2019 Ite
2019 Ite
2019 Ite
an urgent care facility. She is feeling a little better after a short course of oral prednisone and use of an
albuterol (Proventil, Ventolin) inhaler. She has had a gradual increase in shortness of breath, a chronic
cough, and a decrease in her usual activity level over the past year. She has brought a copy of a recent
chest radiograph report for your review that describes panlobular basal emphysema. She does not
have a history of smoking, secondhand smoke exposure, or occupational exposures. Spirometry in the
office reveals an FEV1/FVC ratio of 0.67 with no change after bronchodilator administration. Which one
of the following underlying conditions is the most likely cause for this clinical presentation?
A) α1-Antitrypsin deficiency
B) Bronchiectasis
C) Diffuse panbronchiolitis
This patient presents with symptoms of chronic obstructive lung disease, and spirometry confirms airflow
limitation or obstruction with an FEV1/FVC <0.7. Her age, the lack of tobacco smoke or occupational
exposures, and the chest radiograph findings are typical of 1-antitrypsin deficiency. While left heart failure,
interstitial lung disease, bronchiectasis, and diffuse panbronchiolitis are all causes of chronic cough, they are
not necessarily associated with the development of COPD and these spirometry findings. Furthermore, the
radiologic findings in this patient are not consistent with these conditions.
Left heart failure would present with pulmonary edema on a chest radiograph and volume restriction
Bronchiectasis would present with bronchial dilation and bronchial wall thickening on a chest
radiograph.
Interstitial lung disease would present with reticular or increased interstitial markings.
Diffuse panbronchiolitis would present with diffuse small centrilobular nodular opacities along with
hyperinflation.
An otherwise healthy 57-year-old male presents with mild fatigue, decreased libido, and erectile
B) A prolactin level
E) Karyotyping
In men who are diagnosed with hypogonadism with symptoms of testosterone deficiency and unequivocally
and consistently low serum testosterone concentrations, further evaluation with FSH and LH levels is advised
If secondary hypogonadism is indicated by low or inappropriately normal FSH and LH levels, prolactin
and serum iron levels and measurement of total iron binding capacity are recommended to
determine secondary causes of hypogonadism, with possible further evaluation to include other
months. Her mother reports that the child has 1–2 bowel movements per week composed of small
lumps of hard stool. She strains to have the bowel movements, and they are painful. The child eats
B) Lactulose
E) Senna
This patient presents with symptoms compatible with functional constipation. Daily use of polyethylene glycol
(PEG) solution has been found to be more effective than lactulose, senna, or magnesium hydroxide in head-to-
head studies.
Evidence does not support the use of fiber supplements in the treatment of functional constipation.
No adverse effects were reported with PEG therapy at any dosing regimen. Low-dose regimens of PEG are 0.3
A 30-year-old female presents with a 5-day history of subjective fever and malaise. She does not have a
thermometer at home but has felt alternately warm and chilled. She has felt generally unwell and is
sleeping more than usual. She has had a decreased appetite but has been drinking fluids without
difficulty. She does not have a runny nose, cough, headache, abdominal pain, vomiting, diarrhea, joint
pain, rash, or pain with urination. Her medical history includes substance use disorder and she takes
buprenorphine/naloxone (Suboxone). She smokes one pack of cigarettes daily, has 0–2 alcoholic drinks
An examination reveals a blood pressure of 112/68 mm Hg, a pulse rate of 88 beats/min, a respiratory
rate of 16/min, a temperature of 38.9°C (102.0°F), and an oxygen saturation of 95% on room air. The
patient appears fatigued and uncomfortable but nontoxic. Her heart has a regular rate and rhythm
with no murmur. Her lungs are clear to auscultation bilaterally and her abdomen is soft and
nontender. There is no swelling or redness in the extremities and a skin examination reveals no rashes
or lesions.
A) A viral swab
C) Blood cultures
E) A chest radiograph
A patient who uses intravenous drugs and has a fever without a clear source must be evaluated for infectious
endocarditis (IE).
1.The first step in this evaluation is to obtain blood cultures. Although this patient might have a less
2.If the concern for IE is high, blood cultures should be obtained and antibiotics may be started while
IE in people who inject drugs is more likely to be right-sided, specifically involving the tricuspid valve. Right-
sided IE is less frequently associated with systemic findings of endocarditis such as Janeway lesions or Roth
During a newborn examination you note a foot deformity, with the front half of the foot turned
inward. Applying gentle pressure to the forefoot while holding the heel steady brings the heel and
A) Observation only
B) Adjustable shoes
C) Serial casting
D) Surgical correction
This patient has flexible metatarsus adductus, the most common congenital foot deformity. Flexible
metatarsus adductus usually resolves spontaneously by 1 year of age and does not require treatment.
Rigid metatarsus adductus should be treated with serial casting. Using adjustable shoes is an
alternative that is less expensive than serial casting for motivated parents with children who are
Surgical correction should be reserved for older children who are already walking or for those
A 35-year-old female comes to your office for evaluation of a tremor. During the interview you note
jerking movements first in one hand and then the other, but when the patient is distracted the
symptom resolves. Aside from the intermittent tremor the neurologic examination is unremarkable.
