildly ill and are suspected of having a
viral disease, but antibiotic therapy should be started if their clinical status worsens. In the preschool-age
child with pneumonia, amoxicillin remains the first-line antibiotic of choice, as it provides coverage for
Streptococcus pneumoniae and Haemophilus influenzae, which are the predominant bacterial causes of
pneumonia in this age group. The pharmacokinetics of azithromycin do not preclude its use in children,
but it is not the first-line choice for this patient.
Viruses are also the most frequent cause of pneumonia in the older child, although after the age of 5 years
atypical pneumonia becomes more common. This requires antibiotic coverage for organisms such as
Mycoplasma. For these patients, empiric treatment with a macrolide antibiotic such as azithromycin is
Effective therapy for myocarditis-induced dilated cardiomyopathy includes
A) ibuprofen
B) lisinopril (Prinivil, Zestril)
C) methotrexate
D) oseltamivir (Tamiflu)
E) prednisone
ACE inhibitors improve the quality of life and the prognosis for patients with myocarditis-induced dilated
cardiomyopathy, just as they do for other patients with heart failure. Neither antiviral therapy nor
immunosuppression has been shown to improve this type of cardiomyopathy when tested in controlled
trials. NSAIDs actually increase mortality by worsening sodium retention.
A 6-year-old male is brought to your office with a 1-day history of bloody diarrhea. The cause
is determined to be enterohemorrhagic Escherichia coli, which is producing Shiga toxin.
Which one of the following is the most appropriate treatment?
A) Supportive treatment only
B) Ciprofloxacin (Cipro)
C) Clindamycin (Cleocin)
D) Doxycycline
E) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Treatment of enterohemorrhagic Escherichia coli infection consists of supportive measures only.
Antibiotics are contraindicated because they can trigger the release of Shiga toxins, which may lead to
hemolytic-uremic syndrome in children.
A 2-year-old male is brought to your office for a well child check. He was born with pectus
excavatum, which has progressed somewhat as he has grown. You and the parents are concerned
about the potential for abnormal cardiopulmonary function and body image issues as the child
Repair of mild to moderately symptomatic pectus excavatum ideally should be considered when
the patient is
A) a toddler
B) preschool age
C) in elementary school
D) an adolescent
Repair of symptomatic pectus excavatum should be postponed until adolescence, if possible, as this
approach allows for completion of growth and reduces the chance of recurrence. Younger children with
severe cardiopulmonary problems may also be candidates for surgery, but repair at too early an age can
result in improper growth of the chest wall and increases the risk of recurrence of the deformity. Adult
repair is also feasible.
Which one of the following outcomes is associated with hospital palliative care programs?
A) Shortened hospital stays
B) Reduced use of nonphysician personnel
C) Increased ICU utilization
D) Lower overall hospital costs
More than 50% of U.S. hospitals have palliative care programs, which focus on pain and symptom
management. These programs decrease both overall hospital costs and ICU use. Because palliative care
requires a team approach, the number of nonphysician personnel is not decreased. The length of patient
hospital stays is also not decreased (level of evidence 2, SOR A).
A 55-year-old female is concerned about variations in her heartbeat. She describes “fluttering,”
“flip-flopping,” and sometimes “pounding” sensations in her chest, with occasional delays
between beats. Her symptoms are episodic, and have been occurring for several months. They
have not been present for the past week.
The patient’s family history is negative for thyroid disease, but she recalls some “heart trouble”
in several family members that was accompanied by fainting spells, and at least one relative died
suddenly. She takes no medications, has a negative psychiatric review of systems, and has a
normal physical examination.
Which one of the following would be most appropriate at this point?
A) Reassurance that her symptoms are associated with a benign condition
B) A standard 12-lead EKG
C) Echocardiography
D) Intermittent event (loop) cardiac monitoring
E) Admission to a hospital-based cardiac monitoring unit
All patients who present with palpitations should be evaluated for a cardiac cause, since this is the etiology
in 43% of cases. A standard 12-lead EKG is the initial test of choice and, along with a history and physical
examination, can determine the cause in 40% of cases. A normal resting EKG does not exclude a cardiac
arrhythmia. Therefore, if the EKG is normal, palpitations of suspected arrhythmic etiology may require
further investigation with ambulatory EKG monitoring.
Echocardiography is helpful in evaluating patients for structural heart disease and should be performed
when the initial history, physical examination, and EKG are unrevealing, or in patients with a history of
cardiac disease or more complex signs and symptoms. This patient’s family history, along with the fact
that she takes no medications, suggests the possibility of familial long QT syndrome, which often can be
diagnosed from a resting EKG. Diagnosing long QT syndrome is important, since it is associated with an
increased risk of sudden cardiac death. Based on the patient’s clinical presentation and evaluation, hospital
admission is not warranted prior to obtaining a standard 12-lead EKG.
Which one of the following would disqualify a patient from being considered homebound, using
Medicare’s definition for the purpose of conducting a home visit?
A) Participating in a state-licensed adult day care program
B) Regularly attending religious services
C) Being able to leave home with help from another person
D) Being able to leave home without help, but requiring occasional use of a cane
Medicare has an established definition of what constitutes a homebound patient. The definition includes
patients who require the use of a cane or other supportive device in order to leave the home (not just
occasional use) or require the help of another person to leave the home. Participation in a state-licensed
adult day care program or regularly attending religious services does not disqualify a person from being
considered confined to the home.
You are discussing job-related exposure to human immunodeficiency virus (HIV) with your
certified nursing assistants. Exposure to which one of the following from an HIV-positive patient
would require consideration of post-exposure prophylaxis?
A) Breast milk
B) Saliva
C) Sweat
D) Urine
E) Feces
Breast milk is considered potentially infectious in patients with HIV infection, along with vaginal
secretions, semen, and blood. Contact with saliva, sweat, urine, or feces does not require postexposure
A 26-year-old gravida 3 at 29 weeks gestation presents with painless vaginal bleeding. A sterile
speculum examination reveals a small amount of blood in the cervix and dilation estimated at 1
cm. A sonogram shows a complete placenta previa. Her blood pressure is normal, she is not
orthostatic, and her hemoglobin level is 10.7 mg/dL (N 12.0-16.0). The fetal heart rate is
around 130 beats/min with good variability and no decelerations. No contractions are shown on
the tocometer.
In addition to hospital admission for monitoring, which one of the following would be most
A) Magnesium
B) Calcium channel blockers
C) Corticosteroids
D) Antibiotics
E) Urgent cesarean section
Placenta previa is incidentally found on approximately 4% of sonograms performed between 20 and 24
weeks gestation. It often will resolve, and the incidence at term is approximately 0.4%. Symptomatic
placenta previa usually manifests as painless bleeding in the late second or third trimester. It can be painful
bleeding if it is associated with labor or abruption. Most patients with symptomatic placenta previa will
be admitted to the hospital for evaluation. Most neonatal morbidity and mortality associated with placenta
previa is due to the risks associated with preterm birth.
Corticosteroids should be given to women who present with bleeding from a placenta previa between 24
and 34 weeks gestation (SOR A). Tocolytic agents such as magnesium or calcium channel blockers would
be appropriate in patients who have vaginal bleeding associated with preterm contractions.
The goal with tocolytic treatment would be to prolong the pregnancy until fetal lung maturity is achieved.
This patient is not having preterm contractions so tocolytics would not be appropriate. The fetal heart rate
is stable and the mother is hemodynamically stable, so there is no indication for an urgent cesarean section.
Antibiotics do not have a role in the management of symptomatic placenta previa.
A 25-year-old previously healthy female presents to the urgent care clinic with swelling of her
lips and tongue, wheezing, dyspnea, and urticaria that developed after she was stung by a wasp.
Her only medication is atenolol (Tenormin), which she takes for migraine prophylaxis. You
immediately administer epinephrine 1:1000 dilution subcutaneously, but the patient does not
improve even after two more injections 10 minutes apart. She continues to be hypotensive
despite administration of an intravenous normal saline bolus, intramuscular diphenhydramine,
and nebulized albuterol (Proventil, Ventolin).
Which one of the following intravenous medications is most appropriate for treating this patient’s
A) Aminophylline
B) Diphenhydramine
C) Epinephrine
D) Glucagon (GlucaGen)
E) Hydrocortisone
The response to epinephrine may be limited in patients with anaphylaxis who have been taking -blockers.
Such individuals may have persistent hypotension, bradycardia, and prolonged symptoms. Since glucagon
exerts positive inotropic and chronotropic effects on the heart without depending on catecholamines, an
intravenous bolus followed by an infusion would be a good choice to treat the refractory hypotension.
The use of corticosteroids in this setting is common, but their effectiveness has not been established. Their
benefit is not realized for at least 6 hours, however, so they may aid in the prevention of recurrent
anaphylaxis. Diphenhydramine sometimes provides dramatic symptom relief, but it would not improve the
hypotension. beta-Agonists such as albuterol and aminophylline can be used for bronchospasm, but are not
helpful for hypotension.
Which one of the following statements is consistent with current U.S. Preventive Services Task
Force recommendations for skin cancer screening for the adult general population with no
history of premalignant or malignant lesions?
A) Whole-body examination should be conducted by a primary care provider every 3 years
B) Whole-body patient self-examination should be performed every 6 months
C) Benefits from screening have been established only for high-risk patients
D) The evidence is currently insufficient to determine whether early detection reduces
mortality and morbidity from skin cancer
E) The harms of detection and early treatment outweigh the benefits
The U.S. Preventive Services Task Force has concluded that current evidence is insufficient to assess the
balance of benefits and harms of whole-body skin examination by a primary care physician or by patient
skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell
skin cancer in the adult general population. Due to the lack of studies, the evidence is insufficient to
determine whether early detection of skin cancer reduces mortality or morbidity from skin cancer. The
same is true regarding the magnitude of harms from screening for skin cancer. Benefits from screening
are uncertain, even in high-risk patients.
A 72-year-old female presents with a 2-month history of constipation. She says she has to strain
to evacuate at least half the time and reports that her stools have become clay-like in consistency
and narrower in caliber. At least half the time she has the sensation that evacuation is not
complete, and she has occasionally used manual maneuvers to complete evacuation. She had a
normal colonoscopy 8 years ago.
An abdominal examination is normal, and stool with a clay-like consistency is palpated during
a rectal examination. No prolapse is seen with straining, and the anal wink is present. Screening
laboratory tests indicate a mild microcytic, hypochromic anemia.
Which one of the following would be most appropriate at this time?
A) A trial of lactulose
B) Lifestyle modifications
C) Phosphosoda enemas
D) Colonoscopy
E) Pelvic floor muscle exercises
This patient has several red flags that require complete colon evaluation with endoscopy: age >50, a
change in stool caliber, and obstructive symptoms. Other red flags include heme-positive stools, anemia
consistent with iron deficiency, and rectal bleeding. Malignancy should be eliminated as a possible
diagnosis prior to initiating any treatment. Biofeedback training is used to manage pelvic floor dysfunction
caused by incoordination of pelvic floor muscles during attempted evacuation. Common symptoms include
prolonged or excessive straining, soft stools that are difficult to pass, and rectal discomfort. The other
options are appropriate management strategies once malignancy has been eliminated as a possibility.
A 45-year-old male recently recovered from a second episode of left lower extremity cellulitis.
He has onychomycosis on his left foot but is otherwise in good health.
Which one of the following treatments is best overall if eradication of the onychomycosis is
A) Ciclopirox topical (Penlac Nail Lacquer)
B) Oral fluconazole (Diflucan)
C) Oral griseofulvin (Grifulvin V)
D) Oral itraconazole (Sporanox)
E) Oral terbinafine (Lamisil)
Onychomycosis is a difficult condition to treat successfully. If symptoms are minimal, treatment is often
deferred. Cellulitis of the involved extremity may be related to the onychomycosis and is an accepted
reason to consider eradication treatment. Oral terbinafine is the best treatment in terms of cure rate and
tolerability (SOR A). Significant liver disease is a contraindication.
Itraconazole is less effective and more toxic, and griseofulvin is significantly less effective. Topical
ciclopirox lacquer is also less effective than terbinafine, although it eliminates the risk for systemic
toxicity. Fluconazole is not indicated for onychomycosis.
Effective communication with patients from other countries requires knowledge of
communication styles within various cultures. Which one of the following is consistently
appropriate for all patients from non-English-speaking countries?
A) Discouraging the use of family members as interpreters
B) Expecting patients to make their own decisions regarding care
C) Discussing test results with the patient only
D) Maintaining eye contact with the patient
Providing quality health care to individuals from diverse sociocultural backgrounds requires effective
communication. Low health literacy in almost half of the U.S. population makes communication more
difficult. When a language barrier exists it is better to have a professional interpreter than a family
member, and children should be used as interpreters only in cases of emergency when no other source is
The typical approach to medical care in the United States assumes that patients want to make their own
decisions based on guidance from their health care providers. However, there are cultures in which patient
autonomy is not the norm. There may be a specific authority figure in the family that is regarded as the
decision maker.
Effective communication also involves knowledge of communication styles within various cultures.
Nonverbal communication can be through touch, eye contact, and personal space. For example, there are
cultures in which direct eye contact is avoided, but in other cultures it is considered a sign of respect.
A 55-year-old male with type 1 diabetes mellitus is being treated in the wound care clinic for a
skin ulcer on his lower right leg. The ulcer is slow to improve. He comes to see you in the office
because over the past 2 days his right knee has become swollen, red, warm, painful, and difficult
to flex. When you examine him, his right knee is swollen, erythematous, indurated, and held
in full extension. Active and passive ranges of motion are limited. Areas of erythema and
induration continue to surround his leg ulcer. His WBC count is mildly elevated, but his
erythrocyte sedimentation rate and C-reactive protein level are normal.
Which one of the following would be most appropriate at this point?
A) Plain radiographs
B) Ultrasonography
D) Arthrocentesis
E) Antinuclear antibody studies
Any patient with risk factors for infection who presents with acute joint swelling, pain, erythema, warmth,
and joint immobility should be evaluated for septic arthritis. Risk factors for septic arthritis in this patient
include a cutaneous ulcer and diabetes mellitus. Serum markers such as the WBC count, erythrocyte
sedimentation rate, and C-reactive protein levels are often used to determine the presence of infection or
inflammatory response. However, patients with confirmed septic arthritis may have normal erythrocyte
sedimentation rates and C-reactive protein levels.
Because the clinical presentation of septic arthritis may overlap with that of other causes of acute arthritis,
arthrocentesis is needed to differentiate between the various causes and, in the case of septic arthritis, to
identify the causative agent and determine appropriate therapy. No findings on imaging studies are
pathognomonic for septic arthritis. Antinuclear antibody studies may be indicated later in the course of
management if synovial fluid analysis is not consistent with infection, and if synovial fluid cultures are
In addition to fluid resuscitation, which one of the following is the recommended first-line agent
for the management of hypotension in a patient with sepsis?
A) Albumin
B) Dopamine
C) Epinephrine
D) Norepinephrine (Levophed)
E) Phenylephrine (Neo-Synephrine)
Norepinephrine is the recommended first-line vasopressor agent to correct hypotension in patients with
sepsis (SOR A). Vasopressor therapy is required to sustain life and maintain perfusion in the face of
life-threatening hypotension, even when hypovolemia has not yet been resolved. Maintaining a mean
arterial pressure of at least 65 mm Hg is critical for tissue perfusion. Dopamine is recommended as an
alternate first-line agent to elevate arterial pressure, but it is less potent compared to norepinephrine.
Dobutamine is recommended as the first-line agent for managing hypotension in cardiogenic shock.
Phenylephrine is recommended as the second-line agent for managing hypotension in patients with septic
shock who also have tachycardia or dysrhythmias. Albumin and epinephrine are not recommended as
first-line agents for managing hypotension in patients with sepsis.
The husband of a 25-year-old white female consults you about his wife. Eighteen months ago,
her last pregnancy was complicated by placental abruption, hemorrhagic shock, and the birth of
a stillborn infant. She did not lactate and has not menstruated since the delivery. Since that time
she has become increasingly fatigued and apathetic and has noticed a marked decrease in her
Which one of the following is the most likely diagnosis?
A) Prolonged grief reaction
B) Postpartum pituitary necrosis
C) Postpartum depression
D) Iron deficiency anemia
A prolonged grief reaction, postpartum depression, and iron deficiency anemia could all cause fatigue,
apathy, and decreased libido, but none of these conditions is characterized by failure to lactate and
amenorrhea. This patient most likely has postpartum pituitary necrosis (Sheehan’s syndrome), a
complication of childbirth in which hemorrhagic shock leads to pituitary necrosis. The syndrome is caused
by the lack of hormonal influence from the anterior pituitary gland on other endocrine glands, resulting
in failure to lactate, breast atrophy, mental apathy, low blood pressure, absence or deficiency of sweating,
loss of secondary hair characteristics and libido, and loss of ovarian function, resulting in amenorrhea.
A 58-year-old postmenopausal female sees you for an initial health maintenance visit. Her
examination is normal and she has no complaints. You perform a Papanicolaou (Pap) test, which
she has not had done in 15 years. The smear is read as “negative for intraepithelial lesion and
malignancy, benign endometrial cells present.”
What would be the most appropriate follow-up for this finding?
A) A repeat Pap test in 4-6 months
B) A repeat Pap test in 1 year
C) HPV testing
D) An endometrial biopsy
E) Colposcopy and endocervical curettage
This patient should have an endometrial biopsy (SOR C). Approximately 7% of postmenopausal women
with benign endometrial cells on a Papanicolaou smear will have significant endometrial pathology. None
of the other options listed evaluate the endometrium for pathology. An asymptomatic premenopausal
woman with benign endometrial cells would not need an endometrial evaluation because underlying
endometrial pathology is rare in this group.
Which one of the following is most likely to cause hypoglycemia when used as monotherapy?
A) Acarbose (Precose)
B) Exenatide (Byetta)
C) Pioglitazone (Actos)
D) Repaglinide (Prandin)
E) Sitagliptin (Januvia)
Repaglinide is a non-sulfonylurea agent that interacts with a different portion of the sulfonylurea receptor
to stimulate insulin secretion. It has a relatively short duration of action, and while it may cause
hypoglycemia this is less likely than with a sulfonylurea agent. Pioglitazone reduces insulin resistance and
has no hypoglycemic effect. Acarbose delays absorption of carbohydrates such as starch, sucrose, and
maltose, but does not affect the absorption of glucose and other monosaccharides. Sitagliptin inhibits the
enzyme responsible for the breakdown of the naturally occurring incretins, and its major advantage is the
absence of side effects. Exenatide stimulates insulin secretion in a glucose-dependent fashion, inhibits
glucagon secretion, slows gastric emptying, and may have a central satiety effect. It does not cause
hypoglycemia when used as monotherapy, but may increase the risk when used with an insulin
secretagogue such as glyburide or glipizide.
During hospital rounds you are called to attend the resuscitation of one of your patients, a
chronic alcoholic with known esophageal varices secondary to hepatic cirrhosis, who just
experienced sudden massive hematemesis that resulted in aspiration and respiratory arrest.
Endotracheal intubation and suctioning appear to improve her respiratory crisis momentarily,
but her pulse quickly becomes too weak to palpate. After 20 minutes of resuscitative effort,
cardiac monitoring fails to detect any cardiac electrical activity, no spontaneous respiratory
activity is noted, and the process is halted.
When completing the death certificate for this patient, the diagnosis most appropriately listed as
the immediate cause of death is
A) cardiac arrest
B) respiratory arrest
C) upper gastrointestinal hemorrhage
D) esophageal varices
E) cirrhosis of the liver
Although the registration of death is a state function and the details may vary based on the laws and
regulations of each state, recorded data is contractually shared with the National Vital Statistics System.
To ensure consistency of reporting, the National Center for Health Certificates coordinates collection of
the data points by providing a standard form which most state certificates are modeled from. The standard
format includes a section titled “Cause of Death,” which is subdivided into two parts. In part 1, the
immediate cause of death is to be recorded on the top line (labeled “a”). This is defined as the final
disease, injury, or complication directly causing the death, and the directions clearly state that terminal
events such as cardiac arrest, respiratory arrest, or ventricular fibrillation are not to be entered without
showing the etiology.
Additional lines are provided to list conditions leading to the cause of death, including a final line for
entering the disease or injury that initiated the process leading to death. In this case, the proximate cause
of death was the upper gastrointestinal hemorrhage. The source of the bleeding was most likely from
esophageal varices resulting from hepatic cirrhosis, so those conditions should be entered respectively in
the next two lines. The appropriate entry for the final line in part 1 would be chronic alcoholism.
Space is provided in part 2 to include significant conditions contributing to death, such as other chronic
illness and tobacco use.
Which one of the following patients is eligible for the Medicare hospice benefit?
A) A patient with end-stage COPD with a life expectancy of 6 months
B) A patient with amyotrophic lateral sclerosis with a life expectancy of 9 months
C) A patient on hemodialysis with a life expectancy of 12 months
D) A patient with stage IV breast cancer with a life expectancy of 18 months
Patients with a life expectancy of 6 months or less are eligible for the Medicare hospice benefit. This
benefit allows patients to receive hospice care in either the home or hospital setting. In addition to patients
with terminal cancer, patients with end-stage cardiac, pulmonary, and chronic debilitating diseases are
eligible. Approximately two-thirds of patients enrolled in hospice die from non-cancer-related diagnoses,
and approximately 60% of Medicare patients are not enrolled in hospice at the time of their death.
A 16-year-old male asthmatic with no other medical problems presents with a severe attack of
respiratory distress and a peak expiratory flow rate <40%. After 1 hour of acute treatment his
respiratory distress has resolved, but he complains of blurred vision.
Which one of the following therapeutic agents would be the most likely cause?
A) Nebulized albuterol (Proventil, Ventolin)
B) Nebulized ipratropium bromide
C) Nebulized levalbuterol (Xopenex)
D) Subcutaneous terbutaline
E) Intravenous methylprednisolone
Ipratropium bromide is an anticholinergic agent. When nebulized it can sometimes cause inadvertent ocular
effects. Blurred vision and pupil inequality may occur. Ipratropium has been shown to decrease the rate
of hospital admissions in severe asthmatic attacks.
Corticosteroids may elevate glucose levels in diabetic patients. The onset would be more gradual, however.
Adrenergic agents used for acute asthma do not commonly produce adverse ocular effects (level of
evidence 3).
A 77-year-old male presents for a periodic health evaluation. Your practice is organized as a
patient-centered medical home, and this is the patient’s initial visit. His records indicate that he
received all recommended screening tests and immunizations 4 years ago, and he asks what
screening tests are necessary at his age.
The U.S. Preventive Services Task Force recommends that this patient be screened for which
one of the following?
A) Prostate cancer
B) Colorectal cancer
C) Abdominal aneurysm
D) Dementia
E) Depression
While the U.S. Preventive Services Task Force (USPSTF) recommends against screening for prostate
cancer using prostate-specific antigen testing, other screening methods have not been evaluated in
controlled studies. For men who have smoked, one-time ultrasonography is recommended as a screen for
aortic aneurysm between the ages of 65 and 75. The USPSTF has no recommendation for men who have
never smoked.
The USPSTF states that no evidence supports routine colorectal cancer screening in patients age 76-85,
but that there may be some individuals with specific considerations for whom colorectal cancer screening
would be recommended.
At present, there is no evidence to support screening of older adults for dementia, but it is recommended
that all adults be screened for depression when staff support is in place to ensure adequate diagnosis,
treatment, and follow-up. In most instances, the elderly population will present to a primary care provider
with somatic complaints (level of evidence 1b).
An 82-year-old white male consults you following several syncopal episodes that are clearly
orthostatic in nature. During the course of your evaluation you find that he has a large tongue,
mild cardiomegaly, and findings suggestive of bilateral carpal tunnel syndrome.
The most likely diagnosis at this time is
A) pernicious anemia
B) cervical spondylosis
C) amyloidosis
D) cardiomyopathy
E) polymyalgia rheumatica
Amyloidosis is defined as the extracellular deposition of the fibrous protein amyloid at one or more sites.
It may remain undiagnosed for years. Features that should alert the clinician to the diagnosis of primary
amyloidosis include unexplained proteinuria, peripheral neuropathy, enlargement of the tongue,
cardiomegaly, intestinal malabsorption, bilateral carpal tunnel syndrome, or orthostatic hypotension.
Amyloidosis occurs both as a primary idiopathic disorder and in association with other diseases such as
multiple myeloma.
Which one of the following is true concerning people in the United States who do not have health
A) Most uninsured people are members of a family with at least one working adult
B) Most uninsured people who are employed full-time work for large companies
C) Most uninsured people who work part-time and have incomes below the poverty line are
eligible for Medicaid
D) On average, uninsured people have as much access to routine health care as those with
Most uninsured people in the United States are members of a family with at least one working adult. Most
uninsured people who are employed work for small companies or work part-time. Most uninsured people
who work part-time with incomes below the poverty line are not eligible for Medicaid. On average,
uninsured people have less access to care and have poorer health outcomes.
A 36-year-old male requests further testing for infertility. His female partner has undergone all
testing, and her results are normal. He has recently undergone a semen analysis, which revealed
azoospermia. Suspecting hypogonadism, you evaluate morning levels of FSH and total serum
testosterone levels to help distinguish between primary and secondary causes.
Which one of the following would you expect with primary hypogonadism?
A) Normal levels of both FSH and testosterone
B) Low levels of both FSH and testosterone
C) Low FSH and increased testosterone
D) High FSH and low testosterone
E) High levels of both FSH and testosterone
If semen analysis suggests hypogonadism (e.g., severe oligospermia or azoospermia), it is important to
distinguish between primary and secondary causes (SOR C). Evaluation of morning FSH and total serum
testosterone levels can help make this determination. Low testosterone levels correlate with hypogonadism.
High levels of FSH in the presence of low testosterone levels correlate with primary hypogonadism (SOR
B). Low levels of both hormones suggest secondary hypogonadism (SOR B). High testosterone levels are
unlikely to be associated with hypogonadism.
A 32-year-old female presents with a history of recurring headaches. They are usually unilateral,
last for 24-48 hours, have a pulsatile quality, and are associated with nausea. She sometimes
experiences photophobia as well. The patient describes the headaches as intense, usually
requiring her to limit her activities. She has tried several over-the-counter migraine medications
that have been minimally effective in aborting these headaches, and requests a prescription for
an abortive therapy.
Which one of the following would be the best choice for first-line therapy?
A) Acetaminophen
B) Acetaminophen/oxycodone (Percocet)
C) Butalbital/aspirin/caffeine (Fiorinal)
D) Prednisone
E) Sumatriptan (Imitrex)
Several medications from different classes are recommended as first-line abortive therapies to treat acute
migraine. Because relatively few trials have directly compared the different medication classes, there are
no definitive algorithms as to which class works best. NSAIDs and acetaminophen/aspirin/caffeine are
recommended as first-line therapies and can be obtained over the counter (SOR A). Triptans are effective
and safe for treatment of acute migraine and are recommended as first-line therapy (SOR A) but require
a prescription. Opiates and barbiturates are not recommended because of their potential for abuse (SOR
C). Acetaminophen alone is not effective, and the same is true of oral corticosteroids.
A 24-year-old female presents to your office for a health maintenance evaluation. She mentions
that she has had several episodes of indigestion after meals and started taking an over-the-counter
proton pump inhibitor, which she feels has been helpful. She asks if it would be harmful to take
this medicine on a long-term basis.
You tell her that evidence has shown that continuing to take this medication will increase her risk
for which one of the following?
A) Hypomagnesemia
B) Vitamin B12 deficiency
C) Clostridium difficile colitis
D) Having a child with birth defects (if taken in the first trimester)
E) Colon cancer
Proton pump inhibitors (PPIs) have a powerful effect on inhibiting the production of acid in the stomach.
This dramatically reduces symptoms of acid-mediated gastritis, peptic ulcer disease, and gastroesophageal
reflux. However, a significant reduction in stomach acidity may cause unintended consequences involving
processes that are physiologically dependent on low pH in the gastrointestinal tract. These theoretical risks
include decreased levels of vitamin B12, iron, and/or magnesium; decreased bone density; an increase in
gut infections or pneumonia; an increase in gastrointestinal neoplasms; and changes in absorption of other
The evidence has been conflicting on some of these risks. Currently, consensus is emerging that chronic
use of PPIs increases the risk for pneumonia and gut infections, primarily Clostridium difficile colitis (SOR
B). PPIs may also decrease bone density in subsets of patients. These risks need to be weighed against the
benefits that these medicines provide before prescribing them on a long-term basis.
For adolescents with scoliosis, observation is always indicated for a curve below a threshold of
A) 20°
B) 30°
C) 40°
D) 50°
The diagnosis of idiopathic scoliosis is based on a coronal plane curvature >10°. It is a diagnosis of
exclusion after congenital, neuromuscular, and myopathic diseases and conditions have been ruled out.
Adolescent scoliosis is most common, and occurs in about 2%-3% of adolescents. More marked curvature
(>30°) occurs in about 0.3% of adolescents, as measured on posterior-anterior and lateral radiographs
using the Cobb method. For mild degrees of curvature there is an even distribution between girls and boys,
but girls have a tenfold greater risk for more severe curvature.
Screening for scoliosis in the asymptomatic adolescent is controversial; the U.S. Preventive Services Task
Force recommends against routine screening in its most recent update in 2004 (D recommendation).
However, if idiopathic scoliosis is discovered incidentally or when the adolescent or parent expresses
concern about scoliosis, options for further evaluation and treatment include observation for curvatures
of less than 20° and consideration for bracing and/or surgery for more severe curvatures. The risk of
progression depends on the amount of growth remaining, the magnitude of the curve, and the patient’s
A 40-year-old male presents with a 3-month history of persistent low back pain and stiffness.
He cannot recall any specific episode associated with the onset of the pain, and intermittent
ibuprofen has provided little benefit. The pain does not radiate into his legs. He has experienced
similar back pain before, but it had always resolved within 2 weeks with rest, cutting back on
his activities, and taking ibuprofen. During his third episode about a year ago MRI of his
lumbosacral spine did not show any significant pathology.
When you examine the patient he describes mild, generalized discomfort with palpation
throughout his lumbosacral region, but has full range of motion of his back, normal deep tendon
reflexes, and good muscle strength in his legs. The straight leg-raising test produces mild low
back discomfort but does not result in any leg pain.
Which one of the following treatment options has the best evidence for restoring function in this
A) Acupuncture
B) Back school
C) Back exercises
D) Spinal manipulation
E) Epidural corticosteroid injection
This patient suffers from chronic low back pain, defined as pain, muscle tension, or stiffness localized
below the costal margin and above the inferior gluteal folds, with or without sciatica, that has persisted for
12 weeks or more and is not attributed to a recognizable pathology. Among all the listed treatment options
for chronic low back pain, only back exercises are given the “beneficial” recommendation in a systematic
review. Acupuncture and spinal manipulation are in the “likely to be beneficial” category. Back school and
epidural corticosteroid injections are of “unknown effectiveness.”
A 63-year-old white male has been diagnosed with myasthenia gravis and is experiencing
progressive muscle weakness despite maximum pharmacotherapy. Which one of the following
surgical options would be most likely to improve his condition?
A) Thyroidectomy
B) Radioactive thyroid ablation
C) Adrenalectomy
D) Removal of a pituitary microadenoma
E) Thymectomy
Myasthenia gravis is a neuromuscular illness with an underlying immune-related cause. Corticosteroids
and anticholinesterase medications such as oral pyridostigmine can be helpful, but thymectomy may be
appropriate for patients with generalized disease not responding to medication. Thymectomy increases the
remission rate and improves the clinical course.
You are preparing to evaluate a patient in the emergency department. A BNP level was ordered
by the physician from the previous shift who handed the patient over to you. The level is
reported as 459 pg/mL. You have not yet interviewed or examined the patient.
Based upon the information you have at this point, which one of the following is true regarding
this patient?
A) The patient has diastolic heart failure
B) The patient has systolic heart failure
C) The patient has acute heart failure
D) The patient does not have heart failure
E) The patient’s diagnosis is uncertain
According to the 2010 American Heart Association scientific statement regarding acute heart failure
syndrome, levels of natriuretic peptides such as BNP lack the specificity necessary to function as absolute
indicators of acute heart failure syndrome even when they exceed established thresholds for the diagnosis.
BNP levels vary with age, sex, body habitus, renal function, and abruptness of symptom onset.
Elevated BNP levels also have been associated with renal failure (because of reduced clearance),
pulmonary embolism, pulmonary hypertension, and chronic hypoxia. BNP measures are not a substitute
for a comprehensive assessment for signs and symptoms of heart failure, and a laboratory test by itself
cannot be used to determine the diagnosis or management of heart failure. Clinical evaluation and
follow-up are essential to assure proper care for patients with heart failure or any other cardiac problem.
A 45-year-old patient develops acute erythema and pain in the first metatarsophalangeal joint,
the second such episode in 4 months. There is no apparent joint effusion. Results of a standard
laboratory profile are normal, including an erythrocyte sedimentation rate, CBC, liver enzymes,
BUN/creatinine, electrolytes, calcium, and uric acid. A radiograph is read as normal.
The most likely diagnosis is
A) hydroxyapatite crystal disease
B) Morton’s neuroma
C) systemic lupus erythematosus
D) acute gouty arthritis
Erythema, redness, and pain in the first metatarsal-phalangeal joint are typical symptoms of gout. The uric
acid level can be normal at various times in gout. Acute synovitis is occasionally caused by apatite
deposition disease, but it is usually associated with long-standing osteoarthritis, and the joints involved are
most commonly the shoulder, hip, and knee. Morton’s neuroma is an entrapment neuropathy of the
interdigital nerve, usually occurring between the third and fourth toes, not associated with erythema and
redness. Acute arthritis in systemic lupus erythematosus typically involves the wrists, the small joints of
the hands, and the knees.
A 73-year-old female presents with signs of an acute ischemic stroke, which began 2 hours
earlier. She has a National Institutes of Health Stroke Scale score of 14. Noncontrast head CT
shows no sign of hemorrhage.
Which one of the following treatments is recommended and FDA approved for patients with this
problem who have no contraindications?
A) Intravenous tissue plasminogen activator (tPA)
B) Warfarin (Coumadin)
C) Glycoprotein IIb/IIIa receptor antagonists
D) Aspirin and clopidogrel (Plavix)
E) Heparin
Studies have shown that the use of intravenous tissue plasminogen activator offers sustained patient benefit
at 6 and 12 months if given within 3 hours of symptom onset (SOR B). All other listed interventions have
not been shown to be efficacious.
Which one of the following jaundiced infants can be treated expectantly without a full workup
for pathologic causes?
A) A 12-hour-old term infant with a total bilirubin of 10 mg/dL
B) A 1-day-old term infant with a total bilirubin of 20 mg/dL
C) A 2-day-old term infant with a total bilirubin of 10 mg/dL
D) A 1-week-old term infant with a total bilirubin of 25 mg/dL
Term infants with an onset of jaundice before 24 hours of age, jaundice persisting beyond 3 weeks of age,
or a bilirubin level requiring intensive phototherapy should not be considered healthy, and require further
evaluation. A 2-day-old term infant with a total bilirubin of 10 mg/dL may be followed expectantly.
Your laboratory reports a borderline low vitamin B12 level in an anemic patient. Which one of
the following tests can confirm vitamin B12 deficiency?
B) Methylmalonic acid
C) Mean corpuscular volume
D) Serum ferritin
E) Homocysteine
Vitamin B12 and folate deficiencies typically cause macrocytic anemias. When the serum vitamin B12 level
is borderline low, an elevated methylmalonic acid level can be used to confirm a vitamin B12 deficiency.
An elevated homocysteine level plays a similar role for folate deficiency anemia. Hemolysis can be
associated with an elevated LDH level, and serum ferritin is useful for diagnosing iron deficiency anemia.
A clinical trial reports that a new therapy is non-inferior to your usual choice of treatment. You
can assume which one of the following?
A) The new treatment has proven efficacy
B) A large placebo group was studied
C) The study was both double blind and placebo controlled
D) The new therapy is not superior to what you are currently using
E) The new therapy is not less effective than what you are currently using
Noninferiority trials compare an active control group with a new therapy. The use of a placebo group
would be unethical, since the present therapy is either lifesaving or prevents serious injury. The new
therapy may prove superior to or slightly less effective than the standard therapy.
A 35-year-old white female schoolteacher presents with anxiety, fatigue, and insomnia. The
symptoms began after a heart murmur was discovered on a routine physical examination. An
echocardiogram revealed mild mitral valve prolapse. A student at her school recently died
suddenly on a school field trip because of undiagnosed idiopathic hypertrophic cardiomyopathy
and the patient is now afraid she will die in a similar manner. She is anxious, sleepless, and
fearful of physical activity. You perform a physical examination and EKG, with normal results.
Which one of the following would be most appropriate at this point?
A) Reassurance regarding the benign course of her condition
B) A stress test
C) Clonazepam (Klonopin)
D) Referral to a cardiologist
E) Referral for group psychotherapy
Much of the psychological distress caused by the diagnosis of mitral valve prolapse is related to a lack of
information and a fear of heart disease, which may be reinforced by the death of a friend or relative. A
clear explanation of mitral valve prolapse, along with printed material, is a powerful aid in relieving the
patient’s emotional distress. The American Heart Association publishes a helpful booklet about this
condition which can be given to these patients. It is important to avoid reinforcing illness behavior with
unnecessary testing, medications, or referrals to specialists.
A 37-year-old male returns for his first follow-up visit after being diagnosed with major
depression 4 weeks earlier. The patient is taking citalopram (Celexa), 20 mg/day. He is
tolerating the medication well and his energy level and sleep are improved, but he still complains
of anhedonia. He has no other health problems and takes no other medications.
The most reasonable management at this point is to
A) add aripiprazole (Abilify)
B) increase the dosage of citalopram
C) add bupropion (Wellbutrin)
D) add levothyroxine (Synthroid)
All of the treatment options listed may improve the patient’s depression, but it is unnecessary to add a
second agent until the initial drug is at the maximum recommended dosage. Citalopram can be increased
to a dosage of 40 mg/day.
You have recently diagnosed rheumatoid arthritis in a 49-year-old female. She has started
methotrexate (Rheumatrex) for disease-modifying therapy.
You counsel her that she is at increased risk for various diseases related to her arthritis, but that
the leading cause of death in patients with rheumatoid arthritis is
A) infection
B) cardiovascular disease
C) lymphoma
D) lung cancer
Patients with rheumatoid arthritis (RA) are at increased risk for various extra-articular manifestations of
the inflammatory disease, as well as side effects of the medications used to manage it. The leading cause
of death in RA patients is cardiovascular, related to accelerated atherosclerosis (SOR C). Patients with RA
should be screened for cardiovascular risk factors and managed appropriately to lower their risk.