A) Parkinson’s disease
B) Cerebellar tremor
C) Essential tremor
D) Physiologic tremor
E) Psychogenic tremor
1.Abrupt onset,
2.Spontaneous remission,
testing will reveal past-pointing on finger-to-nose testing. CT or MRI of the head is the diagnostic test of choice.
Parkinsonian tremor is noted at rest, is asymmetric, and decreases with voluntary movement. Bradykinesia,
rigidity, and postural instability are generally noted. For atypical presentations a single-photon emission CT or
positron emission tomography may help with the diagnosis. One of the treatment options is
carbidopa/levodopa.
Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head,
voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no specific
Enhanced physiologic tremor is a postural tremor of low amplitude exacerbated by medication. There is
A patient with moderately severe Alzheimer’s disease has been taking quetiapine (Seroquel), 50 mg
daily at bedtime, to manage behavioral symptoms related to the dementia. The patient’s symptoms
have been stable on the quetiapine for 6 months. The patient’s spouse is the primary caregiver and is
not aware of any adverse effects. The patient does not have a history of other psychiatric diagnoses
Which one of the following would be the most appropriate intervention at this time?
D) Start diphenhydramine (Benadryl) while tapering quetiapine with the goal of stopping it
E) Start lorazepam (Ativan) while tapering quetiapine with the goal of stopping it
Behavioral and psychological symptoms of dementia include delusions, hallucinations, aggression, and
agitation. Antipsychotics are frequently used for treatment of these symptoms and are continued indefinitely.
For patients who have been taking antipsychotics for >3 months and whose symptoms have stabilized, or for
patients who have not responded to an adequate trial of an antipsychotic, it is recommended that the drug be
Physicians should collaborate with the patient and caregivers when deciding whether to use an antipsychotic.
This is recommended because antipsychotic medications have adverse effects, including an increased overall
risk of death, cerebrovascular events, extrapyramidal symptoms, gait disturbances, falls, somnolence, edema,
urinary tract infections, weight gain, and diabetes mellitus. The risk of these harms increases with prolonged
One tapering method to consider is to reduce the daily dose to 75%, 50%, and 25% of the original dose every 2
weeks until stopping the medication. This reduction pace can be slowed for some patients.
Diphenhydramine and lorazepam are on the Beers list of potentially inappropriate medications to
A healthy 35-year-old female presents to your office to discuss an upcoming trip to Bangladesh. She
currently feels well and has no health problems. She is a nurse and will be traveling with a church
group to work in a clinic for 1 month. This area is known to have a high prevalence of tuberculosis (TB).
She is worried about contracting TB while she is there and asks for recommendations regarding TB
screening. She had a negative TB skin test about 1 year ago at work. A TB skin test today is negative.
Assuming she remains asymptomatic, which one of the following would you recommend?
A) Prophylactic treatment with isoniazid starting 1 month prior to departure and continuing throughout her
trip
B) Prophylactic treatment with rifampin (Rifadin) starting 1 month prior to departure and continuing
contracting the disease if they have prolonged exposure to individuals with TB, such as working in a health
care setting. The CDC recommends either a TB skin test or an interferon-gamma release assay prior to leaving
the United States. If the test is negative, the individual should repeat the testing 8–10 weeks after returning.
recommended.
A nulliparous 34-year-old female comes to your office for evaluation of fatigue, hair loss, and anterior
neck pain. These symptoms have been gradually worsening for the past few months. Her past medical
history is unremarkable. She has gained 5 kg (11 lb) since her last office visit 18 months ago.
Examination of the thyroid gland reveals tenderness but no discrete nodules. Her TSH level is 7.5 U/mL
(N 0.4–4.2), her T4 level is low, and her thyroid peroxidase antibodies are elevated.
Which one of the following would be the most appropriate next step?
B) Begin thyroid hormone replacement and repeat the TSH level in 6–8 weeks
C) Begin thyroid hormone replacement and repeat the TSH level along with a T3 level in 6–8 weeks
This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most
appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8
weeks later.
There is no need to routinely order thyroid ultrasonography when there are no palpable nodules on
a thyroid examination.
Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient presents
A 35-year-old male presents with depression that started when his wife asked him for a divorce last
month. A depression screen is positive and he has some passive suicidal ideation. He does not have
any prior history of suicide attempts or a specific plan. He does not have any health issues, a family
You would be most concerned that the patient will die from suicide if he
Easy access to a lethal means of suicide is a major risk factor for a successful suicide attempt. It is important to
eliminate access to firearms, drugs, or toxins for a patient with any suicidal ideation. Other risk factors include,
but are not limited to, a family history of suicide, previous suicide attempts, a history of mental disorders, a
history of alcohol or substance abuse, and physical illness. Another risk factor in this patient is loss of a
personal relationship. A history of borderline personality disorder (associated with cutting) is not a risk for
successful suicide. Any support from family or friends is helpful, even if it is limited.
A 49-year-old African American male sees you for a routine health maintenance examination. His past
medical history is significant for sarcoidosis. He has noticed some fatigue and shortness of breath over
the last several months, but he is asymptomatic today. His vital signs are normal except for an
A) Observation only
B) Amiodarone (Cordarone)
C) Apixaban (Eliquis)
This patient’s EKG shows type II second degree (Mobitz type II) atrioventricular (AV) block. Conduction
disturbances are one of the most common manifestations of cardiac sarcoidosis. In addition to AV block,
supraventricular and ventricular arrhythmias can be seen. Mobitz type II AV block is treated with pacemaker
placement.