Patients with RA are also at increased risk for other problems that are not leading causes of mortality.
Their risk for infection is increased, which can be related to either the RA itself or to the use of
immunosuppressive agents. Patients with RA also have a twofold increase in their risk for lymphoma. This
is independent of whether or not they are on immunosuppressive agents. Their risk for lung cancer related
to interstitial lung disease is also increased, and smoking increases this risk further.
A 25-year-old male graduate student develops an acute headache, fever, and rash while visiting
his parents during fall break. When he comes to the emergency department he has a widespread
petechial rash and a stiff neck, and his blood pressure is 78/40 mm Hg. He is treated with
appropriate empiric antibiotics, and the spinal fluid from a tap reveals a large number of
polynuclear leukocytes and gram-negative diplococci.
What is the most appropriate treatment at this point?
A) Ceftriaxone (Rocephin)
B) Rifampin (Rifadin)
C) Ciprofloxacin (Cipro)
D) Amoxicillin
E) Doxycycline
This patient likely has meningitis due to Neisseria meningitidis. Ceftriaxone is recommended as first-line
therapy and should not be delayed once the diagnosis is suspected (SOR B). Ciprofloxacin and rifampin
are not recommended as first-line therapy for infected individuals, but are recommended as prophylaxis
for close contacts (SOR B). Doxycycline and amoxicillin are not proven to be effective for treatment or
While on vacation you get up for an early morning swim and find a young man face down in the
hotel lap pool. He is flaccid and unresponsive when you pull him from the water. You are alone,
there is no automated external defibrillator (AED) available, and the telephone is at the opposite
side of the room.
Which one of the following actions is most consistent with American Heart Association 2010
guidelines for resuscitation?
A) Turning the victim on his side to drain upper airway fluid before starting CPR
B) Performing the Heimlich maneuver before starting CPR
C) Performing 10 minutes of CPR before activating emergency medical services
D) Attempting ventilation before chest compression
E) Maintaining cervical spine immobilization with whatever is available
The 2010 American Heart Association guidelines for resuscitation emphasize the importance of chest
compression in CPR. Compression-Airway-Breathing (C-A-B) is now recommended over Airway-
Breathing-Compression (A-B-C). Individualization of this sequence is recommended, however, and in
drowning victims the A-B-C approach is preferred because of the hypoxic nature of the cardiac arrest.
Emergency medical services (EMS) should be activated when the victim is found flaccid and unresponsive.
In certain situations CPR may be performed for up to 2 minutes before calling 911, but a 10-minute
interval is excessive. The Heimlich maneuver and attempts to positionally drain the airway may be harmful
and delay effective CPR.
The reported incidence of cervical spine injury in drowning victims is 0.009%. Attempts at cervical spine
immobilization are not necessary and may impede airway maintenance (SOR C).
Which one of the following is most appropriate for the treatment of gonorrhea?
A) Azithromycin (Zithromax)
B) Azithromycin plus ceftriaxone (Rocephin)
C) Cefixime (Suprax)
D) Ciprofloxacin (Cipro)
Because of increased resistance to fluoroquinolones, ciprofloxacin is no longer recommended for the
treatment of gonorrhea. In addition, there appears to be emerging resistance to cephalosporins, as
evidenced by an increase in the minimum inhibitory concentrations of cephalosporins between 2000 and
2010. Unfortunately, no other well-studied and effective alternative antibiotic treatment regimens are
currently available. It also appears that gonococcal resistance to cefixime might develop before resistance
to ceftriaxone. As a result, in 2011 the Centers for Disease Control and Prevention recommended dual
treatment with ceftriaxone, 250 mg intramuscularly, and azithromycin, 1 g orally, as the most effective
treatment for uncomplicated gonorrhea.
A 63-year-old male presents with increasing shortness of breath over the past year. He smokes
a pack of cigarettes a day, and has done so since he was 18 years old. Your evaluation leads to
a diagnosis of COPD.
Which one of the following interventions has been shown to slow the decline in lung function
in this situation?
A) Smoking cessation
B) Regular use of an inhaled short-acting 2-agonist
C) Regular use of an inhaled long-acting 2-agonist
D) Regular use of an inhaled long-acting anticholinergic agent
E) Regular use of oral corticosteroids
Smoking cessation slows the decline of lung function in COPD. Long-acting 2-agonists, anticholinergic
agents, and inhaled corticosteroids are useful for improving the symptoms of COPD. They improve
exercise tolerance and quality of life, and can reduce the frequency of exacerbations. However, they do
not slow the progression of COPD. Oral corticosteroids, along with antibiotics, are useful in treating acute
exacerbations of COPD, but long-term treatment is not recommended.
A 25-year-old medical assistant presents with a 3-month history of a tremor that began shortly
after the death of her husband. The tremor starts abruptly and then spontaneously remits. It is
not an action tremor and has no association with posture.
On examination you notice the tremor severity increases with questions calling attention to her
tremor symptoms and lessens when she is distracted with questions about her hobbies and
summer plans. Her neurologic examination is completely normal, including no signs of dystonia,
and she has no laboratory or radiologic evidence of disease. She denies taking any medications
or using any substances that might cause a tremor. The patient also reports that the tremor does
not improve with moderate alcohol consumption, and it did not respond to a trial of anti-tremor
medications prescribed by another physician.
Based on your findings, you suspect this patient most likely has which type of tremor?
A) Cerebellar
B) Dystonic
C) Essential
D) Parkinsonian
E) Psychogenic
This patient most likely has a psychogenic tremor, given its abrupt onset, spontaneous remission, changing
tremor characteristics, and extinction with distraction (SOR C). Other characteristics of this case that
suggest psychogenic tremor are the associated stressful life event, the patient’s employment in a health care
setting, and no evidence of disease by laboratory or radiologic investigations. In addition, the tremor
increases with attention and has been unresponsive to anti-tremor medications (SOR C).
Dystonic tremor is a rare tremor found in less than 1% of the population, and other signs of dystonia, such
as abnormal flexion of the wrists, are usually present. Essential tremor is an action tremor and is usually
postural; however, persons with essential tremor typically have no other neurologic findings. Essential
tremor typically improves with alcohol consumption (2 drinks/day). A cerebellar tremor is usually
associated with other neurologic signs, such as dysmetria (overshoot on finger-to-nose testing), dyssynergia
(abnormal heel-to-shin testing and/or ataxia), and hypotonia. A parkinsonian tremor is most often a resting
tremor, and although it may become less prominent with voluntary movement, it usually does not
spontaneously remit.
Which one of the following is associated with testosterone replacement for men with
A) Osteoporosis
B) Depression
C) Reduced cognitive function
D) Increased fat deposition
E) Infertility
Testosterone replacement therapy can improve many of the effects of hypogonadism. Beneficial effects
include improvements in mood, energy level, sexual functioning, sense of well-being, lean body mass and
muscle strength, erythropoiesis, bone mineral density, and cognition. However, there are also some risks
associated with testosterone use, including an increased risk for prostate cancer, worsening of symptoms
of benign prostatic hyperplasia, liver toxicity and tumor, worsening of sleep apnea and heart failure,
gynecomastia, infertility, and skin diseases. Testosterone replacement therapy is not appropriate in men
who are interested in maintaining fertility, as exogenous testosterone will suppress the
hypothalamic-pituitary-thyroid axis.
A 70-year-old male sees you for a preoperative evaluation 3 days prior to iliofemoral bypass
surgery. He has a 54-pack-year history of cigarette smoking, and has a long-term history of
hypertension and peripheral vascular disease. His current medications include lisinopril (Prinivil,
Zestril), hydrochlorothiazide, and low-dose aspirin. He has no past history of myocardial
infarction, diabetes mellitus, or hyperlipidemia.
His blood pressure is 156/84 mm Hg and his pulse rate is 80 beats/min. The cardiopulmonary
examination is normal. Foot pulses are diminished but present bilaterally.
In order to reduce this patient’s risk of perioperative cardiac complications, which one of the
following is recommended prior to his surgery?
A) A pharmacologic cardiac stress test
B) Discontinuation of aspirin
C) Starting a beta-blocker
D) Starting enoxaparin (Lovenox)
E) Starting a statin
In addition to their lipid-lowering effects, statins have been shown to have plaque-stabilizing and vascular
anti-inflammatory effects. There is strong clinical evidence that perioperative statin therapy, even when
initiated within days of the procedure and without regard to lipid levels, significantly reduces
cardiovascular risk for patients undergoing vascular surgery (SOR A).
There is strong clinical evidence of benefit in perioperative cardiovascular risk reduction for continuation
of -blockers before, during, and after vascular surgery in patients who have been on them for at least 4
weeks preoperatively (SOR A). However, in patients who have not been on a beta-blocker for at least 1-4
weeks preoperatively, initiation prior to surgery may be harmful (SOR B).
Traditionally, aspirin has been discontinued prior to surgery for fear of increased surgical bleeding
complications. However, studies have shown that in most cases it is safe to continue low-dose aspirin in
the perioperative period, and doing so reduces cardiovascular complications. This is especially true for
patients with a past history of myocardial infarction or with coronary stents (SOR B).
Preoperative cardiac stress testing is of little value in patients with low or medium cardiovascular risk
status, such as the patient described here. Enoxaparin would not be indicated preoperatively in this patient.
In counseling a 35-year-old female about smoking cessation, you find that her greatest concern
is that she will gain weight. Among the following therapies, which one is most strongly
associated with weight gain after smoking cessation?
A) Bupropion (Wellbutrin)
B) Clonidine (Catapres)
C) Varenicline (Chantix)
D) Nicotine gum
At every office visit, family physicians should encourage smokers to quit (SOR A). Patients who are ready
to quit may be helped by various pharmacologic treatments. Sustained-release bupropion and nicotine
replacement, especially gum and lozenges, may delay the weight gain often associated with smoking
cessation. Varenicline has a variety of side effects, including an increased risk for cardiovascular events
and a multitude of neuropsychiatric symptoms. It is also the agent most commonly associated with
post-smoking cessation weight gain. Clonidine, considered a second-line, off-label alternative for smoking
cessation, is not associated with weight gain.
You make a diagnosis of polymyalgia rheumatica in a 72-year-old female. This is a new
diagnosis for this patient and she has not received any treatment for this condition up to this
Which one of the following prednisone regimens would be the best initial treatment?
A) 15 mg daily with a slow taper
B) 15 mg daily with a rapid taper
C) 30 mg daily with a slow taper
D) 30 mg daily with a rapid taper
E) 60 mg daily with a rapid taper
For the initial treatment of polymyalgia rheumatica, current evidence suggests using prednisone, 15 mg
daily, or its equivalent, with slow tapering. Relapses are more common with an initial dosage of 10 mg
daily, and slow tapering is associated with fewer relapses. Few patients require a dosage greater than 15
mg/day, which increases the risk for adverse effects.
An otherwise healthy 53-year-old male presents with acute shortness of breath and pleuritic chest
pain. His O2 saturation on room air is 85%, and he is hemodynamically stable. The patient
underwent an appendectomy 2 weeks ago and his postoperative course was complicated by an
abscess, which required a week-long hospital stay.
Which one of the following should be the initial test to further evaluate this patient?
A) D-dimer
B) CT angiography of the chest
C) Pulmonary angiography
D) Venous ultrasonography
This patient has a high probability of pulmonary embolism, given his clinical presentation and recent
hospitalization with bed rest. Multidetector CT is the best initial test to confirm pulmonary embolism in
this situation. D-dimer testing is of limited value in patients with a high probability of pulmonary
embolism. If positive for deep-vein thrombosis, venous ultrasonography of the lower limbs can eliminate
the need for CT or lung scans, but this occurs in only about 10% of patients. Pulmonary angiography is
currently reserved for the rare case in which catheter-based treatment is indicated.
A 52-year-old male presents with major depressive disorder. He reports a decrease in his libido
and is concerned about the impact of medication on his sex life.
Which one of the following antidepressants is least likely to cause sexual dysfunction?
A) Bupropion (Wellbutrin)
B) Duloxetine (Cymbalta)
C) Fluoxetine (Prozac)
D) Mirtazapine (Remeron)
E) Paroxetine (Paxil)
Paroxetine has been shown to cause the highest rate of sexual dysfunction among the SSRIs and other
antidepressants. The fewest sexual side effects occur with bupropion.h
A hospitalized 75-year-old white male with well-controlled type 2 diabetes mellitus is scheduled
for abdominal CT with oral and intravenous iodinated contrast. Which one of the following
medications should be withheld for at least 48 hours after the procedure?
A) Acarbose (Precose)
B) Glipizide (Glucotrol)
C) Glyburide (Micronase, DiaBeta)
D) Metformin (Glucophage)
E) Rosiglitazone (Avandia)
Contrast-induced nephropathy is a concern in patients undergoing contrast studies, and can lead to
decreased renal function. Theoretically, this can cause an increased risk of lactic acidosis in patients taking
metformin. Current guidelines recommend stopping metformin use before imaging procedures that use
contrast, and restarting it 48 hours after the procedure if renal function is unchanged. The other drugs
listed do not carry this risk, although they can cause other problems in hospitalized patients, such as
hypoglycemia, depending on the situation.
An adult male has obvious gynecomastia, without galactorrhea, that has been present for the past
10 years. A careful drug history, physical examination, and endocrine and malignancy workups
are negative. He wants the problem resolved.
Which one of the following is the treatment of choice?
A) Clomiphene (Clomid, Serophene)
B) Danazol
C) Tamoxifen (Soltamox)
D) Topical testosterone (AndroGel)
E) Surgery
When gynecomastia persists for a prolonged period, the initial glandular hyperplasia is transformed to a
progressive fibrosis and hyalinization. Surgery remains the mainstay of therapy. Medical management is
most useful when the onset is recent or to prevent the initial development of the problem. All the drugs
listed have been tried with varying success in this context, but their clinical usefulness is not established.
A 46-year-old African-American male presents to your office with a 1-day history of the sudden
onset of severe dizziness. His symptoms include a sensation of abnormal rotation of his
environment, as well as occasional headaches. He has felt nauseated but has not vomited. On
examination he has resting nystagmus. There is no hearing loss, and a thorough neurologic
examination is otherwise normal. He is vertiginous in all positions.
Which one of the following is the most likely diagnosis?
A) Basilar artery migraine with vertigo
B) Benign positional vertigo
C) Vestibular neuronitis
D) Meniere’s disease
E) Eustachian tube dysfunction
This patient’s presentation is characteristic of vestibular neuronitis, a common condition affecting the
vestibular apparatus. The exact location and cause of the derangement is uncertain, although a viral or
post-viral cause has been postulated.
Benign positional vertigo is characterized by brief attacks of vertigo. Meniere’s disease is associated with
tinnitus and hearing loss. Migraines have a more gradual onset, and the symptoms of eustachian tube
dysfunction would be milder.
A 48-year-old female has had no menses for the past 12 months. She complains of hot flashes,
especially at night, which significantly interfere with sleep. She also complains of fatigue,
decreased appetite, unrefreshed sleep, and feeling “down” 4 or 5 days per week. A physical
examination and laboratory findings are unremarkable. The patient prefers not to take estrogen
replacement therapy.
Which one of the following medications would be appropriate for this patient?
A) Bupropion (Wellbutrin)
B) Nortriptyline (Pamelor)
C) Escitalopram (Lexapro)
D) Imipramine (Tofranil)
Many patients are concerned about the risks associated with estrogen replacement therapy, and alternative
options should be addressed. Escitalopram has been shown to be effective for hot flashes in
postmenopausal women. This would be a reasonable choice for this patient, who also likely has depression.
Which one of the following can cause a person’s normal hemoglobin level to be lower than the
reference range?
A) Hemochromatosis
B) African-American ethnicity
C) Cigarette smoking
D) Living at a high altitude
The range of normal hemoglobin values for healthy individuals varies with age, sex, pregnancy, smoking,
altitude, and ethnicity to an extent that an adjustment derived from population-based studies is appropriate
in each of these situations. A healthy individual should have their lifetime highest hemoglobin
concentrations at full-term birth, exclusive of any later changes from altitude or smoking. Hemoglobin
levels fall during the first 2 months of life and thereafter gradually increase until stabilizing at
approximately 6 months of age.
Studies of ethnic groups in the U.S. demonstrate no significant differences in normal hemoglobin values
among East Asians, Hispanics, Japanese, Native Americans, and non-Hispanic whites; hemoglobin values
of African-Americans tend to be 1 g/dL lower compared to the other U.S. ethnic groups studied. Living
at higher altitudes has a direct effect on hemoglobin levels, and a hemoglobin reference range adjustment
of +1 g/dL at 1000 meters up to +5.5 g/dL at 5000 meters is appropriate. Similarly, smoking increases
hemoglobin levels by 3 g/dL for a 1 pack/day smoker to as high as +7 g/dL for individuals smoking more
than 2 packs/day. The plasma volume expansion that occurs during pregnancy results in a 1.0-1.5 g/dL
reduction in normal hemoglobin levels.
When stratifying patient risk to determine whether an implantable cardioverter-defibrillator is
indicated for the primary prevention of sudden cardiac death, which one of the following is
associated with the greatest risk?
A) Atrial fibrillation
B) Heart failure, with an ejection fraction less than or equal to 35%
C) Uncontrolled hypertension
D) Complete heart block
Sudden cardiac death affects 500,000 people in the United States each year, causing more deaths than lung
cancer, breast cancer, and stroke combined. The most common final pathway is ventricular tachycardia
degenerating into ventricular fibrillation. The best predictor of sudden cardiac death is an ejection fraction
less than or equal to 35%. Thus, it is critical for family physicians to evaluate the ejection fraction of patients with heart
A 72-year-old male is hospitalized for pneumonia. During his hospitalization he develops
diarrhea due to Clostridium difficile infection. Appropriate antibiotics are prescribed.
What other measures should be taken to prevent the spread of infection in the hospital?
A) Contact precautions with gown and gloves plus handwashing with soap and water
B) Contact and respiratory precautions with gown, gloves, and face mask
C) Use of hand sanitizers before and after patient contact
D) Placing the patient in a reverse airflow room
Clostridium difficile infection is a common cause of diarrhea in hospitalized patients, and recent antibiotic
use is a risk factor for infection. The bacteria can be spread in a hospital setting by contact, and contact
precautions with gown and gloves are indicated in addition to hand washing with soap and water to ensure
removal of spores (SOR A). Hand sanitizer is inadequate, as it does not kill the spores. Respiratory
precautions are not necessary.
A 23-year-old male comes to your office accompanied by his girlfriend to talk about
attention-deficit disorder. He minimizes the concerns she raises, which include sleeping less
(sometimes just 2-3 hours a night), rambling on tangentially during conversations, and being
highly irritable. When you ask him about these observations, he agrees that they are true and
reflect a change in his usual behavior. However, he explains that he is just becoming more social
and that his girlfriend is probably jealous of his new popularity. The patient has no family
history of attention-deficit disorder. His father died at a young age as a result of alcoholism. He
denies stimulant use and a urine drug screen is negative.
Which one of the following mental disorders is most likely in this patient?
A) Attention-deficit disorder
B) Attention-deficit/hyperactivity disorder
C) Generalized anxiety disorder
D) Major depressive disorder
E) Bipolar disorder
It is estimated that about one-third of patients with bipolar disorder seek medical care within a year of the
onset of symptoms, but that nearly 70% do not receive an accurate diagnosis. The symptoms can often be
subtle and may be attributed to other causes by patients or their loved ones.
A diagnosis of attention-deficit disorder requires that a patient’s symptoms be present since early
childhood, although they are sometimes not recognized at the time. This patient and his girlfriend have
both acknowledged that he is not his usual self. He presents with increased self-esteem, a decreased need
for sleep, pressured/tangential speech, and irritability, which point to the possibility of a manic or
hypomanic episode. Together these symptoms suggest bipolar disease (SOR C). Patients with full-blown
mania are often out of touch with reality and easy to identify. However, patients with hypomania consider
themselves to have increased well-being and productivity, and will not always seek attention or consider
themselves to have a problem.
Other symptoms that should alert the physician to this diagnosis include substance abuse (present in over
70% of cases) and involvement in other pleasurable but destructive activities such as overspending or
hypersexuality. If substance abuse is present, however, it must be addressed before making a diagnosis
of bipolar disorder. Bipolar disorder is highly genetic, and asking about affected first degree family
members can often assist in making the diagnosis.
A 73-year-old white female sees you for a routine visit. The patient is on multiple medications,
and on examination her blood pressure is 140/80 mm Hg and her heart rate is 75 beats/min. She
also has a systolic heart murmur, osteoarthritic changes of the knees, and a trace of peripheral
edema. Her free T4 level is elevated, and her TSH level is <0.01 microU/mL (N 0.5-5.0).
Which one of the following medications the patient is taking is most likely to cause abnormal
thyroid hormone levels?
A) Amiodarone (Cordarone)
B) Digoxin
C) Enalapril (Vasotec)
D) Furosemide (Lasix)
E) Lithium
This patient has asymptomatic hyperthyroidism, which is more common in the elderly. Elevated T4 and
markedly suppressed TSH are diagnostic. Common causes include Graves’ disease, toxic adenoma,
multinodular goiter, thyroiditis, and use of iodine-containing medications such as amiodarone.
Amiodarone-associated hyperthyroidism may be related to either iodine excess or a toxic effect on the
gland, causing thyroiditis (level of evidence 3). Lithium is associated with hypothyroidism.
You are writing a prescription for amoxicillin for a 6-year-old female with acute otitis media.
Her mother has had an anaphylactic reaction to penicillin in the past and is concerned that she
may have passed this trait down to her daughter. You reassure her that this is not usually the
case but warn her about potential signs of an allergic reaction.
Which one of the following is the most concerning early symptom of a dangerous drug reaction?
A) Tachycardia and elevated blood pressure
B) Small, bright, erythematous macules diffusely over the trunk
C) Pruritus around the mouth and on the palms of the hands and soles of the feet
D) Eczematous patches in the antecubital and popliteal fossae
E) Diarrhea with blood on the tissue paper
Allergic reactions to medications have four primary mechanisms, referred to as Gell and Coombs
classifications. The most frequent forms are type I reactions, which are immediate and mediated through
IgE, and type IV reactions, which are delayed and mediated through T-cell hypersensitization. Severe type
I reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little
warning. Recognition of the early signs of anaphylaxis is the first step in preventing such catastrophes.
Anaphylactic reactions result from a massive release of histamine and start with pruritus around the mouth,
on the scalp, and on the palms and soles; flushing of the face and neck, with rhinitis and conjunctivitis;
angioedema of the oral mucosa, especially of the pharynx and larynx; severe urticaria; dyspnea and
bronchospasm (especially in known asthmatics); and hypotension. A delay in lifesaving therapy during this
phase will result in full shock, hypotension, and death. Type IV reactions usually result in benign, diffuse
erythematous macules on the trunk and proximal extremities, often referred to as a drug rash. These
reactions infrequently become more severe and rarely are life threatening. In severe cases the lesions
become painful and palpable, and may involve blistering, mucositis, and ecchymosis.
A 52-year-old female presents with vulvovaginal dryness and pain with intercourse. She has not
menstruated for 6 months and denies hot flashes, insomnia, or other vasomotor symptoms. She
has no past history of cancer or surgery. Her examination is consistent with vaginal atrophy.
Which one of the following is the recommended first-line treatment for this patient?
A) Oral estrogen
B) Oral estrogen and progestogen
C) Vaginal estrogen
D) Vaginal estrogen and oral progestogen
Vaginal atrophy is a common symptom accompanying menopause. Local application of estrogen is the
most effective treatment (SOR A) and is FDA approved for this indication. Efficacy ranges from 80% to
100%. All formulations are equally effective, so patient preference should drive the choice. Potential
adverse effects of vaginal estrogen include candidal infections, bleeding, burning with application, and
breast pain.
It is not necessary to add an oral progestogen to the local estrogen treatment. Vaginal estrogen does not
lead to endometrial proliferation, so endometrial protection in a patient who still has her uterus is not
A 1-year-old female has head lice. She has three siblings who have been treated unsuccessfully
for this problem with permethrin (Nix).
Which one of the following would be the best alternative treatment for this child?
A) Benzyl alcohol lotion (Ulesfia)
B) Malathion 0.5% lotion (Ovide)
C) Permethrin cream rinse
D) Pyrethrin shampoo (Pronto)
E) Spinosad (Natroba)
The frequency of head lice infestations has increased in recent years, and resistance to permethrin is now
common. Permethrin is unlikely to be effective in this child since her siblings’ infestations have failed to
respond to it. Of the other choices, only benzyl alcohol lotion is approved for use in children under 2 years
of age.
A 32-year-old female presents with complaints of moderate irritability and anxiety during the
week before nearly all of her menstrual periods. During this time she also has problems with
weight gain and breast tenderness. She says she is her “usual happy self” at other times during
the month. You diagnose premenstrual syndrome (PMS).
Which one of the following complementary and alternative therapies has been shown to be
helpful in reducing the symptoms of this problem?
A) Saffron
B) St. John’s wort
C) Soy
D) Pyridoxine (vitamin B6)
E) Vitamin E
Premenstrual syndrome (PMS) may be diagnosed when recurrent psychological and physical symptoms
occur only during the week prior to menses. The presence of more severe affective and somatic symptoms
that cause significant dysfunction in a patient’s social and work life is more consistent with premenstrual
dysphoric disorder. Both pyridoxine (vitamin B6), 50-100 mg/day, and chasteberry, 20 mg/day, have been
shown in randomized, controlled trials to reduce the symptoms of PMS compared with placebo. No good
evidence supports the use of vitamin E, saffron, St. John’s wort, or soy.
During a routine office visit, a 65-year-old female asks if she should be screened for carotid
artery stenosis. The patient has a history of controlled hypertension and hypercholesterolemia,
and a family history of stroke. Physical examination of the carotid artery is normal and the
patient is asymptomatic.
Which one of the following is consistent with U.S. Preventive Services Task Force and
American Heart Association recommendations regarding carotid artery ultrasonography for this
A) She does not need screening ultrasonography at this time
B) She should have one-time screening ultrasonography now
C) She should have routine screening ultrasonography now and every 5 years
D) She should have routine screening ultrasonography now and every 10 years
The U.S. Preventive Services Task Force and the American Heart Association/American Stroke
Association recommend not performing carotid artery screening with ultrasonography or other screening
tests in patients without neurologic symptoms because the harms outweigh the benefits. In the general
population, screening tests for carotid artery stenosis would result in more false-positive results than
true-positive results. This would lead to surgical procedures that are not indicated or to confirmatory
angiography. As a result of these procedures, some patients would suffer serious harms such as death,
stroke, or myocardial infarction, which outweigh the potential benefit surgical treatment may have in
preventing stroke.
A 35-year-old white female comes to your office with a 3-month history of the gradual onset of
pain and tenderness in her wrists and hands. She also complains of 1 hour of morning stiffness.
She denies rash, fever, or skin changes. On physical examination she has symmetric swelling
of the proximal interphalangeal joints and metacarpophalangeal joints. Motion of these joints is
painful. She has no rash or mouth ulcers. Radiographs of the hands and wrists are negative, and
a chest film is unremarkable. A CBC is normal, but the erythrocyte sedimentation rate is
elevated at 40 mm/hr. Latex fixation for rheumatoid factor is negative, and an antinuclear
antibody (ANA) test is negative.
The most likely diagnosis in this patient is
A) rheumatoid arthritis
B) systemic lupus erythematosus
C) sarcoidosis
D) Lyme disease
E) calcium pyrophosphate deposition disease
This patient has rheumatoid arthritis (RA) by symptoms and physical findings. A positive latex fixation
test for rheumatoid factor is not necessary for the diagnosis. A negative rheumatoid factor does not
exclude RA, and a positive rheumatoid factor is not specific. Rheumatoid factor is found in the serum of
approximately 85% of adult patients with RA; in subjects without RA, the incidence of positive rheumatoid
factor is 1%-5% and increases with age.
The ANA test is positive in at least 95% of patients with systemic lupus erythematosus, but in only about
35% of patients with RA. Elevation of the erythrocyte sedimentation rate is seen in many patients with
RA, and the degree of elevation roughly parallels disease activity. At a mean of 6 months after the onset
of Lyme disease, 60% of patients in the United States have brief attacks of asymmetric, oligoarticular
arthritis, primarily in the large joints and especially in the knee.
A 68-year-old female with a previous history of multiple medical problems presents to your
office with dizziness. She describes this dizziness as an “off-balance” or “wobbly” feeling. She
has not had a sensation of spinning or motion, or loss of consciousness. She is not anxious or
depressed. She takes the following medications:
Lovastatin (Mevacor), 20 mg daily for hypercholesterolemia
Metoprolol succinate (Toprol-XL), 25 mg daily
Chlorthalidone, 12.5 mg daily
Lisinopril (Prinivil, Zestril), 20 mg daily for hypertension
Sertraline (Zoloft), 25 mg daily for menopausal symptoms
Alendronate (Fosamax), 70 mg weekly
Calcium, 600 mg 2 times daily
Vitamin D, 1000 units daily for osteoporosis
Oxybutynin (Ditropan XL), 10 mg daily for overactive bladder
Acetaminophen, 1000 mg 2 times daily for osteoarthritis
Meclizine (Antivert, Bonine), 25 mg 3 times daily as needed for dizziness
Cyclobenzaprine (Flexeril), 5 mg 3 times daily as needed for muscle spasm
Zolpidem (Ambien), 5 mg at bedtime as needed
A physical examination is normal, including a neurologic examination, and the patient has a
normal gait. There is no evidence of peripheral neuropathy, and Romberg testing is normal.
There is no orthostatic decrease in blood pressure. The Dix-Hallpike maneuver is negative. A
CBC, chemistry profile (CMP), TSH level, and vitamin B12 level are normal.
Which one of the following would be most appropriate at this point?
A) A 24-hour heart monitor
B) A tilt table test
C) Carotid ultrasonography
D) Medication reduction
E) Increasing the dosage of sertraline to 50 mg daily
This patient has a disequilibrium type of dizziness. Causes of this include medication side effects,
Parkinson’s disease, and peripheral neuropathy. In this patient the history and examination do not indicate
a specific cause. She is on several medications, and one or more could be contributing to her symptoms.
A trial of medication reduction should be considered before ordering additional studies.
A 54-year-old male presents to your office with a chief complaint of vomiting and diarrhea,
along with stomach cramps. He has not noticed blood in his stool or vomit.
His symptoms began in the middle of the night, approximately 4 hours after he ate at a local
delicatessen. He has not been out of the country and has not eaten any exotic foods or foods that
are not part of his normal diet. His vital signs include a temperature of 37.0°C (98.6°F), a pulse
rate of 90 beats/min, and a blood pressure of 130/80 mm Hg.
Which one of the following organisms is implicated in this patient’s presumed case of food
A) Staphylococcus aureus
B) Clostridium botulinum
C) Campylobacter jejuni
D) Enterohemorrhagic Escherichia coli
Among the causes of food poisoning, Staphylococcus aureus is associated with the shortest incubation
period (1-6 hours). Most cases are related to contamination of food by infected human carriers. Leaving
food to cool slowly at room temperature allows organisms that produce enterotoxins to multiply. Common
food sources include ham, poultry, potato or egg salad, cream, and pastries.
Campylobacter jejuni infections can be subclinical or symptomatic. Symptoms usually occur within 2-4
days of exposure to the organism in food or water. A prodrome of fever, headache, and myalgias occurs
24-48 hours before the diarrheal symptoms begin. Vomiting is usually not a symptom of the infection.
Clostridium botulinum is usually associated with canned foods. Enterohemorrhagic Escherichia coli
produces a Shiga-like toxin, which kills intestinal epithelial cells. While the symptoms are like those of
food poisoning, they are much more severe and are usually associated with bloody diarrhea (SOR C).
A 45-year-old male with type 1 diabetes mellitus receives a corticosteroid injection for
osteoarthritis of the left knee. Which one of the following is true regarding monitoring of his
blood glucose levels?
A) Glucose levels should be closely monitored for 48 hours
B) Glucose levels should be closely monitored for 7 days
C) Glucose levels should be closely monitored for 14 days
D) No additional monitoring is necessary
A single intra-articular injection has little or no effect on glycemic control (SOR A). Soft-tissue or
peritendinous injections can affect blood glucose levels for 5-21 days, however, and diabetic patients
should closely monitor blood glucose levels for 2 weeks following these injections.
A 14-year-old male with Tanner stage 1 pubic hair has prepubertal-size testes. His height is at
the 3rd percentile. The physical examination is otherwise unremarkable.
Which one of the following additional findings would be most consistent with constitutional delay
of growth and puberty?
A) Impairment of the sense of smell
B) Delayed bone age
C) Elevated LH and FSH
D) Elevated thyrotropin
E) Elevated prolactin
Constitutional delay of growth and puberty (CDGP) tends to be inherited. Bone age is delayed, but growth
potential is often normal. LH and FSH are elevated in hypergonadotropic hypogonadism, but this is not
characteristic of CDGP. Thyrotropin is most often elevated in hypothyroidism, which can cause a
secondary delay in growth and puberty. Anosmia is characteristic of Kallmann syndrome, but not CDGP.
Puberty is also delayed in this form of hypogonadotropic hypogonadism. Prolactin is elevated in some
pituitary tumors and by dopamine-blocking agents (SOR C).
A 52-year-old African-American male sees you for a routine visit. His only medical problem is
hypercholesterolemia. Because you wish to initiate a statin, you order a liver profile with the
following results:
Total bilirubin… 2.0 mg/dL (N 0.0-1.0)
Direct bilirubin… 0.2 mg/dL (N 0.0-0.4)
Albumin… 4.0 g/dL (N 3.5-5.0)
LDH…250 U/L (N 45-90)
AST (SGOT)… 25 U/L (N 7-27)
ALT (SGPT)…15 U/L (N 1-21)
Alkaline phosphatase… 25 U/L (N 13-39)
Which one of the following would best explain these results?
A) Alcoholic hepatitis
B) Steatohepatitis
C) Chronic hepatitis C
D) Hemolysis
E) Gilbert’s syndrome
The combination of elevated LDH and elevated unconjugated bilirubin with otherwise normal liver enzyme
levels suggests hemolysis. Gilbert’s syndrome would not explain the LDH elevation. Hepatitis is unlikely
with normal transaminase levels.
A 44-year-old female has recently lost her best friend to ovarian cancer. She has no family
history of cancer in her siblings, parents, or grandparents. She requests screening for ovarian
cancer. Her physical examination, including a pelvic examination, is normal.
According to current guidelines, which one of the following would be best for this patient?
A) CA-125 testing
B) CA-125 testing and ovarian ultrasonography
C) Ovarian ultrasonography alone
D) CT of the pelvis
E) No screening
Routine screening of the general population for ovarian cancer is not recommended by any professional
A pregnant 32-year-old gravida 2 para 1 develops an acute deep-vein thrombosis in the left lower
extremity during the third trimester. The patient had a cesarean delivery with her first pregnancy
and wants to breastfeed.
Which one of the following is the treatment of choice?
A) Low molecular weight heparin
B) Unfractionated heparin
C) Warfarin (Coumadin)
D) A vena cava filter
The preferred anticoagulant for venous thrombosis during pregnancy is low molecular weight heparin.
Unfractionated heparin requires more monitoring and may increase the risk of heparin-induced
thrombocytopenia. Warfarin should not be used during pregnancy but may be used in women who are
breastfeeding (SOR B).
A 40-year-old male presents with a new rash. On examination you note multiple
erythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities, on his
buttocks, and on his hands. The papules are tender and pruritic. A biopsy reveals foamy
macrophages and dermal extracellular lipids.
This patient’s rash is associated with
A) endocarditis
B) systemic vasculitis
C) a viral infection of the skin
D) hypertriglyceridemia
E) urticaria
Eruptive xanthomas like these are associated with elevated triglycerides, obesity, alcohol abuse, diabetes
mellitus, and estrogen or retinoid therapies. The lesions of molluscum contagiosum can be distinguished
from these xanthomas by the characteristic central umbilication of molluscum.
For most patients, which one of the following is the most effective treatment for anemia of
chronic disease?
A) Elemental iron
B) Erythropoietin
C) Prednisone
D) Optimal management of the underlying disorder
E) Combined therapy with oral iron, vitamin B12, folic acid, and erythropoietin
There is no specific therapy for anemia of chronic disease except to manage or treat the underlying
disorder. Iron therapy is of no benefit, but erythropoietin may be helpful in some patients. There is no
available data to suggest that combination therapy or prednisone is beneficial for this disorder.
Which one of the following interventions for bed-wetting in children should be recommended
as initial therapy?
A) Waking a child during the night and carrying him or her to the toilet
B) Restriction of fluids during the day
C) An enuresis alarm
D) Imipramine (Tofranil)
E) Oxybutynin (Ditropan)
Enuresis alarms should be offered as initial treatment for bed-wetting, based on randomized, controlled
trials and cost-effectiveness evidence. Desmopressin can also be considered if the child or parents do not
want to try an alarm. Restriction of fluids during the day should not be recommended, as it is important
that children have enough to drink. Waking a child and carrying him or her to the toilet has not been
shown to have a long-term effect on bed-wetting. Oxybutynin and imipramine should only be considered
in cases where bed-wetting does not respond to initial treatment.
Which one of the following is a contraindication to the use of combined hormonal
A) A family history of breast cancer in a first degree relative
B) Rheumatoid arthritis treated with immunosuppression
C) Morbid obesity
D) Migraine headaches with aura
E) Ovarian cancer
The U.S. Medical Eligibility Criteria for Contraceptive Use were created to guide health care providers
in assessing the safety of contraceptive use for patients with specific conditions. Category 1 includes
conditions for which no restrictions exist for use of the contraceptive method. Category 2 indicates that
the method generally can be used, but careful follow-up may be required. Category 3 is used to classify
conditions for which the method usually is not recommended unless more-preferred methods are not
available or acceptable. Category 4 comprises conditions that represent an unacceptable health risk if the
method is used. For combined hormonal contraceptives, migraine headaches with aura at any age are
classified as category 4 because of the increased risk of ischemic stroke. A family history of breast cancer
is category 1, rheumatoid arthritis treated by immunosuppression is category 2, a BMI 30 kg/m2 is
category 2, and ovarian cancer is category 1.
A 5-month-old child begins to cough and wheeze. He has no previous history of respiratory
problems, although he has had upper respiratory symptoms for the past 2 days. On physical
examination you note tachypnea and mild intercostal retractions and wheezes.