Apixaban for anticoagulation in patients with atrial fibrillation or atrial flutter, and
A 70-year-old male presents to your office for follow-up after he was hospitalized for acute coronary
syndrome. He has not experienced any pain since discharge and is currently in a supervised cardiac
rehabilitation exercise program. His medications include aspirin, lisinopril (Prinivil, Zestril), and
metoprolol, but he was unable to tolerate atorvastatin (Lipitor), 40 mg daily, because he developed
muscle aches.
Which one of the following would you recommend?
A) Evolocumab (Repatha)
B) Ezetimibe/simvastatin (Vytorin)
C) Fenofibrate (Tricor)
D) Niacin
High-intensity statin therapy is recommended for patients younger than 75 years of age with known coronary
artery disease. For those who are intolerant of high-intensity statins, a trial of a moderate-intensity statin is
appropriate. There is evidence to support ezetimibe plus a statin in patients with acute coronary syndrome or
Omega-3 fatty acids, fibrates, and niacin should not be prescribed for primary or secondary
outcomes.
PCSK9 inhibitors such as evolocumab are injectable monoclonal antibodies that lower LDL-
cholesterol levels significantly and have produced some promising results, but more studies are
A 50-year-old male presents with difficulty straightening his left ring finger. Examination of the
affected hand reveals a nodule of the palmar aponeurosis and associated fibrous band that limits full
extension of the fourth finger. He is unable to fully extend both the metacarpophalangeal (MCP) joint
and the proximal interphalangeal (PIP) joint, with MCP and PIP contractures estimated at 40° and 20°,
respectively.
Which one of the following would be the most appropriate management strategy?
This patient has Dupuytren’s disease with a contracture of the affected finger. Surgical release is indicated
when the MCP joint contracture reaches 30° or with any degree of contracture of the PIP joint.
Intralesional injection may reduce the need for later surgery in a patient with grade 1 disease, but
A 44-year-old female presents for a pretravel consultation and asks about medication options for
traveler’s diarrhea. She will be on an organized tour traveling to a country with a very low risk for this
problem. She plans to take all precautions to further reduce her risk but would also like you to
B) Loperamide (Imodium) daily, starting 1 day prior to travel and continued until 1 day after returning home
C) Probiotics daily, starting 1 week prior to travel and continued until 1 week after returning home
D) Ciprofloxacin (Cipro) daily, starting 2 weeks prior to travel and continued until 4 weeks after returning home
E) Bismuth subsalicylate daily, starting 2 weeks prior to travel and continued until 4 weeks after returning
home
Traveler’s diarrhea is the most common infection in international travelers. A short course of antibiotics can be
taken after a traveler develops diarrhea and usually shortens the duration of symptoms (SOR A). Azithromycin
For patients at high risk, bismuth subsalicylate reduces the risk but does not need to be initiated
prior to travel.
There is insufficient evidence for the use of probiotics to prevent traveler’s diarrhea.
Loperamide can be used with or without antibiotics after symptoms develop but is not
A 69-year-old female presents to your office with a 5-day history of cough and low-grade fever. She has
a past history of hypertension and obstructive sleep apnea. Her daughter brought her in this morning
because of worsening symptoms. The patient’s temperature is 37.4°C (99.3°F), her blood pressure is
110/74 mm Hg, her pulse rate is 88 beats/min, her respiratory rate is 36/min, and her oxygen
saturation is 95% on room air. She is alert and oriented to person, place, and time. A CBC and basic
metabolic panel are normal except for an elevated WBC count of 12,500/mm3 (N 4300–10,800). A chest
This patient has a higher risk of mortality and should be considered for inpatient treatment due to her
A) female sex
B) underlying hypertension
C) respiratory rate
CURB-65
Confusion (1pt)
BP <80/60 mmHg
Age >65
There are several decision support tools to assist in predicting 30-day mortality for patients with community-
acquired pneumonia. Calculating the number of high-risk markers can aid in deciding whether to admit the
patient to the hospital. The risk of mortality increases with a respiratory rate >30/min, hypotension, confusion
or disorientation, a BUN level >20 mg/dL, age >65 years, male sex, or the presence of heart failure or COPD.
A 78-year-old male is brought to your office by his daughter. She is concerned that her father is no
longer attending his weekly cribbage and bingo games, has stopped bathing regularly, and is eating
much less.
C) A trial of megestrol
This elderly patient is exhibiting classic signs of depression. The PHQ-2 has a similar sensitivity to the PHQ-9,
but the PHQ-9 has a higher specificity in diagnosing depression (91%–94% compared to 78%–92%) and can
assist in diagnosing depression. In addition to the PHQ-2 and PHQ-9 there are specific screening tools for use
in the elderly population, including the Geriatric Depression Scale and the Cornell Scale for Depression in
Dementia. Somatic issues and dementia can make it more difficult to screen for and diagnose depression in
this population.
2.Megestrol is used to stimulate the appetite, but in this patient the appetite symptoms are likely
secondary to depression so treating the depression would be a more appropriate starting point.
3.The tricyclic nortriptyline is used to treat depression but is not first-line therapy, especially in the
elderly.
4.In general, a more extensive medical history and a physical examination are indicated before
prevention of falls in community-dwelling adults >65 years of age who are at increased risk for falls?
The U.S. Preventive Services Task Force (USPSTF) recommends exercise interventions to prevent falls in
community-dwelling adults >65 years of age who are at increased risk for falls (B recommendation). This
recommendation is based on several studies that demonstrated improved fall-related outcomes for
individuals from this population who participated in exercise programs. Strength and resistance exercises
were specifically identified as beneficial. The evidence exists to support group-based exercises is less
convincing.
It is also recommended that clinicians selectively offer multifactorial interventions to prevent falls in this
population, based on the possible small benefit and minimal risk (C recommendation). The USPSTF
recommends against vitamin D supplementation to prevent falls in community-dwelling adults >65 years of
age with the caveat that this applies only to those who are not known to have osteoporosis or vitamin D
deficiency (D recommendation).
A 30-year-old gravida 1 para 0 develops erythematous patches with slightly elevated scaly borders
during her first trimester. There was a 2-cm herald patch 2 weeks before multiple smaller patches
appeared. The rash on the back has a “Christmas tree” pattern. She has not had any prenatal
laboratory work.
B) a small-for-gestational-age newborn
C) congenital cataracts
D) multiple birth defects
E) spontaneous abortion
This patient has classic pityriasis rosea. This is generally a benign disease except in pregnancy. The
epidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible to
Pityriasis rosea is associated with an increased rate of spontaneous abortion in the first 15 weeks of gestation.
A 57-year-old male with diabetes mellitus and hypertension presents with a 1-month history of pain in
his hands and elbows. His hands are shown below. On examination they are tender and he has soft
swelling of the wrists, metacarpophalangeal (MCP) joints, and proximal interphalangeal (PIP) joints.
Plain films show mild, diffuse bony erosions in the MCP and PIP joints.
A) Dermatomyositis
B) Osteoarthritis
C) Psoriatic arthritis
D) Rheumatoid arthritis
rheumatoid arthritis:
1.Symmetric
2.Small-joint
3.Inflammatory
All are typical of rheumatoid arthritis and systemic lupus erythematosus (SLE), but bony erosions are
Psoriatic arthritis can also affect small joints but is typically not symmetric.
Dermatomyositis can present with a thick, bright red rash over the metacarpophalangeal (MCP) and
interphalangeal joints (Gottron’s sign) but is typically associated with proximal muscle weakness
Osteoarthritis does not typically cause the soft-tissue swelling seen in the image. It usually affects the
distal and proximal interphalangeal joints while sparing the MCP joints, and it results in
A 77-year-old Spanish-speaking female with end-stage heart failure has elected hospice care to be
provided at home for the duration of her life. A trained interpreter is available for assistance when you
Which one of the following is considered a best practice when using interpreters?
B) Seating the interpreter closest to the clinician, slightly in front of the patient, to observe body language
when translating
C) Asking the interpreter to serve as a witness for a consent form for hospice
D) Explaining to the interpreter the entire care plan, then having him or her repeat it back to the patient
E) Explaining in full detail all possible scenarios for symptom management and what to expect
When professional interpreters participate in patient care it is important to speak directly in the first person,
using “I” statements rather than statements that start with “tell her” (SOR C). It is ideal to seat the interpreter
next to or slightly behind the patient, so that the patient is the focus of the interaction. Sentence-by-sentence
interpretation can prevent miscommunication errors, as opposed to expecting the interpreter to remember
every detail of a complex care plan. It is not appropriate for the medical interpreter to also serve as a witness
to consent. Focusing on three or fewer key points rather than over-communicating multiple complex issues
increases the likelihood that the patient will comprehend the plan of care.
Which one of the following treatments has been shown to improve the quality of life for a patient
with tinnitus?
A) Antidepressant therapy
B) Ginkgo biloba
C) Niacin
D) Vitamin B12
E) Cognitive-behavioral therapy
Treatments to reduce awareness of tinnitus and tinnitus-related distress include cognitive-behavioral therapy,
No medications, supplements, or herbal remedies have been shown to substantially reduce the severity of
tinnitus.
A 28-year-old female who was recently diagnosed with polycystic ovary syndrome presents to discuss
treatment of irregular menses. She has 2–3 menstrual periods every 6 months that happen at irregular
times and can often produce heavy bleeding. She is not obese and has no significant acne or hirsutism.
She does not desire pregnancy and her primary goal is to decrease the heavy menstrual bleeding.
Which one of the following would be the most effective initial recommendation?
C) Metformin (Glucophage)
D) Spironolactone (Aldactone)
Polycystic ovary syndrome can significantly affect multiple organ systems, and menstrual irregularities from
anovulatory cycles are very common. Treatment should be based on the patient’s goals and modified based
In a patient who is not interested in near-term fertility and whose goal is to control menstrual
irregularities, a levonorgestrel IUD is most likely to reduce the frequency, duration, and volume of
bleeding.