The most likely diagnosis is
A) asthma
B) bronchiolitis
C) croup
D) pertussis
E) pneumonia
Acute bronchiolitis is a viral illness most frequently caused by the respiratory syncytial virus. Its peak
incidence occurs at approximately 6 months of age. The illness frequently causes a few days of mild upper
respiratory symptoms, followed by increased coughing and wheezing. Examination often reveals tachypnea
and use of the accessory muscles of respiration, such as intercostal retractions. Acute asthma is uncommon
in the first year of life, and is difficult to diagnose without recurrent episodes or prior respiratory
problems. Croup usually presents with stridor, and pertussis and pneumonia do not usually present with
Which one of the following cardiac arrhythmias is associated with antipsychotic use?
A) Third degree heart block
B) Paroxysmal atrial tachycardia
C) Atrial fibrillation
D) Ventricular fibrillation (torsades de pointes)
E) Wolff-Parkinson-White syndrome
All antipsychotic agents can prolong ventricular repolarization, leading to a prolonged QT interval, which
can in turn lead to torsades de pointes and sudden cardiac death. Although all antipsychotics can affect
EKG intervals, the agents with the greatest propensity to prolong QTc are thioridazine, pimozide,
droperidol, and ziprasidone. The incidence of sudden cardiac death among patients taking antipsychotics
is about twice that of the general population.
A 16-year-old female has had foot pain for the past 3 weeks. She has no known history of
trauma, but is participating in cross-country running events for her high school and has
significantly increased her training schedule over the past 2 months. An examination reveals
tenderness at the base of the fifth metatarsal, but no swelling. Radiographs are negative, but a
radionuclide bone scan shows increased uptake in the proximal portion of the fifth metatarsal.
Which one of the following would be most appropriate?
A) A reduced training schedule for 1 month
B) A DXA scan to evaluate bone mineral density
C) A wooden cast shoe
D) Ice and NSAID therapy only
E) Referral to an orthopedist
Stress fractures are caused by repetitive loading that exceeds the bone’s ability to heal. They occur more
commonly in female athletes. Patients should be evaluated for risk factors such as eating disorders,
menstrual irregularities, and chronic medical conditions. Lower-extremity alignment, gait, and strength
should also be evaluated. High-risk fractures such as those of the femoral neck, anterior cortex of the tibia,
or proximal fifth metatarsal should be referred to an orthopedist, as there is a high likelihood of
fracture-related complications.
You are treating a 68-year-old male for COPD, hypertension, systolic heart failure, and
coronary artery disease. You are considering adding a -blocker but you are concerned that it
could affect his COPD.
Which one of the following options would be most appropriate for this patient?
A) Metoprolol tartrate (Lopressor), 12.5 mg twice daily
B) Nadolol (Corgard), 20 mg daily
C) Sotalol (Betapace), 40 mg twice daily
D) Timolol, 5 mg daily
E) Avoiding -blocker use
Cardioselective -blockers, such as metoprolol, should not be withheld from patients with COPD.
Metoprolol could be started at a low dosage in this patient. Nadolol, timolol, and sotalol are not
A 77-year-old white female complains of fatigue and mild dyspnea with exertion. After a
thorough evaluation you conclude that she has early heart failure. She has no edema or evidence
of volume overload, and echocardiography reveals an ejection fraction of 34%.
Which one of the following would be most appropriate as INITIAL treatment?
A) Digoxin
B) Furosemide (Lasix)
C) Hydrochlorothiazide
D) Isosorbide dinitrate
E) Lisinopril (Prinivil, Zestril)
While most patients with heart failure should be treated with an ACE inhibitor and a diuretic, a subset of
patients with heart failure present with only fatigue or mild dyspnea on exertion, and no evidence of
volume overload. Since ACE inhibitors alone appear to prevent or slow the development of heart failure
in patients with asymptomatic left ventricular dysfunction, it is reasonable to start an ACE inhibitor such
as lisinopril in patients with very mild symptoms and observe to see if the symptoms resolve. The other
medications listed are useful in the treatment of heart failure but would not be appropriate as initial
treatment in the patient described.
For a 1-year-old patient, pneumococcal 13-valent conjugate vaccine (Prevnar) is preferred rather
than polyvalent pneumococcal vaccine (Pneumovax) because of which one of the following
A) It is available in an oral form
B) It is less expensive
C) It requires only one dose
D) It can be combined with MMR in a single injection
E) It is more immunogenic
Pneumococcal 13-valent vaccine produces a satisfactory immune response in 1-year-old children, while
polyvalent vaccine does not cause a good antibody response in children under the age of 2 years. Neither
vaccine is available orally, and cost is not a factor. The 13-valent vaccine requires multiple doses. The
vaccine cannot be combined with MMR in a single injection, but can be administered concurrently with
routine childhood immunizations at a separate site using a separate syringe.
A 49-year-old female with type 1 diabetes mellitus presents to your office with a 1-week history
of a red, hot, swollen foot. She recalls twisting her ankle when stepping off a curb the day
before the swelling began. She denies fever or significant pain. She has difficulty walking due
to stiffness in the foot.
On examination you find the patient is in no distress. Her temperature is 36.7°C (98.1°F), blood
pressure 144/82 mm Hg, and heart rate 80 beats/min. Her right foot is edematous,
erythematous, and excessively warm. Monofilament testing reveals significant impairment of
sensation of both feet. She has restricted range of motion of the right ankle and foot compared
to the left. No skin lesions are present. Dorsalis pedis pulses are brisk and symmetric. A
radiograph of the right foot is normal.
Laboratory Findings
Hemoglobin A1c
… 8.2%
Capillary blood glucose…213 mg/dL
Hematocrit… 37.2% (N 36.0-46.0)
WBCs… 11,000/mm3 (N 4300-10,800)
Platelets…350,000/mm3 (N 150,000-350,000)
Erythrocyte sedimentation rate… 30 mm/hr (N 1-25)
Which one of the following is the most likely diagnosis?
A) Osteomyelitis
B) Osteoarthritis
C) Acute gout
D) Charcot foot
This patient most likely has Charcot foot (neuropathic arthropathy). This is an uncommon condition, most
often found in patients with at least a 10-year history of type 1 or 2 diabetes. Patients have peripheral
neuropathy and typically present with painless swelling of a foot. About 50% of patients can recall minor
trauma preceding the onset of symptoms. Early radiologic findings may be normal, but as the condition
progresses plain films may reveal bony fractures, fragmentation, and bone destruction. On examination
the foot is either stiff or hypermobile, warm, erythematous, and edematous. Crepitus can be felt in later
stages of the disease. Laboratory results can be normal or show increases in the WBC count. Any patient
with long-standing diabetes mellitus and a warm, red, swollen foot should be presumed to have Charcot
foot and have the foot immobilized immediately to protect it from stress and to prevent further destruction
and disability (SOR C).
The differential diagnosis of Charcot foot includes osteomyelitis, which can be difficult to distinguish.
Patients with osteomyelitis can have skin ulcers that may be probed to the bone. They will often be febrile,
with higher erythrocyte sedimentation rates and WBC counts than patients with Charcot foot. Aspiration
of the joint fluid is helpful in distinguishing between the two conditions.
Aspiration can also help distinguish between acute gout and Charcot foot. Patients may have pain and
stiffness in their foot with either condition. Patients with gout may have an elevated uric acid level, and
plain films may reveal tophi.
Patients with osteoarthritis are unlikely to have warm, erythematous skin overlying the involved joint.
Symptoms often have an insidious onset rather than the more acute onset of Charcot foot.
A 37-year-old male returns for follow-up after an episode of nephrolithiasis. He passed a 3-mm
calcium oxalate stone and requests information about preventing further stones.
You would advise that he
A) drink up to 2 L of water/day
B) increase his consumption of meats and grains
C) increase the level of fructose in his diet
D) restrict foods high in oxalate, such as spinach and rhubarb
General recommendations regarding prevention of recurrent nephrolithiasis include increasing fluid intake
up to 2 L of water daily (SOR B); greater volumes may lead to electrolyte disturbances and are not
recommended. More specific dietary recommendations depend on the stone type. If the stone is not
recovered, the type may be inferred from a 24-hour urine collection for calcium, phosphorus, magnesium,
uric acid, and oxalate.
Approximately 60% of all stones in adults are calcium oxalate. Uric acid stones account for up to 17% of
stones and, like cystine stones, form in acidic urine. Alkalinization of the urine to a pH of 6.5-7.0 may
reduce stone formation in patients with these types of stones. This includes a diet with plenty of fruits and
vegetables, and limiting acid-producing foods such as meat, grains, dairy products, and legumes. Drinking
mineral water, which is relatively alkaline with a pH of 7.0-7.5, is also recommended. Restriction of
dietary oxalates has not been shown to be effective in reducing stone formation in most patients.
Acidification of the urine to a pH 7.0 is recommended for patients with the less common calcium
phosphate and struvite stones. This can be accomplished by consumption of at least 16 oz of cranberry
juice per day, or by taking betaine, 650 mg three times daily.
When discussing end-of-life issues with patients, physicians may inadvertently send the wrong
message. Which one of the following has the greatest potential to be misinterpreted by a patient?
A) “We can offer many options to control your symptoms”
B) “If you become extremely ill, would you like to be put on artificial life support?”
C) “The cancer has not responded to the treatment as we had hoped”
D) “We want to provide coordinated care with a team of professionals to help you remain
E) “It is time to consider withdrawal of care”
The statement, “It is time to consider withdrawal of care,” can make patients think that the physician no
longer wants to care for them. It would be better to ask, “Do you think it is time for us to consider a
different type of treatment that focuses on your symptoms?” Telling the individual that you want to provide
intense coordinated care with a team that will treat symptoms and maintain comfort is a way of involving
hospice without making the patient feel hopeless.
A 32-year-old secretary complains of wrist pain at rest and when holding a pen. She says it feels
like her thumb locks up at times. On examination you note tenderness on the radial side of her
right wrist. A radiograph shows multiple sesamoid bones around her first metacarpophalangeal
You suspect
A) rheumatoid arthritis
B) carpal joint arthritis
C) de Quervain’s tenosynovitis
D) cervical radiculopathy
E) carpal tunnel syndrome
De Quervain’s tenosynovitis is a tenosynovitis of the first dorsal compartment of the wrist, specifically a
chronic inflammation of the extensor pollicis brevis and abductor pollicis longus tendons. It is a fairly
common cause of pain in the distal forearm. The diagnosis is made by physical examination. Pain,
tenderness, and occasionally swelling are present on the radial side of the wrist. The pain is exacerbated
by passive wrist ulnar deviation while the thumb is flexed and the fingers curled around it.
These symptoms are not typical for rheumatoid disease, and cervical radiculopathy would not cause radial
tenderness. Carpal joint arthritis would be more distal. The sesamoid bones are common and of no clinical
significance. Carpal tunnel syndrome is caused by an entrapment neuropathy of the median nerve as it
traverses the carpal tunnel. Symptoms typically include pain and paresthesias in the hand. Numbness
occurs in the first two fingers, in the distribution of the median nerve. Thenar muscle weakness is a later
A 45-year-old female presents to your office with a complaint of hair loss. Examination reveals
thinning of the hair over the central superior portion of the scalp. Her frontal hairline is
preserved. There are no oval patches of baldness and no scarring. She has a history of hirsutism,
infertility, irregular menses, and cystic acne. Her testosterone, dehydroepiandrosterone sulfate,
and prolactin levels are normal, as are thyroid and iron levels.
Of the following, which one would be most appropriate for treatment of this patient’s hair loss?
A) Oral estrogen
B) Oral corticosteroids
C) Topical corticosteroids
D) Finasteride (Propecia)
E) Topical minoxidil (Women’s Rogaine)
This patient’s examination is consistent with female pattern hair loss. Women with female pattern hair loss
who also have a history of abnormal menses, infertility, cystic acne, and hirsutism should have an
evaluation for hyperandrogenism. Minoxidil 2% topically is the only treatment approved by the FDA for
treating female pattern hair loss in women over 18, but a hyperandrogenic state may limit the response to
minoxidil. If the hyperandrogenism evaluation is normal, spironolactone, 100-200 mg daily, may slow the
rate of hair loss. Approximately 90% of such women report a modest decrease in hair loss with this
Tourette’s syndrome is associated with which one of the following comorbidities?
A) Cardiac arrhythmias
B) Partial or complex seizures
C) Hypertension
D) Attention-deficit disorder
E) Hypothyroidism
Tourette’s syndrome is often associated with psychiatric comorbidities, mainly
attention-deficit/hyperactivity disorder and obsessive-compulsive disorder. The other conditions listed are
not associated with Tourette’s syndrome.
An overweight 42-year-old female complains of foot pain. Which one of the following would
be most suggestive of plantar fasciitis?
A) A sudden onset of ecchymosis and plantar heel pain
B) Sharp, stabbing pain with palpation of the medial plantar calcaneal area
C) Posterior medial ankle pain
D) Burning pain in the medial plantar region
Plantar fasciitis affects more than 1 million people in the United States each year. Risk factors include
excessive pronation, running, obesity, and prolonged standing. Patients often have pain when they get out
of bed and take their first steps in the morning, or after prolonged sitting. Palpation usually causes pain
in the medial plantar calcaneal region. The pain is described as sharp and stabbing.
A sudden onset of ecchymosis and heel pain is more consistent with a diagnosis of plantar fascia rupture.
Pain in the region of the posterior medial ankle is more consistent with posterior tibial tendinitis. Burning
pain in the medial plantar region is more consistent with medial calcaneal and abductor digiti quinti nerve
Which one of the following is most consistent with the rash of infantile seborrheic dermatitis?
A) Sparing of the diaper area
B) An onset after 6 months of age
C) Pruritus at the time of onset
D) Resolution within weeks to months
E) Progression to atopic dermatitis
Seborrheic dermatitis is one of the more common skin conditions affecting infants within the first few
months of life. The characteristic reddish, waxy rash most commonly involves the scalp (cradle cap), but
can also appear on the face, ears, neck, skin folds, and diaper area. While the rash is similar to that of
atopic dermatitis, seborrheic dermatitis is not associated with pruritus. Although the rash can appear
alarming to parents, reassurance that the condition can be expected to resolve within a few months is the
most appropriate management.
A 38-year-old white female who complains of abdominal pain insists that she be referred for
surgical evaluation. She has a history of multiple unexplained physical symptoms that began in
her late teenage years. She is vague concerning past medical evaluations, but a review of her
thick medical chart reveals multiple normal blood and imaging tests, several surgical procedures
that have failed to alleviate her symptoms, and frequent requests for refills of narcotic
This history is most compatible with which one of the following?
A) Hypochondriasis
B) Malingering
C) Panic disorder
D) Generalized anxiety disorder
E) Somatization disorder
Somatization disorder usually begins in the teens or twenties and is characterized by multiple unexplained
physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history.
Abuse of alcohol, narcotics, or other drugs is also common in these patients.
Hypochondriacs are overly concerned with bodily functions, and can often provide accurate, extensive,
and detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain.
Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic,
or gastrointestinal symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life
circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and
A concerned father brings his 20-month-old daughter to see you because of the overnight onset
of a “barky” cough along with hoarseness, a runny nose, and a fever to 100.8°F. She is an
otherwise healthy child who is up to date on her vaccinations. During the course of the visit you
observe her to be coughing intermittently, and on examination you note clear lungs with
occasional stridor and no retractions. She is not tachypneic or tachycardic. Her oxygen
saturation is 95% on room air.
Appropriate medical management of this patient includes which one of the following?
A) Inhaled albuterol (Proventil, Ventolin)
B) Inhaled epinephrine
C) Oral azithromycin (Zithromax)
D) Oral dexamethasone
E) Oral oseltamivir (Tamiflu)
This patient has mild acute croup, also known as laryngotracheobronchitis. She has no signs of pneumonia,
epiglottitis, or bacterial tracheitis. Acute croup is almost always viral in nature, with parainfluenza viruses
being the most common etiologic agents. A single dose of oral dexamethasone has been shown to benefit
children with even mild croup, presumably by decreasing edema of the laryngeal mucosa. Inhaled
epinephrine is helpful in severe croup with signs of respiratory distress. Inhaled albuterol is used to treat
asthma. Oseltamivir would be appropriate treatment for influenza, and azithromycin for bacterial
A 75-year-old male complains of loose stools and pain with defecation. This problem seems to
have developed gradually over the last several months. His past medical history includes prostate
cancer treated with radiation therapy 5 years ago, hypertension, and osteoarthritis. His
medications include hydrochlorothiazide, a -blocker, and acetaminophen. Colonoscopy is
negative for polyps and cancer, but the rectal and sigmoid areas show pallor with friability and
The most likely diagnosis is
A) familial angiodysplasia
B) Osler-Weber-Rendu syndrome
C) radiation proctitis
D) late-onset ulcerative colitis
E) sensitivity to acetaminophen breakdown products
Chronic radiation proctitis develops months to years after radiation exposure and is characterized by pain
with defecation, along with diarrhea and sometimes rectal bleeding. On colonoscopy, the mucosa is pale
and friable with telangiectases which are sometimes large, multiple, and serpiginous.
A 40-year-old female with chronic asthma presents for a 6-month follow-up visit. For the past
year she has done very well on fluticasone/salmeterol (Advair), 250/50 g, except for when she
had to use an albuterol (Proventil, Ventolin) inhaler for 2 days because of cold symptoms 5
months ago.
The most reasonable change to this patient’s medication regimen would be to
A) add montelukast (Singulair)
B) replace fluticasone/salmeterol with fluticasone (Flovent)
C) replace fluticasone/salmeterol with budesonide/formoterol (Symbicort)
D) replace fluticasone/salmeterol with tiotropium (Spiriva)
It is recommended that asthmatics, once stabilized, be taken off long-acting -agonists and maintained on
an inhaled corticosteroid such as fluticasone. It is not recommended to change from a combination inhaled
corticosteroid/long-acting -agonist to a long-acting anticholinergic agent. Montelukast can be used for
maintenance, but inhaled corticosteroids are preferable.
A 52-year-old African-American female has a chest radiograph after a PPD test is equivocal.
She is a schoolteacher, and a child in her classroom has been confirmed as a TB contact. The
radiograph shows large bilateral hilar nodes. She has recently been diagnosed with psoriatic
arthritis on the basis of a scaly skin rash and arthralgias. A physical examination also reveals
nodular skin lesions on her shins, and scattered, slightly enlarged lymph nodes.
Which one of the following would be the most appropriate next step for confirming the
A) A lymph node biopsy
B) An antinuclear antibody test
C) CT angiography of the chest
D) Pulmonary function tests
E) An echocardiogram
This patient almost certainly has sarcoidosis. The diagnosis is supported by a compatible clinical and
radiographic presentation, and histologic evidence of noncaseating granulomas on a biopsy (without
organisms or particles). In patients who present with Löfgren syndrome (erythema nodosum, hilar
adenopathy, and polyarthralgias), a probable diagnosis of sarcoidosis can be made without a biopsy. In
all other cases a biopsy should be performed on the most accessible organ, such as the skin or peripheral
lymph nodes.
While the thorax is the most common site of disease, skin involvement occurs in at least 30% of patients
and is often missed. This patient was diagnosed with psoriasis, which may have been another manifestation
of sarcoidosis. Cutaneous sarcoidosis presents as single foci or crops, and is often attributed to other
causes, perhaps because of its highly variable manifestations such as macular-papular, nodular,
psoriatic-like, and hypomelanotic lesions. Careful skin examination is warranted because biopsy of a
sarcoidal lesion has a high diagnostic yield.