Metformin is used to treat insulin resistance, dietary modifications are used to treat obesity,
A 6-month-old male is brought to the urgent care center with a 3-day history of rhinorrhea, cough, and
increased respiratory effort. His temperature is 37.5°C (99.5°F), his heart rate is 120 beats/min, his
respiratory rate is 42/min, and his oxygen saturation is 96% on room air. On examination the child
appears well hydrated with clear secretions from his nasal passages, there is diffuse wheezing heard
bilaterally, and there is no nasal flaring or retractions. The mother states that the child has a
Which one of the following would be the most appropriate management for this patient?
B) Bronchodilators
C) A corticosteroid taper
D) Epinephrine
E) Nebulized hypertonic saline
This patient’s symptoms and the examination suggest viral bronchiolitis. Supportive therapy, including
adequate hydration, is recommended for treatment. Treatment with bronchodilators, epinephrine, hypertonic
In asymptomatic patients with sarcoidosis, which one of the following organ systems should be
A) Cardiac
B) Neurologic
C) Ocular
D) Integumentary
Sarcoidosis has numerous extrapulmonary manifestations. Because inflammation of the eye can result
in permanent impairment and is often asymptomatic, patients require yearly eye examinations as well as
Although skin involvement is common it is usually readily apparent and rarely has serious sequelae.
Cardiac sarcoidosis can potentially lead to progressive heart failure and sudden death, but evaluation
Similarly, evaluation for neurologic involvement is needed only in patients who are symptomatic.
In addition to a thorough history and physical examination, the routine evaluation of patients
Orthostatic blood pressure measurement and an EKG are indicated in the routine evaluation of patients with
syncope. All other testing should be directed by findings obtained in the history and on the physical
examination.
A 67-year-old male presents for a Medicare wellness visit. He underwent basic laboratory work prior to
the office visit. He is feeling well and does not have any concerns or symptoms. His blood pressure is
127/76 mm Hg, his heart rate is 64 beats/min, and he is afebrile. A comprehensive metabolic panel is
Which one of the following would be the most appropriate next step in the workup of this patient?
D) Referral to a gastroenterologist
Anemia is often diagnosed incidentally on laboratory testing and is often asymptomatic. It is associated with
increased morbidity and mortality in older adults, and is often caused by nutritional deficiencies, chronic
kidney disease, occult blood loss from gastrointestinal malignancies, or chronic inflammation. However, in
many patients the cause remains unknown. A detailed history and physical examination are indicated. In
patients with normocytic or microcytic anemia, a serum ferritin level should be ordered. A low serum ferritin
level is associated with iron deficiency and should be further evaluated so the underlying cause can be
addressed.
A serum transferrin-receptor–ferritin index should be determined for patients with a serum ferritin
level between 46 and 100 ng/mL to distinguish between iron deficiency anemia and other types of
anemia.
A 57-year-old male presents with left posterior heel pain that started several weeks ago. An
examination reveals a nodular appearance at the site of insertion of the Achilles tendon to the
Which one of the following would be the safest and most appropriate initial management?
This patient has typical symptoms and findings of Achilles tendinopathy. The best management involves
A local injection with corticosteroids or with platelet-rich plasma is ineffective and may increase the
Immobilization and surgical debridement may be considered if more conservative therapies have
failed.
A 35-year-old gravida 2 para 2 reports diminished sexual arousal since initiating antidepressant
therapy with sertraline (Zoloft). She has normal menstrual cycles and does not have any other
symptoms.
Black cohosh is considered a safe alternative for treating menopausal vasomotor symptoms, but not
Ethinyl estradiol may be taken to improve sexual dysfunction related to menopausal symptoms.
Vaginal estrogen therapy is recommended over oral estrogen when vaginal dryness is the primary
symptom.
Ospemifene is indicated for dyspareunia related to vulvar and vaginal atrophy due to menopause.
Testosterone has proven to be effective for treating menopause-related low sexual desire but the
evidence is limited due to the lack of long-term data. The Endocrine Society recommends
A 67-year-old male presents to your office for evaluation of chronic redness, flaking, and discomfort of
his eyelids. Additionally, his eyes feel irritated, dry, and sandpapery at times. He has had difficulties
with these symptoms on and off throughout his life but they have worsened lately. He has not had any
On examination his eyelids appear red and mildly swollen with yellow crusting at the bases of the
eyelashes. You note bilateral mild conjunctival injection. Visual acuity is intact, as are pupil reactions
Which one of the following treatments is appropriate first-line therapy for this condition?
This patient has blepharitis, a chronic inflammation of the eyelids. Seborrhea is a common cause in older
adults. In younger patients including children, colonization with Staphylococcus may be a contributing factor.
Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of tear films,
which leads to dry eyes and irritation. Other diagnoses to consider in this patient include conjunctivitis,
Conjunctivitis typically involves the conjunctiva and an eye discharge but less involvement of the
eyelids is present.
Cellulitis is an acute rather than chronic condition and involves more pain and swelling.
Sjögren’s syndrome causes dry eye but not inflammatory changes of the lid.
The initial treatment of blepharitis consists of lid hygiene using warm compresses to remove dried secretions
and debris. Mild shampoo can help in this process and aid in keeping the bacterial colonization load down. In
severe or recalcitrant cases a topical antibiotic ointment may be applied to the lids. Oral antibiotics can be
A patient with a BMI of 32 kg/m2 has type 2 diabetes that is currently controlled by lifestyle
interventions, including moderate-intensity physical activity and healthy low-calorie meals. The
According to the American Diabetes Association, which one of the following would be the most
appropriate advice?
Nonnutritive sweeteners contain few or no calories. According to the American Diabetes Association,
nonnutritive sweeteners may be acceptable to use instead of nutritive sweeteners such as sucrose. They
The use of nonnutritive sweeteners can help to reduce overall intake of carbohydrates and calories. They do
not significantly affect glycemic control. Research is inconsistent regarding the effects of nonnutritive
sweeteners on weight loss, but most systematic reviews and meta-analyses demonstrate a benefit.
There is no recommendation to avoid sucralose or aspartame in patients with type 2 diabetes. Beverages
sweetened with sugar are associated with an increased risk of type 2 diabetes.
A 32-year-old female presents with a 4-month history of nasal drainage, congestion, and loss of her
sense of smell. She reports having a cold about 4 months ago that never resolved. On examination the
nasal turbinates are swollen and you note mucopurulent drainage on the right.
Which one of the following is the most likely cause of her symptoms?
A) Chronic rhinosinusitis
C) Nasal polyposis
D) Sarcoidosis
The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of two of four
1.nasal drainage,
2.nasal obstruction,
examination.
Granulomatosis with polyangiitis and sarcoidosis can both present similarly but are uncommon
Allergic rhinitis can be associated with chronic rhinosinusitis but would also present with allergic
symptoms.
A 52-year-old female with metastatic breast cancer is hospitalized for treatment of complications from
her cancer treatment. She has developed a new onset of back pain that has been progressively
worsening over the past few hours. The pain is worse when she is lying down and is not responsive to
pain medication.
Which one of the following would be the most appropriate next step to address this patient’s back
pain?
C) Order cyclobenzaprine
Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm
the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset
progressive back pain that is worse when the patient is lying down. It is most commonly associated with breast
cancer and develops in approximately 5% of all patients with cancer. Once the diagnosis is confirmed, an
Corticosteroids and neurosurgical intervention can preserve motor and sensory function.
daughter has asked to complete an advance directive giving her medical power of attorney.
Which one of the following would indicate that the patient lacks capacity to make decisions with
A) A dementing illness
D) Asking that her son make medical decisions for her instead of her daughter
In order for patients to show they have the capacity to make a decision they must demonstrate an
understanding of the situation, including the risks, benefits, and consequences of the decision or refusal of
care. If a patient gives inconsistent answers to questions after multiple explanations, this indicates that there
is a lack of understanding and would meet one of the criteria to determine that the patient lacks the capacity
The presence of dementia can be associated with an increased incidence of having a lack of capacity;
however, a diagnosis of dementia by itself does not indicate that the patient lacks the capacity to
make a decision.
While disorientation to time or a lower score on the Mini-Mental State Examination is associated with
an increased risk of lacking capacity, these findings alone would not be enough to determine that
The patient asking that her son be her medical decision maker instead of her daughter would not be
A 72-year-old male with a past history of hypertension, COPD, and pulmonary embolism presents with
nonspecific symptoms including fatigue and syncope. You suspect he has pulmonary hypertension.
Which one of the following would be the most appropriate initial test?
C) Echocardiography
According to national guidelines echocardiography is the preferred initial noninvasive testing modality when
Pulmonary function tests provide helpful information in regard to pulmonary capacity but are not
CT of the chest with contrast will not provide pulmonary pressures but may assist in the detection of
pulmonary emboli.
A coronary calcium scan may be indicated to evaluate for coronary artery disease but it is not a
Although right heart catheterization would provide pulmonary pressure values it is considered more
invasive than echocardiography and is not always necessary for making the diagnosis.
A 19-year-old female member of a college cross-country team presents with a 1-week history of right
knee pain. She does not have any acute injury to the knee. An examination reveals no deformity and
she has a normal gait. She has tenderness and subtle swelling localized 1 cm distal to the right medial
joint line, and examinations of the knee and hip are otherwise normal.
Iliotibial band syndrome is often related to overuse but causes pain in the lateral knee.
Osgood-Schlatter disease is also often related to overuse but causes pain at the insertion of the
A medial meniscal tear would localize to the medial joint line rather than distal to the joint line and
would more likely be associated with positive findings from other examinations, such as a
McMurray test.
A 52-year-old female sees you because of a vaginal discharge. An examination reveals a malodorous,
A) Atrophic vaginitis
B) Irritant/allergic vaginitis
C) Bacterial vaginosis
D) Trichomoniasis
E) Vulvovaginal candidiasis
Trichomoniasis classically presents as a greenish-yellow, frothy discharge with a foul odor. Erythema and
inflammation of the vagina and cervix are often present and can include punctate hemorrhages (strawberry
cervix).
Atrophic vaginitis may cause a thin, clear discharge and is usually associated with a thin, friable
vaginal mucosa.
Irritant/allergic vaginitis causes burning and soreness with vulvar erythema but usually does not
Bacterial vaginosis more commonly presents as a thin, homogenous discharge with a fishy odor and
The father of a healthy 14-year-old male calls you about a recent mumps outbreak in your community.
The child never received the MMR vaccine because the parents declined the immunization despite
D) Koplik spots or whitish papules in the mouth are pathognomonic for mumps
E) the MMR vaccine is not recommended for patients in this age range
1.myalgia,
2.fatigue,
3.loss of appetite,
4.fever, and
5.headache.