Most of the gait disturbances identified in geriatric patients in the outpatient primary care setting
are related to which one of the following?
A) Sensory ataxia
B) Parkinson’s disease
C) Osteoarthritis
D) Multiple strokes
E) Myelopathy
Problems with gait and balance increase in frequency with advancing age and are the result of a variety
of individual or combined disease processes. Findings may be subtle initially, making it difficult to make
an accurate diagnosis, and knowing the relative frequencies of primary causes may be useful for
management. A cautious gait (broadened base, slight forward leaning of the trunk, and reduced arm swing)
may be the first manifestation of many diseases, or it may just be somewhat physiologic if not excessive.
In the past, a problematic gait abnormality in an elderly person was generally termed a senile gait if there
was no clear diagnosis; it is more accurate, however, to describe this as an undifferentiated gait problem
secondary to subclinical disease. From the long list of potential causes, arthritic joint disease is by far the
most likely to be seen in the family physician’s office, accounting for more than 40% of total cases. It most
frequently causes an antalgic gait characterized by a reduced range of motion. The patient favors affected
joints by limping or taking short, slow steps.
A 23-year-old female becomes pregnant while using a copper T 380A intrauterine device
(ParaGard) for contraception. Ultrasonography indicates an estimated gestational age of 8 weeks
and confirms the location of the intrauterine device (IUD) within the uterus. A speculum
examination shows the string coming through the cervix.
Which one of the following is the best management strategy?
A) Remove the IUD now
B) Remove the IUD during the second trimester
C) Remove the IUD after 37 weeks gestation
D) Remove the IUD when the patient goes into labor
E) Leave the IUD in place until delivery
Pregnancy with an intrauterine device in place is rare but does occur. Removal of an in situ intrauterine
device in early pregnancy reduces the risks of spontaneous abortion, preterm labor, and sepsis, so gentle
removal should be accomplished as soon as the pregnancy becomes known.
A 20-year-old white male states that he was physically abused by his natural parents, and as a
result of running away from home on several occasions he was placed in a series of foster
homes. His schooling was sporadic, and he was frequently in trouble for truancy, vandalism,
initiating fights, and stealing. He dropped out of school at the age of 16, and during that year
he was arrested for car theft and driving while intoxicated. He has not worked at any job for
more than 6 months, and has had frequent changes of address due to failure to pay rent and other
financial obligations. He brags that he has fathered three children by three different women, but
has not provided any support or made any contact with any of them since their pregnancies. He
has used several aliases, one of which he had printed on a business card listing his occupation
as “Barroom Brawler and Superstud.” IQ testing is normal and there is no history of a psychotic
The most accurate diagnosis of this patient’s condition is
A) borderline personality disorder
B) unipolar manic disorder
C) antisocial personality disorder
D) abused child reaction formation
E) schizotypal personality disorder with psychoactive substance abuse
This patient meets the criteria for antisocial personality disorder, including age over 18, evidence of
conduct disorder in childhood, a pattern of irresponsible and antisocial behavior since age 15, and absence
of schizophrenia or manic episodes. Although the patient has some features of borderline personality
disorder, such as unstable relationships, the persistently aggressive nature and lack of remorse are much
more typical of antisocial personality. While the boasting quality of the patient might appear somewhat
grandiose, there are no other features to suggest mania. Abused child reaction formation is not a
recognized diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. Schizotypal personality
disorder is not usually associated with such pervasive antisocial behavior and violence.
You see a 75-year-old male for his Medicare annual wellness visit. Which one of the following
satisfies the Medicare requirement for vision screening?
A) Questioning the patient about vision changes
B) Use of the Amsler grid to detect age-related macular degeneration
C) Use of the Snellen eye chart to evaluate visual acuity
D) Use of an ophthalmoscope to detect cataracts
E) Use of tonometry to detect glaucoma
Although Medicare does not pay for an “annual physical,” it does provide for annual preventive screening
services, including a complete health history and an array of screening measures for depression, fall risk,
cognitive problems, and other challenges. The physical examination conducted as part of the annual
wellness visit includes measurement of blood pressure and weight, a vision check, and hearing evaluation,
as well as additional elements depending on the individual’s health risks.
While questioning the patient or caregiver regarding perceived hearing difficulties may suffice when
screening for hearing loss, screening for vision loss requires use of a standard screening tool.
Documentation of visual acuity by use of the Snellen chart is an accepted means of screening for visual
acuity in the primary care setting (SOR A). Vision screening will not pick up age-related macular
degeneration or cataracts, however.
Which one of the following combination hormonal contraceptives is most effective in obese
A) The etonogestrel/ethinyl estradiol vaginal ring (NuvaRing)
B) The norelgestromin/ethinyl estradiol transdermal patch (Ortho Evra)
C) Oral norethindrone/ethinyl estradiol (Aranelle, Brevicon)
D) Oral levonorgestrel/ethinyl estradiol (Aviane, Seasonale)
E) Oral drospirenone/ethinyl estradiol (Ocella, Yaz)
Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective
hormonal contraceptives for obese women because they do not appear to be affected by body weight.
Women using the combination contraceptive patch who weight 90 kg may experience decreased
contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of
An asymptomatic 30-year-old female has developed hypertension that has been difficult to
control despite the use of hydrochlorothiazide, lisinopril (Prinivil, Zestril), atenolol (Tenormin),
and hydralazine. She sees you for a follow-up visit, and her blood pressure is 165/98 mm Hg.
The examination is otherwise unremarkable, including cardiac auscultation and distal pulses. Her
CBC, TSH level, complete metabolic panel, and urinalysis are all normal.
Which one of the following tests would be best to confirm the most likely diagnosis?
A) An aldosterone/renin ratio
B) A renal biopsy
C) 24-hour urinary free cortisol
D) 24-hour urinary total metanephrines
E) CT angiography
There are several possible causes of secondary hypertension in young adults age 19-39, including
coarctation of the aorta, thyroid dysfunction, renal parenchymal disease, and fibromuscular dysplasia.
Fibromuscular dysplasia is more common in females, and has a predilection for causing stenosis of the
renal arteries. The diagnosis can be made using MRI with gadolinium contrast media, or with CT
Middle-aged adults (age 40-64) are more likely to have primary aldosteronism (evaluated with an
aldosterone/renin ratio), sleep apnea, pheochromocytoma (associated with elevated metanephrines), or
Cushing’s syndrome (elevated 24-hour urinary cortisol). The patient described has no signs or symptoms
of any of these problems.
A 17-year-old female comes to your office with an 8-month history of amenorrhea. Menarche
occurred at age 12 and her menses were regular until the past year. The patient’s vital signs are
in the normal range for her age except for a BMI of 16.1 kg/m2 (below the third percentile for
age). She is a high-school senior who dances with the local ballet company. She practices dance
several hours a day and works out regularly. She admits that she follows a strict 800-calorie/day
diet to keep in shape for ballet.
You order a CBC, a complete metabolic profile, a urine beta-hCG level, FSH and LH levels, and
a TSH level. Which one of the following is also recommended as part of the workup?
B) Pelvic ultrasonography
C) Abdominal/pelvic CT
D) A DXA scan
E) A nuclear bone scan
The female athlete triad is a relatively common condition in athletes, and is characterized by amenorrhea,
disordered eating, and osteoporosis. It is more common in sports that promote lean body mass. Female
athletes should be screened for the disorder during their preparticipation evaluations. Individuals who
present with one or more components of the triad should be evaluated for the other components. This
patient evidences disordered eating (low BMI for age) and secondary amenorrhea, and should be screened
for osteoporosis using a DXA scan. The International Society for Clinical Densitometry recommends using
the Z-score, rather than the T-score, when screening children or premenopausal women. The T-score is
based on a comparison to a young adult at peak bone density, whereas the Z-score uses a comparison to
persons of the same age as the patient. A Z-score less than -2.0 indicates osteoporosis. The American
College of Sports Medicine defines low bone density as a Z score of -1.0 to -2.0.
An EKG is not required in this patient since she has normal vital signs. Pelvic ultrasonography is not
necessary unless an abnormal finding is identified on a pelvic examination. Abdominopelvic CT would be
inappropriate given the patient’s age and lack of abdominopelvic symptoms such as pain or a mass. A
nuclear bone scan likewise is not recommended, as it is not used to diagnose osteoporosis (SOR C).
To decrease stroke risk in patients undergoing coronary artery bypass grafting (CABG) who
have concomitant carotid stenosis, current evidence supports which one of the following?
A) Carotid endarterectomy at the same time as CABG
B) Postoperative beta-blockers
C) Postoperative aspirin
D) Postoperative statins
To address and minimize perioperative neurologic morbidity in patients undergoing coronary artery bypass
grafting (CABG), individualized surgical management strategies are now recommended. These address
patient risk factors for postoperative stroke, such as carotid stenosis, hypertension, older age, a past history
of stroke, small-vessel disease in the brain, and diabetes mellitus. Because concomitant carotid disease is
often associated with CAD, pre-CABG carotid Doppler ultrasonography is routinely recommended.
Several approaches have been evaluated for decreasing the risk associated with carotid stenosis.
Performing both carotid and CABG surgery at the same time increases stroke risk, and no studies have
compared doing one before the other. While the use of statins has increased in patients with systemic
atherosclerosis, the roles of both postoperative statins and beta-blockers are still controversial. The only
treatment that has been shown to reduce postoperative cerebrovascular events is the use of aspirin in the
first 48 hours after surgery.
With regard to screening mammography, which one of the following is lower in women 40-49
years of age compared to women age 50 and older?
A) Radiation risk
B) The false-positive rate
C) The false-negative rate
D) The absolute risk reduction for breast cancer mortality
Based on a review of randomized, controlled trials, screening mammography reduces breast cancer
mortality for women between 40 and 49 years of age (SOR A). The absolute risk reduction is less for
women in this age group than for older women, however. For technical reasons, and because of greater
breast density, the false-positive and false-negative rates may be higher in this group than in older women.
Radiation risk is also greater in younger women.
In otherwise healthy, nonsmoking, previously unimmunized 65-year-olds, current Centers for
Disease Control and Prevention recommendations for immunization with pneumococcal vaccine
(Pneumovax) recommend administration of the vaccine
A) yearly
B) every 3 years
C) every 5 years
D) once
E) only for patients who are immunocompromised
Pneumococcal vaccine is usually given only once to individuals 65 years of age. A repeat dose may be
given 5 years later for those at higher risk. Immunization is also recommended for younger persons with
chronic medical problems, such as heart disease, diabetes mellitus, renal failure, and sickle cell anemia,
as well as those who have undergone splenectomy or who work or live with high-risk persons.
A 67-year-old female sees you for a routine follow-up visit for hypertension. Her chemistry
profile and other laboratory studies are normal except for a serum calcium level of 10.9 mg/dL
(N 8.4-10.4). This result is confirmed on repeat testing and is elevated when adjusted for her
albumin level.
Her current medications are lovastatin (Mevacor), 20 mg daily for hypercholesterolemia, and
lisinopril (Prinivil, Zestril), 10 mg daily for hypertension. Her medical history is otherwise
negative. Her parathyroid hormone level is 74 pg/mL (N 15-75), her serum creatinine level is
1.1 mg/dL (N 0.6-1.5), and her 25-hydroxyvitamin D level is 26 ng/mL (N 14-60).
Which one of the following is the most likely diagnosis?
A) Primary hyperparathyroidism
B) Occult malignancy
C) Sarcoidosis
D) Paget’s disease of bone
E) Hypervitaminosis D
All of the diagnoses listed may cause elevations of serum calcium, but malignancy, sarcoidosis, Paget’s
disease, and hypervitaminosis D are all associated with suppressed levels of parathyroid hormone. While
the parathyroid levels in this patient are within the normal range, they are inappropriately high for the level
of serum calcium and suggest hyperparathyroidism, the most common cause of hypercalcemia in this age
A 7-year-old male is brought to your office by his mother because she is concerned about his
ability to focus and stay still in school all day. She has paperwork from school and home,
including his report card, Connor Rating Scales, behavioral screening, IQ tests, and performance
testing. Your evaluation leads to a diagnosis of attention-deficit/hyperactivity disorder (ADHD)
with no apparent comorbidities. As you discuss management options the mother expresses
concern because her parents tell her that medications for ADHD are overprescribed and
addictive. She asks you for further guidance.
After providing the mother with comprehensive educational material, which one of the following
would you recommend as first-line treatment?
A) Cognitive-behavioral therapy
B) Atomoxetine (Strattera)
C) Bupropion (Wellbutrin)
D) Clonidine (Catapres)
E) Methylphenidate (Ritalin LA, Concerta)
Research has consistently confirmed that stimulant medications are the most efficacious first-line treatment
for children with attention-deficit/hyperactivity disorder (ADHD) (SOR A). No research supports the
notion that the use of a stimulant in ADHD patients will promote addiction. To the contrary, some evidence
suggests that ADHD patients who take stimulant medication have lower rates of drug abuse than those who
do not. Diversion and misuse of prescription stimulants is a growing concern, however, and the use of a
long-acting stimulant can decrease the chances for diversion.
There are a number of well-supported behavioral interventions for ADHD. Most behavioral approaches
focus on rewarding desired behavior and applying consequences for unwanted behavior to gradually
reshape the child’s thinking and actions. Interventions that help reinforce parental involvement include
support groups, which connect parents who have children with similar problems, and parenting skills
training, which gives parents techniques and tools for managing their child’s behavior. Psychotherapy and
cognitive-behavioral therapy have little or no documented effectiveness for the treatment of ADHD.
A multicenter, randomized study comparing the effectiveness of multimodal treatment (combined
behavioral interventions and pharmacotherapy) with either treatment alone showed that combination
treatment and pharmacotherapy alone yielded similar results and each was more effective than behavioral
treatment alone or standard care in reducing core ADHD symptoms. A tool kit has been developed by the
American Academy of Pediatrics and the National Initiative for Children’s Healthcare Quality to help
physicians improve the management of ADHD. While the second edition is only available in print form,
the first edition can be downloaded free at http://www.nichq.org/adhd_tools.html.
A 65-year-old male has complaints of insomnia and fatigue. His past medical history is
significant only for hypertension and osteoarthritis. His physical examination is normal except
for a blood pressure of 145/90 mm Hg and a heart rate of 105 beats/min. He has a normal BMI,
does not smoke or drink alcohol, and denies any pain or chest pressure. He has not changed his
daily exercise routine or diet, and has not traveled recently. Routine blood work is normal except
for a TSH level of 0.3 U/mL (N 0.5-5.0).
Which one of the following would be most appropriate at this point?
A) Order a repeat TSH level and instruct the patient to fast beforehand
B) Order a thyroglobulin level
C) Order free T3 and free T4 levels
D) Order a 24-hour radioactive iodine uptake test
E) Begin treatment with levothyroxine (Synthroid)
The low TSH level suggests hyperthyroidism. If TSH is <0.5 U/mL, the immediate next step is to
measure free T3 and free T4 levels (SOR C), which are elevated in hyperthyroidism and normal in
subclinical hyperthyroidism. If levels of free T3 and free T4 are elevated and the underlying cause of
hyperthyroidism is unknown, then it is advisable to order a 24-hour radioactive iodine (RAI) uptake test.
With Graves’ disease, RAI uptake is increased and diffuse, whereas with toxic multinodular goiter it is
increased and nodular (SOR A). If RAI uptake is low, subacute thyroiditis should be suspected and could
be confirmed by measuring levels of thyroglobulin (SOR A). Levothyroxine is not indicated, as it is used
to treat hypothyroidism. Fasting does not significantly affect TSH levels.
A 50-year-old male presents to your office with recurrent irritative voiding symptoms that are
accompanied by testicular, perineal, and low back discomfort. He also reports occasional distal
penile pain. Four months ago he visited another physician because of a similar episode. He was
told then that he had a urinary tract infection, based on a positive urine culture that grew
Escherichia coli, and was given a prescription for an antibiotic to take for 2 weeks. His
symptoms improved but never completely resolved. On examination the patient is afebrile. His
prostate is slightly enlarged, boggy, and moderately tender.
Which one of the following is the most appropriate management step at this time?
A) A prostate-specific antigen level prior to initiating treatment
B) Transrectal ultrasonography of the prostate prior to initiating treatment
C) Ciprofloxacin (Cipro)
D) Tamsulosin (Flomax)
E) High-dose oral ampicillin
The patient has symptoms consistent with chronic bacterial prostatitis: irritative voiding symptoms;
testicular, perineal, and low back pain; recurrent urinary tract infections; and distal penile pain. His
symptoms have also been present for more than 3 months. Because chronic bacterial prostatitis is a
bacterial infection, an appropriate antibiotic with good tissue penetration in the prostate should be selected.
Fluoroquinolones have the best tissue concentration and are recommended as first-line agents.
Penicillin derivatives, commonly used to treat acute prostatitis, have not been shown to provide good
symptom relief for chronic bacterial prostatitis. -Blockers are second-line agents for treating chronic
pelvic pain. Transrectal ultrasonography is indicated in patients whose acute prostatitis fails to resolve and
who have a persistent fever or whose maximal temperature is not trending downward after 36 hours. In
this case a prostatic abscess should be suspected, and transrectal ultrasonography can facilitate the
diagnosis. Prostate-specific antigen is a screening test for prostatic malignancy and would contribute
nothing to the management of this patient’s problem.
A 46-year-old male admits to consuming at least 4 alcoholic drinks a day. He states that he
doesn’t think his alcohol use is a problem, and that he has read that drinking helps keep the heart
The cardiovascular effects of this level of alcohol use include
A) a decrease in blood pressure while drinking
B) a decreased risk for acute coronary events
C) an increased risk of valvular disease
D) an increased risk of heart failure
E) no apparent effect on stroke risk
Observational studies have consistently shown that alcohol use has a J-shaped curve for several health
effects. Small amounts of alcohol on a daily basis (less than ½-1 drink/day for women, and 1-2 drinks/day
for men) are associated with an 18% lower risk for all-cause mortality and a 30% decreased risk for
coronary heart disease. As the use of alcohol increases these benefits disappear and even reverse, showing
a dose-dependent increase in all-cause mortality when women consume more than 2 drinks/day or men
over 4 drinks/day. At this level of alcohol use, rates increase for hypertension, cancer, stroke, heart
failure, dementia, and diabetes mellitus.
A 22-year-old female has a 4-month history of suprapubic pain, urinary frequency, urinary
urgency, dysuria, and dyspareunia. She has been empirically treated with antibiotics for a
urinary tract infection despite the fact that multiple urine tests have been negative for infection
or other abnormalities. You suspect the patient has interstitial cystitis.
Which one of the following would be most appropriate at this point?
A) Fluoxetine (Prozac)
B) Ibuprofen
C) Nitrofurantoin (Macrobid)
D) Pentosan polysulfate sodium (Elmiron)
E) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
The only FDA-approved oral medication for the treatment of interstitial cystitis is pentosan polysulfate
sodium, which is thought to repair the urothelium (SOR B). Trimethoprim/sulfamethoxazole and
nitrofurantoin are indicated for urinary tract infections (UTIs), but usually not in cases of cystitis with no
infection. In addition, this patient has already received empiric treatment for a UTI despite having multiple
negative urine cultures. Ibuprofen is an anti-inflammatory medication commonly used to treat pain but is
not specifically indicated for interstitial cystitis. While tricyclic antidepressants such as amitriptyline have
been used to treat interstitial cystitis, fluoxetine is not generally recommended.
Which one of the following is a risk factor for depression during pregnancy?
A) High socioeconomic status
B) Nonsmoking
C) Age over 25
D) A family history of hyperthyroidism
E) Childhood abuse
A previous history of depression is the strongest risk factor for depression during pregnancy. Other risk
factors include childhood abuse, smoking, age under 20, and low socioeconomic status, especially without
social support. A family history of hyperthyroidism is not a risk factor.
A 62-year-old female presents with painful lesions at both corners of her mouth characterized
by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth.
She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it
has not helped.
Which one of the following would be most appropriate at this point?
A) A biopsy of the lesions
B) An anticandidal medication
C) Bacitracin
D) Vitamin B12
This patient has perlèche, or angular cheilitis. Most cases are secondary to moisture from patients licking
their lips, promoting a monilial or staphylococcal infection. Other causes include contact and irritant
dermatitis. Underlying HIV infection, celiac disease, or vitamin B12 and iron deficiencies have also been
reported. Treatment may include appropriate topical creams such as mupirocin or antifungal agents, or
low-potency nonfluorinated corticosteroid creams for irritant or contact causes.
A 40-year-old male presents with right eye pain and redness. There is no history of trauma or
Which one of the following should be done initially?
A) Irrigation
B) Funduscopic examination
C) Visual acuity testing
D) Fluorescein staining
E) Application of a local anesthetic
Almost all patients with ocular problems should have visual acuity testing before anything else is done
(level of evidence 3, SOR A). If this is difficult, a local anesthetic may be applied. The main exception
to this rule is a chemical burn of the eye, which should be irrigated for 30 minutes before further
evaluation or treatment is undertaken..
While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72
hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms
and neck. He began treating himself with an over-the-counter topical hydrocortisone cream, and
when the eruption did not improve after 24 hours of treatment he sought help from the local
emergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with
24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day
6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and
vesiculation, involving extensive areas of his arms, neck, and face.
The most appropriate management at this time would be to
A) prescribe a superpotent topical corticosteroid
B) repeat the oral methylprednisolone treatment
C) begin diphenhydramine (Benadryl), 4 times a day
D) begin high-dose oral prednisone and taper over 2 weeks
E) discontinue all medications and recommend cool compresses
Systemic corticosteroids are recognized for their dramatic impact on both the subjective and objective
course of poison ivy dermatitis. Oral prednisone at an initial dosage of 1 mg/kg/day tapered over 14-21
days is the standard regimen. Complications can result from the use of shorter prepackaged courses of
corticosteroid therapy, resulting in significant rebound flares. These products usually begin with an initial
dosage approximately half that of the recommended dosage, with the course tapering too rapidly.
Over-the-counter topical hydrocortisone is ineffective for all but the mildest cases, and once the disease
is established, superpotent topical corticosteroids do little to alter the overall course and natural history.
Antihistamines and compresses provide some symptomatic relief, but do little to alter the course of
established disease.
A 56-year-old male sees you for a health maintenance visit. He inquires about the options for
colon cancer screening. He has not had any screening tests performed in the past and has no
personal or family history of colon cancer. You tell him that there are several alternatives, but
according to the U.S. Preventive Services Task Force, recommendations regarding the optimal
screening intervals vary by test. He opts for fecal occult blood testing.
You recommend he repeat this test at which one of the following intervals?
A) Yearly
B) Every 5 years
C) Every 7 years
D) Every 10 years
E) Never, if the results are negative
The U.S. Preventive Services Task Force recommends that all adults be screened for colon cancer
beginning at age 50 and continue regular screening until age 75 (SOR A). They recommend against
continued routine screening in previously screened adults 75-85 years of age and against any screening
in adults over 85 (SOR A). Most organizations do not recommend a particular screening method, but
instead list screening options, including fecal occult blood testing, flexible sigmoidoscopy, and
colonoscopy. The recommended interval for fecal occult blood testing is every year. There is new evidence
based on randomized, controlled trials that participation and detection rates for advanced adenomas and
cancer are higher for immunochemical fecal testing than for stool guaiac testing (SOR A). As long as
results are normal, screening colonoscopy is recommended at 10-year intervals and screening
sigmoidoscopy at 5-year intervals.
Which one of the following is the leading cause of death among adolescents age 12-19 in the
United States?
A) Accidents
B) Suicide
C) Homicide
D) Cancer
E) Heart disease
Teenage mortality is an important public health issue because the majority of deaths among teenagers are
caused by external causes of injury such as accidents, homicide, and suicide. The leading causes of death
for the teenage population remained constant throughout the period 1999-2006: accidents (48% of deaths),
homicide (13%), suicide (11%), cancer (6%), and heart disease (3%). Motor vehicle accidents accounted
for 73% of all deaths from unintentional injury.
An 80-year-old female who lives independently at home is admitted to the hospital with acute
pyelonephritis. When she is taken to her hospital room she is incontinent, unsteady when
walking, and somewhat disoriented. Her past medical history includes hypertension with
evidence of diastolic dysfunction on echocardiography and asymptomatic glucose intolerance.
Which one of the following orders would be appropriate for this patient?
A) Telemetry
B) Continuous pulse oximetry
C) Foley catheter placement
D) A regular diet
E) Bed rest
Interventions recommended for hospitalized older patients to reduce the risk of hospital-induced disability
include minimizing restricted diets. Bed rest orders should be avoided, with recommendations that the
patient ambulate 3-4 times/day and be out of bed and in a chair for all meals. This patient is disoriented
and probably has delirium. Restraints should be avoided if possible, and should be limited if they become
necessary. This would also apply to functional restraints, such as indwelling urinary catheters, IV poles,
nasal cannulas, continuous pulse oximetry, and telemetry, which all increase the risk of delirium.
A 70-year-old male sees you because his left leg feels tender and swollen. Questioning reveals
that a few days ago he returned from a long road trip with his wife, and that they had spent
several days driving to visit relatives. On examination there is marked asymmetry between his
left calf and his right calf; there is also a slight discoloration around the area of his left calf
where it is most tender.
You suspect the edema may be due to a deep-vein thrombosis (DVT). The patient has no
personal or family history of blood clots. Further investigation reveals a high pretest probability
score on the Wells Clinical Prediction Rule test for DVT.
Which one of the following would be the most appropriate diagnostic test at this point?
A) D-dimer
B) Contrast venography
C) Compression ultrasonography
D) Helical CT
The first step in diagnosing deep-vein thrombosis (DVT) is to complete a validated clinical prediction
inquiry such as the Wells Clinical Prediction Rule in order to estimate the pretest probability of DVT. The
Wells criteria include such factors as active cancer, calf swelling, pitting edema, prolonged inactivity, or
major surgery within the previous 12 weeks.
The next step for patients with a low pretest probability of DVT is a high-sensitivity D-dimer assay, with
a negative result indicating a low likelihood of DVT (SOR A). D-dimer is a degradation product of
cross-linked fibrin blood clots and is usually elevated in patients with DVT, although it can also be elevated
with other conditions such as recent surgery, hemorrhage, trauma, pregnancy, or cancer. If the assay is
negative, the likelihood of DVT is very small.
In this case, the patient has several factors listed in the Wells criteria, indicating a high pretest probability
of DVT. D-dimer testing would not be useful, as the next step in this patient’s evaluation should be
imaging. Ultrasonography is the best test for symptomatic proximal-vein thrombosis, with a sensitivity
ranging between 89% and 96% (SOR A). Although ultrasonography is the most appropriate first imaging
test, contrast venography is considered the definitive test to rule out the diagnosis of DVT if there is still
a high degree of suspicion after negative ultrasonography.
Helical CT is commonly used to detect pulmonary embolism but is not routinely recommended to diagnose
DVT. Similarly, MRI is not routinely recommended for detecting DVT.
A 45-year-old female with type 1 diabetes mellitus currently takes NPH insulin (Humulin,
Novolin) twice a day. She expresses a desire to change to insulin glargine (Lantus). Her diabetes
has always been well controlled, and her current hemoglobin A1c of 7.4% is typical for her.
Which one of the following is most likely to be reduced if this change is made?
A) Quality of life
B) Hemoglobin A1c
C) Morbidity from all causes
D) Treatment costs
E) Her risk for hypoglycemia
The extended flat pharmacokinetic curve of long-acting insulin analogues makes once-daily administration
of larger doses of insulin possible. Such treatment should, in theory, provide increased flexibility with
regard to the timing of injections and improve compliance. This should improve control of the patient’s
diabetes, reduce the risk of hypoglycemia, and improve overall patient satisfaction. To date, however, the
only proven benefit of treatment with insulin analogues is a reduction in the low rate of symptomatic,
nocturnal, and overt hypoglycemia experienced by patients treated with isophane insulin. Although the total
cost of treatment with insulin analogues is higher, a Cochrane review of the limited number of studies
comparing insulin treatments showed no statistically significant differences in the hemoglobin A1c levels
measured at the end of the studies in any treatment group (SOR C). Significant changes in morbidity,
mortality, or quality of life have not been demonstrated (SOR C).
A 52-year-old female sees you for the first time to establish care for her stable COPD. Since
losing her insurance 4 months ago she has been off all medications except for a short-acting
bronchodilator. She stopped smoking 2 years ago. She has a frequent, chronic cough and is
dyspneic when climbing stairs. Pulmonary function testing reveals an FEV1 of 55%. Her O2
saturation is 90% on room air.
In addition to the short-acting inhaled bronchodilator, recommended maintenance monotherapy
for this patient would be either an inhaled long-acting anticholinergic agent or an inhaled
A) corticosteroid
B) long-acting beta-agonist
C) mast-cell stabilizer
D) antihistamine
In 2011, the American College of Physicians published new guidelines on COPD management. For
patients with COPD who are symptomatic and have an FEV1 less than 60% of predicted, the
recommendation is monotherapy with either a long-acting inhaled anticholinergic (tiotropium) or a
long-acting inhaled -agonist such as salmeterol or formoterol. This is in addition to rescue therapy with
a short-acting inhaled bronchodilator such as albuterol. Long-acting inhaled anticholinergics and
long-acting inhaled -agonists reduce exacerbations and improve quality of life. The evidence is
inconclusive with regard to their effect on mortality, hospitalizations, and dyspnea.
Inhaled corticosteroids have been found to be better than placebo for decreasing COPD exacerbations, but
their side-effect profile keeps them from being preferred as monotherapy. Neither inhaled mast-cell
stabilizers nor inhaled antihistamines are recommended as first-line agents for the treatment of COPD.
A 62-year-old female presents to your office because of painless rectal bleeding. Over the past
several months she has occasionally noted blood on the toilet tissue and in her stool after bowel
movements. She also reports periodic anal itching and discharge, and protrusion of rectal tissue
during bowel movements that resolves spontaneously. She had a normal colonoscopy at age 50.
An abdominal examination is normal and a digital rectal examination is not painful and no mass
is palpated. However, her stool is positive for occult blood. Anoscopy demonstrates dilated
purplish-blue veins above the dentate line.
Which one of the following has the best evidence for reducing symptoms in this situation?
A) Sitz baths
B) Fiber supplementation
C) Topical 1% hydrocortisone
D) Topical diltiazem (Cardizem)
E) Topical lidocaine cream (LidaMantle)
This patient has grade 2 internal hemorrhoids. These protrude with defecation but reduce spontaneously.
Sitz baths are commonly recommended, but a review of studies found no benefit from sitz baths for various
anorectal disorders, including hemorrhoids. A meta-analysis of seven randomized trials of patients with
symptomatic hemorrhoids showed that fiber supplementation with psyllium, sterculia, or unprocessed bran
decreased bleeding, pain, prolapse, and itching. No randomized, controlled trials support the use of
corticosteroid creams for treating hemorrhoidal disease. Topical diltiazem and topical lidocaine have been
shown to provide pain relief postoperatively following excision of external hemorrhoids.
Which one of the following reflects the percentage of patients with a disease who have a positive
test for the disease in question?
A) Likelihood ratio
B) Sensitivity
C) Specificity
D) Positive predictive value
E) Negative predictive value
Sensitivity is defined as the percentage of patients with a disease who have a positive test for the disease
in question. Specificity is the percentage of patients without the disease who have a negative test. The
positive predictive value is the percentage of patients with a positive or abnormal test who have the disease
in question. The negative predictive value is the percentage of patients with a negative or normal test who
do not have the disease in question. Likelihood ratios correspond to the clinical impression of how well
a test rules in or rules out a given disease.
Patients with which one of the following platelet disorders should be hospitalized and treated
A) Drug-induced thrombocytopenia
B) Congenital thrombocytopenia
C) Gestational thrombocytopenia
D) Thrombotic thrombocytopenic purpura
E) Thrombocytopenia associated with Lyme disease
Thrombotic thrombocytopenic purpura (TTP) is an emergent condition that can result in up to 30%
mortality. Prompt hospitalization with plasma exchange is the preferred treatment. Patients with TTP
present with nonspecific symptoms such as fever, abdominal pain, nausea, and weakness. Patients may
also exhibit neurologic deficits. Microangiopathic anemia is also likely to be present, as evidenced by
schistocytes on a peripheral smear and elevated levels of LDH and nucleated RBCs.
Congenital thrombocytopenia is a benign condition in which patients have long-standing low platelet counts
and/or a family history of thrombocytopenia. It is usually asymptomatic but a concomitant bleeding
diathesis may occur.
Gestational thrombocytopenia is also benign and asymptomatic. It is often confused with mild immune
thrombocytopenic purpura. Platelet counts rarely drop below 70,000/mm3. There is no associated fetal
thrombocytopenia. Preeclampsia and HELLP syndrome should also be ruled out. Platelet counts return
to normal after delivery (SOR C).
Drug-induced thrombocytopenia can be severe, but platelet counts do not usually drop below 20,000/mm3.
It is characterized by an abrupt drop in the platelet count within a week of starting the offending medication
and resolves within 2 weeks after the medication is stopped.
Lyme disease can be associated with a transient thrombocytopenia. Patients present with common
symptoms of Lyme disease, such as fever, myalgias, and rash. The thrombocytopenia resolves with
treatment of the underlying infection.
A 12-year-old male presents to the office with a 2-day history of fever, myalgias, and
rhinorrhea. He is otherwise healthy, and you suspect influenza.
Which one of the following is the most appropriate next step in the management of this patient?
A) Symptomatic treatment only
B) Diagnostic testing to confirm influenza infection
C) Oseltamivir (Tamiflu)
D) Amantadine (Symmetrel)
E) Antibiotics to prevent bacterial coinfection
Influenza should be diagnosed on the basis of clinical signs and symptoms rather than diagnostic testing.
Antiviral treatment is not recommended in otherwise healthy adults and children. Symptomatic treatment
should be initiated with over-the-counter antipyretics and anti-inflammatory medications, and aspirin should
be avoided due to the risk of Reye’s syndrome. Antibiotics are indicated only when a bacterial coinfection
is diagnosed and not for prophylaxis.
A 40-year-old male with diabetes mellitus has the following fasting lipid profile:
Total cholesterol…204 mg/dL
Triglycerides… 223 mg/dL
Low-density lipoprotein (LDL)… 112 mg/dL
High-density lipoprotein (HDL)…42 mg/dL
The patient is currently on simvastatin (Zocor), 40 mg, for management of his dyslipidemia.
Which one of the following would be most appropriate?
A) Continuing the current medication regimen
B) Increasing the dosage of simvastatin
C) Switching to atorvastatin (Lipitor)
D) Adding gemfibrozil (Lopid)
This patient does not meet the LDL-cholesterol goals for a diabetic patient and therefore needs adjustment
of his antihyperlipidemic regimen. In June 2011, the Food and Drug Administration recommended limiting
the use of the highest dosage of simvastatin (80 mg/day) because of concerns about an increased risk of
muscle damage. This dosage should only be used in patients who have already been taking 80 mg/day for
12 months or more without evidence of muscle injury, and it should not be started in new patients. This
patient should be switched to an alternative medication that provides a greater reduction of
LDL-cholesterol, such as atorvastatin. Gemfibrozil is contraindicated for use with simvastatin because it
can raise simvastatin drug levels and increase the risk of myopathy.
An obese 32-year-old female has not conceived after more than 4 years of unprotected
intercourse. You perform an appropriate workup and diagnose polycystic ovary syndrome.
Of the following, the most effective management for her infertility would be
A) spironolactone (Aldactone)
B) luteinizing hormone
C) basal body temperature monitoring
D) clomiphene (Clomid)
E) bromocriptine (Parlodel)
Polycystic ovary syndrome may be the most common cause of female infertility, affecting 6%-8% of
women. Some patients with polycystic ovary syndrome have hyperandrogenism, elevated levels of
luteinizing hormone, and hyperinsulinemia. While early studies supported the use of metformin to increase
fertility, a more recent study has shown that only 7% of women treated with metformin were able to
conceive, whereas 22% of women treated with clomiphene citrate had a live birth. Spironolactone is useful
for treating hirsutism, but not infertility. Since levels of other hormones are already elevated, the other
measures listed would not be of benefit.
A patient has fatigue and joint pain and is concerned about the possibility of systemic lupus
erythematosus (SLE) after reading about this condition on the Internet. After taking a brief
history you decide that further evaluation is appropriate.
In addition to the history and physical findings, which one of the following laboratory findings
would most support the diagnosis of SLE?
A) An abnormal C-reactive protein level
B) An erythrocyte sedimentation rate of 48 mm/hr
C) A positive antimicrosomal antibody test
D) A positive test for antiphospholipid antibodies
E) A positive test for rheumatoid factor
The American College of Rheumatology criteria for the diagnosis of systemic lupus erythematosus (SLE)
includes the presence of 4 of 11 criteria. One criterion is evidence of the presence of an immunologic
disorder. Evidence of an immunologic disorder includes a positive finding of antiphospholipid antibodies,
based upon one of the following: an abnormal serum level of immunoglobulin G or M anticardiolipin
antibodies, a positive lupus anticoagulant test, or a false-positive serologic test for syphilis. The other test
results listed are not criteria for the diagnosis of SLE.
A 54-year-old female presents with a new onset of headaches. She rates her pain as severe and
reports that the headaches frequently awaken her in the early morning. The patient has a history
of hypertension and stage 4 chronic kidney disease. Her glomerular filtration rate is 24 mL/min.
You suspect the patient has a brain tumor and order gadolinium-enhanced MRI of the head.
Which one of the following is the patient at high risk for developing with the use of gadolinium
A) Nephrogenic systemic fibrosis
B) Anaphylaxis to contrast dye
C) Dermatomyositis
D) Focal seizures
E) Hypertensive crisis
This patient has stage 4 chronic kidney disease with a glomerular filtration rate (GFR) <30 mL/min. This
puts her at high risk for developing nephrogenic systemic fibrosis. The FDA recommends against using
gadolinium-based contrast agents in patients with acute or chronic kidney disease and a GFR <30 mL/min.
While anaphylaxis is possible, this patient would not be at a high risk for this. Dermatomyositis, focal
seizures, and hypertensive crisis are not associated with gadolinium-based contrast agents.
You suspect mild Pneumocystis jiroveci pneumonia in a patient whose past medical history is
significant for HIV infection. He has not been compliant with his disease management and is not
on any medications.
What is the recommended treatment for this patient’s pneumonia?