Measles is characterized by
1.cough,
2.coryza,
3.conjunctivitis, and
4.Koplik spots.
A 42-year-old female with diabetes mellitus comes to your office because of recurrent yeast infections.
Which one of the following classes of antidiabetic agents is associated with an increased risk for
candidiasis?
SGLT2 inhibitors are known to cause an increased risk of yeast vaginitis because their mechanism of action
involves blocking renal uptake of glucose, which results in an increase in glucosuria (SOR A).
A gravida 2 para 0 at 34 weeks gestation presents to your office because of diffuse itching. She does not have
any known allergies other than seasonal allergies, and she does not have any new contacts. An examination is
normal other than some scattered excoriations, and there is no other distinct rash. She has tried moisturizers
C) Topical corticosteroids
D) Oral antihistamines
Whenever a pregnant woman presents with pruritus without a primary rash, it is important to evaluate her
for intrahepatic cholestasis of pregnancy. This diagnosis is associated with increased fetal mortality and
warrants increased antenatal surveillance as well as possible induction by 35–37 weeks gestation. It is most
appropriate to check for elevation of liver function tests and serum bile acids.
Emollients, topical corticosteroids, and oral antihistamines can all be helpful for pruritus and certain
rashes, but in this patient it is most important to promptly look for the cause of the pruritus.
Varicella-zoster immune globulin would be indicated if she had no immunity to varicella and had
been exposed to varicella or if she had a rash that was suspected to be chickenpox.
When titrating the dosage of opioids, the CDC recommends that you should also consider prescribing
naloxone when the opioid dosage reaches what morphine milligram equivalent (MME) per day
threshold?
A) 30
B) 50
C) 80
D) 90
E) 100
To mitigate the risk of opioid harm, it is essential to understand morphine milligram equivalents (MME). The
evidence shows that the risk of an opioid overdose increases at the threshold of 50 MME/day. It is therefore
recommended by the CDC that a prescription for naloxone be ordered when an opioid dosage reaches 50
In general one should avoid prescribing >90 MME/day because of the substantially higher risk of an
A 62-year-old female with stage 3 chronic kidney disease and an estimated glomerular filtration rate of 37
mL/min/1.73 m2 is found to have a mildly low ionized calcium level. Which one of the following would you
Chronic kidney disease–mineral and bone disorder (CKD-MBD) is found in many patients with CKD and is
associated with an increased risk of bone fractures and cardiovascular events due to vascular calcification. In
patients with CKD, phosphate is not appropriately excreted and the subsequent hyperphosphatemia leads to
secondary hyperparathyroidism and binding of calcium. Decreased production of calcitriol in patients with
CKD also leads to hypocalcemic hyperparathyroidism. Patients with CKD stages 3a–5 should have phosphorus,
calcium, parathyroid hormone, and 25-hydroxyvitamin D levels checked regularly, and consultation with a
A 1-day-old newborn is brought to your office for a routine examination. His parents report that he is
well. The prenatal course and delivery were unremarkable. An examination is normal except for a 1-cm
wide dimple on the sacrum, 1 cm superior to the anus. The dimple has a tuft of dark hair.
At this point you would recommend
B) ultrasonography
C) MRI
D) a fistulogram/sinogram
E) a dermatology consultation
Recognizing clinically significant abnormalities on the newborn examination is important. Newborns with
small sacral dimples located far from the anal verge, without other skin findings such as hair, do not need
imaging to rule out spinal dysraphism (tethered cord). While the exact parameters of what is considered large
(>0.5 cm diameter) and close (within 2.5 cm of the anal verge) can easily be found in reference materials, the
dimple described here is clearly concerning and needs imaging. Ultrasonography can accurately and
A 63-year-old female sees you for evaluation of recurrent right foot swelling and redness. She has a
history of obesity and type 2 diabetes with retinopathy, nephropathy, and peripheral neuropathy. She
presented with similar symptoms 2 weeks ago and was diagnosed with cellulitis and treated with a 10-
day course of amoxicillin/clavulanate (Augmentin). Her symptoms seemed to initially improve with
this therapy along with elevation of the foot but then worsened. She does not have any pain in the
foot, fever, or chills. She does not recall any trauma or other inciting event.
The patient’s vital signs include a temperature of 37.1°C (98.8°F), a pulse rate of 72 beats/min, and a
blood pressure of 124/82 mm Hg. Her right foot appears swollen, red, and warm to the touch, and
is not tender to palpation. There are no open sores or calluses. Her dorsalis pedis pulse is 2+.
A) immobilization
B) antibiotics
C) bisphosphonates
D) corticosteroids
E) surgical repair
This patient has acute Charcot neuroarthropathy, an inflammatory condition that occurs in obese patients
with peripheral neuropathy and ultimately leads to foot deformities (the classic rocker-bottom foot) and
resultant ulcerations and infections. Its clinical appearance can easily be initially mistaken for cellulitis.
However, the absence of tenderness and other signs of infection such as fever, an elevated WBC count, and
inflammatory markers is not consistent with cellulitis. Radiography is an appropriate initial imaging modality
but the results are often interpreted as normal early in the disease process. MRI is the modality of choice for a
definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent soft-tissue edema, joint
The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which increases
the total surface area of contact to the entire lower extremity, distributing pressure away from the foot.