A) Azithromycin (Zithromax)
B) Clindamycin (Cleocin)
C) Rifampin (Rifadin)
D) Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Trimethoprim/sulfamethoxazole is the drug of choice for treating Pneumocystis jiroveci pneumonia.
Atovaquone has been shown to be very effective for treating mild to moderate Pneumocystis jiroveci
pneumonia and is also very well tolerated, and would be the first choice for a patient with a sulfa allergy.
Clindamycin plus primaquine is also effective therapy, but clindamycin is not effective as monotherapy.
Azithromycin and rifampin are not effective against this organism. Other treatment options include
pentamidine, dapsone plus trimethoprim, and clindamycin plus primaquine.
A 66-year-old white female presents to your office for a routine physical examination. Her
medical problems include hypertension, diabetes mellitus, hypercholesterolemia, and
gastroesophageal reflux, all controlled with medications. A bone density study is consistent with
osteopenia. She is taking a multivitamin and calcium carbonate, 1200 mg daily.
Which one of her medications would reduce her calcium carbonate absorption?
A) Atorvastatin (Lipitor)
B) Hydrochlorothiazide
C) Lisinopril (Prinivil, Zestril)
D) Metformin (Glucophage)
E) Omeprazole (Prilosec)
Because of the high prevalence of reduced gastric acidity related to either endogenous causes or
medications such as proton pump inhibitors, calcium carbonate is best taken with meals to optimize
absorption. Calcium citrate, which is well absorbed regardless of gastric acidity, may be taken with or
without food. The other medications listed do not impair calcium absorption.
A 3-year-old male is brought to your office by his father for evaluation of 5 days of knee pain
and fever up to 101.6°F. There was no known trauma preceding these symptoms. The pain and
fever respond well to oral acetaminophen but continue to recur 4 hours after each dose.
On examination the child appears well and is afebrile. He had a dose of acetaminophen about
2 hours ago. There are no signs of upper respiratory infection. Examination of the knee reveals
no redness, warmth, or swelling, and you see no other skin changes. He has full range of motion
of both the knee and hip without pain. You note tenderness to firm palpation of the proximal
tibia. He is able to bear weight and walk but refuses to jump due to anticipation of pain in his
knee. Plain films of the knee are normal.
The next step in the evaluation of this patient should include which one of the following?
A) Close monitoring at home
B) A CBC, a C-reactive protein level, and an erythrocyte sedimentation rate
C) Ultrasonography of the hip
D) Knee joint aspiration
E) MRI of the knee
Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or
rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a
C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even
though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a
single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence
of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could
help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient,
but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first
step toward identifying the source of his pain and fever.
A 58-year-old female with diabetes mellitus complains of 2 years of right shoulder pain, which
is worse with activity. There has been no trauma. She tells you one of her friends had a similar
problem and was treated successfully with “some sort of shock wave treatments.”
Which one of the following diagnoses is most likely to be successfully treated with
extracorporeal shock wave therapy?
A) Calcific tendinitis
B) Gout
C) Partial rotator cuff tear
D) Frozen shoulder
E) Hooked acromion
Extracorporeal shock wave therapy is effective for calcific tendinitis of the rotator cuff. Side effects include
bruising and pain. Needling and irrigation, physical therapy, and cortisone injections are sometimes used
in patients with acute symptoms. Endoscopic and open surgical treatments are alternatives to extracorporeal
shock wave therapy in refractory cases. Extracorporeal shock wave therapy does not have an established
role in gout, rotator cuff tear, frozen shoulder, or hooked acromion.
A 24-year-old female presents with a 10-day history of cough productive of green sputum. Her
past medical history is unremarkable and she is up to date on all immunizations. The patient’s
temperature is 37.2°C (98.9°F), blood pressure 127/76 mm Hg, pulse rate 89 beats/min,
respiratory rate 24/min, and O2 saturation 95% on room air. Her physical examination is
unremarkable except for a loose cough.
Which one of the following is best supported by evidence for management of this patient’s
A) A macrolide antibiotic such as azithromycin (Zithromax)
B) An oral corticosteroid such as prednisone
C) An inhaled -agonist such as albuterol (Proventil, Ventolin)
D) An expectorant such as guaifenesin
E) Reassurance that symptoms will likely resolve on their own within 3 weeks
This patient has acute bronchitis. The most appropriate management option is to provide reassurance that
symptoms will likely resolve on their own within 3 weeks. Approximately 90% of cases are caused by
viruses, and antibiotics do not significantly change the course of the condition. For this reason, and
because of concerns about antibiotic resistance and side effects from antibiotic use, antibiotics should not
be used routinely for the treatment of acute bronchitis (SOR B). Despite this, approximately two-thirds of
patients in the United States diagnosed with bronchitis are still treated with antibiotics. Corticosteroids and
-agonists are not indicated in the absence of asthma or wheezing on examination. Expectorants have not
been shown to be effective in the treatment of bronchitis (SOR B).
You are managing a patient who is critically ill and is being placed on a ventilator. Management
should include which one of the following to reduce the occurrence of ventilator-associated
A) Continuous sedation
B) Nasotracheal intubation
C) Metoclopramide (Reglan) prophylaxis
D) Elevation of the head of the bed
E) Initiation of tube feedings within 24 hours
Recommendations for reducing ventilator-associated pneumonia (VAP) include elevation of the head to
an angle of at least 30°, noninvasive mechanical ventilation rather than intubation when appropriate, oral
intubation when an endotracheal tube is necessary, orogastric rather than nasogastric tubes, minimization
of sedation, administration of a proton pump inhibitor when prophylaxis is indicated, changing ventilator
tubing every 7 days or when it becomes soiled, avoidance or elimination of endotracheal tube leaks, good
technique in removal of condensate, and excellent hand hygiene. One study favored waiting more than 5
days before initiating tube feedings, as this reduced the incidence of VAP, although further data is needed
to confirm this.
Which one of the following has good evidence of effectively improving borderline personality
B) Second-generation antipsychotics
C) Omega-3 fatty acids
D) No currently available pharmacotherapy
There are no proven therapies to reduce the severity of borderline personality disorder (SOR A). The most
promising psychological therapy is dialectic behavioral therapy (DBT). DBT is a multi-faceted program
specifically designed to treat borderline personality disorder. The few, small studies of DBT found
improvement in many symptoms of borderline personality disorder, but long-term data is lacking. Another
promising therapy is psychoanalytic-oriented day hospital therapy. Again, study sizes have been small and
data cannot be extrapolated to the population as a whole.
Omega-3 fatty acids, second-generation antipsychotics, and mood stabilizers have been shown to be helpful
for some symptoms of borderline personality disorder but not for overall severity. Their benefits are based
on single-study results and side effects were not addressed in the studies. SSRIs are not recommended for
borderline personality disorder unless there is a concomitant mood disorder.
A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks
gestation for prenatal care. Her physical examination is normal except for a blood pressure of
156/114 mm Hg.
Which one of the following would be most appropriate as initial treatment?
A) Labetalol (Trandate)
B) Lisinopril (Prinivil, Zestril)
C) Losartan (Cozaar)
D) Metoprolol (Lopressor, Toprol-XL)
E) Nifedipine, immediate release (Procardia)
The drug most often recommended as first-line therapy for hypertension in pregnancy is labetalol. Reports
of an association of metoprolol with fetal growth restriction have given rise to the recommendation to avoid
its use in pregnancy. Both ACE inhibitors and angiotensin-receptor blockers are contraindicated in
pregnancy because of the risk of birth defects and fetal or neonatal renal failure. Immediate-release
nifedipine is not recommended due to the risk of hypotension.
A 26-year-old male presents to the emergency department with a fever, and he appears acutely
ill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracic
echocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.
Which one of the following is the most likely causative organism?
A) Cardiobacterium hominis
B) Enterococcus faecalis
C) Pseudomonas aeruginosa
D) Staphylococcus aureus
E) Streptococcus viridans
Staphylococcus aureus is the most common cause of acute infectious endocarditis worldwide. Additionally,
the most common cause of tricuspid valve endocarditis is intravenous drug abuse, and Staphylococcus
aureus is the infecting organism in 80% of tricuspid valve infections. Streptococcus viridans is also a
frequent cause of infectious endocarditis, with Enterococcus, Pseudomonas, and Cardiobacterium being
less likely causes.
A neurologically intact 77-year-old female presents with severe low back pain following a fall
2 days ago that caused her to land on her buttocks. A radiograph of her lower spine shows a
compression fracture of L3 with a loss of about 50% of the vertebral body height.
Which one of the following is most appropriate at this point?
A) Referral for kyphoplasty
B) Referral for vertebroplasty
C) Back bracing
D) Bed rest
E) Calcitonin-salmon (Miacalcin)
A number of measures for managing spinal compression fractures have been evaluated. The evidence for
recommending kyphoplasty is weak, and the evidence for recommending against vertebroplasty is strong.
The data on bracing is inconclusive, as is the recommendation for bed rest. Calcitonin has been shown to
reduce the incidence of recurrent fractures and may be useful in the relief of pain.
Which one of the following is the most common cause of death for African-American males in
the United States?
A) Heart disease
B) Stroke
C) Cancer
D) Accidental injuries
E) Homicide
Heart disease is the leading cause of death in the U.S., and this holds true for both men and women.
Among men the only ethnicity for which heart disease is not the most common cause of death is
Asian/Pacific Islander.
A 45-year-old female has an alkaline phosphatase level that is twice the normal level on a
chemistry panel ordered for evaluation of pruritus. Other tests of liver function are within
normal limits, including bilirubin and ALT (SGPT) levels, and repeat testing 2 months later
shows no change. A -glutamyltransferase level is also significantly elevated, as is an
antimitochondrial antibody titer. Hepatic ultrasonography is unremarkable.
Which one of the following diagnoses is most likely?
A) Primary biliary cirrhosis
B) Paget’s disease of the bone
C) Sarcoidosis
D) Choledocholithiasis
E) Drug-induced cholestasis
A middle-aged woman with pruritus and elevated levels of alkaline phosphatase, -glutamyltransferase
(GGT), and antimitochondrial antibody titers is likely to have primary biliary cirrhosis. Levels of
5′-nucleotidase or GGT are usually elevated in parallel with those of alkaline phosphatase in patients with
liver disease, but not in patients with bone disorders. Infiltrative liver disease, as seen with sarcoidosis,
drug-induced cholestasis, and choledocholithiasis, is not associated with elevated antimitochondrial
antibody levels. Patients with choledocholithiasis will also usually have dilated hepatic ducts on
ultrasonography. This patient should next have a liver biopsy to confirm her diagnosis.
A 19-year-old sexually active female comes to your office for a routine checkup. She is
generally healthy with no chronic conditions and does not smoke.
For this patient, screening for which one of the following is supported by the best evidence?
A) Hypercholesterolemia
B) Cervical cancer
C) Chlamydia infection
D) HPV infection
E) Intimate partner violence
According to the U.S. Preventive Services Task Force (USPSTF), there is good evidence that screening
for Chlamydia infection in women who are at increased risk can reduce the incidence of pelvic
inflammatory disease, while the harms are minimal. The evidence regarding screening for cervical cancer
with Papanicolaou testing or human papillomavirus (HPV) testing, however, shows that the harms
outweigh any possible benefits. Harms include overdiagnosis and overtreatment, including invasive
cervical procedures that can affect future pregnancy outcomes. In addition, there is adequate evidence that
screening women younger than 21 years of age (regardless of sexual history) does not reduce the incidence
of cervical cancer or mortality compared with beginning screening at age 21. The USPSTF concludes that
the evidence is insufficient to recommend for or against routine screening for lipid disorders or intimate
partner violence in women this age.
You see a 72-year-old male for follow-up after his third hospital admission for heart failure
within the past 4 months. He is a widower and lives alone, but he wants to talk about options for
in-home nursing care. He is accompanied today by his sister and his neighbor. This is the first
time you have seen the patient.
Which one of the following is the best choice regarding your interactions with the three of them?
A) Construct a family genogram to determine how to proceed with the patient’s care
B) Speak privately with the sister and neighbor to determine possible ulterior motives
C) Determine the reason each person is present today
D) Discuss the patient’s health information freely, as he willingly brought the neighbor and
sister along
Interactions between the physician and patient involve the patient’s family and friends, as well as others
who may be part of the patient’s social support system. These interactions, as well as the physician-patient
relationship itself, are also strongly influenced by ethnic, cultural, and spiritual values and by beliefs about
illness and approaches to treatment and ongoing care. Involvement of family members in a patient’s care
is advantageous to good communication and helpful for both accurate diagnosis and appropriate treatment
(SOR C).
Patient confidentiality should be protected, and the mere presence of other people accompanying the patient
does not automatically constitute permission to discuss private health information with them. The physician
should determine not only who is present with a patient, but also each person’s reason for being present
(SOR C). Speaking to relatives or friends without the patient present may be appropriate under certain
circumstances but would not be the best option in this scenario. Constructing a genogram can also be
helpful, but that would not be the first priority in this case.
Radiographs confirm the clinical diagnosis of small-bowel obstruction in most patients and more accurately
define the site of obstruction. Small-bowel obstruction typically occupies the more central portions of the
abdomen. Patients with mechanical small-bowel obstruction usually have minimal or no colonic gas. Films
taken in the upright or lateral decubitus position in patients with small-bowel obstruction usually show
multiple gas-filled levels, with the distended bowel resembling an inverted U.
Patients with small-bowel obstruction are likely to be depleted of fluids and electrolytes, and will require
intravenous fluids, electrolyte management, and surgical evaluation.
An 80-year-old male presents with a 4-hour history of generalized abdominal pain, vomiting,
and fever to 101°F. On examination you note normal cardiovascular findings, generalized
moderate abdominal tenderness, absent bowel sounds, and a normal rectal examination.
Figure 1 shows a diagnostic abdominal film, which suggests
A) a leaking abdominal aortic aneurysm
B) toxic megacolon
C) small bowel obstruction
D) diverticulitis
E) a perforated viscus
The salient feature of atrial fibrillation is the absence of P waves, along with normal QRS complexes that
are irregular in time (irregularly irregular) and sometimes vary in amplitude. Sinus tachycardia,
paroxysmal tachycardia, multifocal atrial tachycardia, and atrial flutter are all associated with P waves that
are constantly related to QRS complexes, although they may sometimes be abnormal and difficult to
The EKG shown in Figure 2 reveals
A) sinus tachycardia
B) paroxysmal atrial tachycardia
C) multifocal atrial tachycardia
D) atrial fibrillation
E) atrial flutter
Scleritis is an inflammatory disorder affecting the sclera, often associated with a connective tissue disorder
such as rheumatoid arthritis, systemic lupus erythematosus, Wegener’s granulomatosis, polyarteritis
nodosa, or relapsing polychondritis. In the anterior form of scleritis, inflammation results in local or
diffuse erythema and thickening of the sclera. Patients present with either diffuse or focal ocular erythema,
tenderness, and pain. When the inflammation is focal, a tender nodule may be present. The initial
treatment of scleritis is an oral NSAID to help reduce ocular inflammation. Topical or systemic
corticosteroids may be used when NSAIDs fail or are contraindicated (SOR B).
A 37-year-old previously healthy male presents with a 1-week history of a painful swollen area
on his left eye, associated with redness (see Figure 3). He complains of dull aching in the eye
that radiates to his ipsilateral temple. He denies any ocular discharge or vision changes. His
visual acuity is normal.
Which one of the following is the most appropriate first step in managing this patient’s
A) A topical mydriatic agent
B) A topical cycloplegic agent
C) A topical antibiotic
D) An oral NSAID
E) An oral antibiotic
The condition shown is representative of a simple anterior dislocation of the lunate. The semilunar shape
of the lunate bone is displaced anterior to the distal radial articular surface. Occasionally, a transnavicular
fracture may occur along with this injury and is termed a trans-scaphoid perilunate fracture-dislocation.
There is no evidence in the radiograph shown, however, of dislocations of the other areas mentioned.
The most likely diagnosis of the condition shown in the radiographs in Figure 4 is
A) dislocation of the trapezium
B) dislocation of the scaphoid
C) dislocation of the lunate
D) fracture of the distal radius
E) fracture of the distal ulna
The findings in this patient are consistent with a lung abscess caused by anaerobic organisms, which is
usually related to aspiration. Most patients have a history of compromised consciousness, such as a seizure
disorder or drug and alcohol abuse, and many have dental or gingival disease.
Routine bacteriologic studies of expectorated sputum are hampered by mouth contamination, but are useful
for detecting mycobacteria and other potential etiologic agents. An open lung biopsy, immediate
bronchoscopy, and transtracheal aspiration are useful when the patient has not responded to initial therapy.
Since this is a typical clinical picture for anaerobic lung abscess, the treatment of choice would be large
doses of intravenous clindamycin.
A 28-year-old white male alcoholic presents with a 4-week history of fever, malaise, cough,
sputum production, and weight loss. Twelve hours ago his cough increased and he noted frank
blood in his sputum, along with a foul taste. Sputum is obtained for routine culture. A chest
radiograph is shown in Figure 5.
Which one of the following diagnostic procedures should be performed prior to the initiation of
A) A culture of expectorated sputum
B) An open lung biopsy
C) Immediate bronchoscopy
D) Transtracheal aspiration
Right ventricular infarction is most frequently an extension of an inferior myocardial infarction (MI).
Right-sided precordial leads may need to be evaluated to document this on the EKG. Hypotension during
the acute event, especially after nitrate administration, is characteristic. Frequently, 1-2 liters of normal
saline must be administered.
Acute pericarditis most frequently develops 2-4 days after the infarction. Free wall rupture, septal rupture,
and papillary muscle rupture typically do not occur until 1-5 days after the acute MI. Septal rupture is
more common with anterior MI.
A 58-year-old African-American male presents to the emergency department with a 6-hour
history of substernal pain. He has a previous history of hypertension. His blood pressure drops
to 60 mm Hg systolic after three sublingual nitroglycerin tablets. His EKG is shown in Figure
In addition to nitrate side effects, which one of the following should be the first diagnostic
A) Right ventricular infarction
B) Pericarditis with tamponade
C) Papillary muscle rupture
D) Ventricular free wall rupture
E) Ventricular septal rupture
Eczema craquelé, a common complication of aging, is due to dryness of the skin. It is best treated with
wet compresses and antibiotics to remove crusts and suppress infection, followed by topical corticosteroids
and lubricants. The primary lesions do not suggest scabies or necrobiosis lipoidica, and neurodermatitis
and lichen sclerosis are secondary responses to itching.
During a follow-up visit for a 72-year-old white female with type 2 diabetes mellitus, her
daughter asks you to treat the lesions shown in Figure 7. These lesions bother the patient and
she complains of itching, especially at night.
The most likely diagnosis is
A) chronic, reactive scabies infestation
B) eczema craquelé (xerotic eczema)
C) neurodermatitis
D) necrobiosis lipoidica
E) lichen sclerosus
A 35-year-old female immigrant from a rural village in Southeast Asia visits your clinic shortly
after arriving in the United States. She presents with a 1-week history of low-grade fever and
a nonproductive cough, and has crackles but no signs of consolidation or pleural effusion on
examination. You order a chest radiograph and see several oval infiltrates, 1-2 cm in size.
Which one of the following is the most likely cause of these symptoms?
A) Ascaris lumbricoides
B) Enterobius vermicularis (pinworm)
C) Taenia saginata
D) Taenia solium
E) Diphyllobothrium latum

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