Immobilization is typically required for at least 3–4 months but in some cases may be needed for up to 12
neuroarthropathy. Corticosteroids and antibiotics have no role in the treatment of Charcot foot but would be
appropriate therapy for cellulitis or gout, which are important alternative diagnoses to consider. The role of
surgery is more controversial but may be indicated in the acute phase of Charcot neuroarthropathy in patients
A 38-year-old female with a 6-month history of mild shortness of breath associated with some
intermittent wheezing during upper respiratory infections presents for follow-up. You previously
prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler, which she says helps her
symptoms. You suspect asthma. Pulmonary function testing reveals a normal FEV1/FVC ratio for her
age.
Which one of the following would be the most appropriate next step?
Spirometry is central to confirming the diagnosis of asthma, which is characterized by a reversible obstructive
pattern of pulmonary function. In this case the patient’s FEV1/FVC ratio is normal, which neither confirms nor
A methacholine challenge is recommended in this scenario to assess for the airway hyperresponsiveness that
in FEV1 >20%) observed at low levels of methacholine administration (<4 mg/mL) is consistent with asthma.
If the FEV1/FVC ratio is reduced on initial spirometry, a bronchodilator response should be tested.
A fixed or partially reversible obstructive pattern suggests an alternative diagnosis such as COPD, and full
reversal after bronchodilator use is consistent with asthma. Inhaled corticosteroids are not appropriate for
intermittent asthma.
An 80-year-old former smoker sees you for a 6-month follow-up for hypertension. He is taking
carvedilol (Coreg), amlodipine (Norvasc), and low-dose aspirin. His home blood pressure readings have
been 130–150/80–90 mmHg. Over the last 4 months he has developed pain in his thighs when walking
to his mailbox a block away. The pain resolves after he sits for a few minutes.
On examination he has a blood pressure of 135/85 mm Hg, a heart rate of 72 beats/min, a BMI of 26
kg/m2, and an oxygen saturation of 95% on room air. Examinations of the heart and lungs are normal.
There is dependent rubor of both legs but posterior tibial pulses are palpable. No ulcerations are
noted. You obtain ankle-brachial indices of 0.85 on the left and 0.80 on the right. You prescribe a daily
walking program.
Which one of the following additional measures would be most appropriate for this patient?
Management of asymptomatic peripheral artery disease (PAD) should initially be conservative and should
include a walking program (SOR A), smoking cessation, and a healthy diet.
1.Statins should be started for all patients with PAD regardless of their LDL-cholesterol levels (SOR A).
3.A single antiplatelet agent is recommended for patients with PAD. Both aspirin and clopidogrel are
effective in the reduction of stroke, but the combination of the two is recommended only after
revascularization surgery.
Blood pressure control is indicated in patients with PAD but no antihypertensive class is clearly
superior to another, although there is some evidence that ACE inhibitors may have additional
benefits in terms of walking and pain. In an 80-year-old patient, lowering blood pressure below
120/80 mm Hg can be associated with significant side effects, including a greater risk of falls.
Anticoagulants have not been shown to reduce the risk of major cardiovascular events in patients
symptoms worsen acutely, pain occurs at rest, or the patient develops ulcerations or loss of tissue.
An 84-year-old male nursing home resident with dementia is noted to have a weight loss of about 5%
in the past 6 months. Which one of the following would be most appropriate?
E) Tube feeding
Effective interventions for weight loss in nursing home patients include providing meals in a pleasant, home-
like environment. Avoiding dietary restrictions has low quality evidence of effectiveness. There is high quality
evidence that initiating tube feedings in patients with severe dementia is not only ineffective but may lead to
problems such as decubitus ulcers and aspiration. There is low to very low evidence of the effectiveness for
prescribing appetite stimulants, selenium, vitamin B, or vitamin D supplements unless there is a documented
According to the most recent American College of Cardiology/American Heart Association guidelines,
A) 120/80 mm Hg
B) 130/80 mm Hg
C) 135/85 mm Hg
D) 140/90 mm Hg
E) 150/90 mm Hg
The latest American College of Cardiology/American Heart Association guidelines promote a radical change in
the management of hypertension, which they now define as a blood pressure >130/80 mmHg.
ready to start testing her blood glucose at home. Which one of the following is the recommended goal
A) <75 mg/dL
B) <95 mg/dL
C) <120 mg/dL
D) <150 mg/dL
E) <180 mg/dL
The goal fasting blood glucose level in patients with gestational diabetes is <95 mg/dL.
A fasting glucose level <80 mg/dL is associated with increased maternal and fetal complications.
The goal 2-hour postprandial glucose level is <120 mg/dL and the
therapy. Which one of the following is the recommended first-line agent to prevent steroid-induced
osteoporosis?
A) Alendronate (Fosamax)
B) High-dose vitamin D
C) Raloxifene (Evista)
D) Teriparatide (Forteo)
Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term glucocorticoid
The American College of Rheumatology recommends pharmacologic treatment for these patients, as well as
1.bone mineral density T-score <–2.5 at either the spine or the femoral neck and are either
2.male and >50 years of age or
Therapy is also recommended in patients >40 years of age who do not meet these criteria but have a 10-year
risk of major osteoporotic fracture of at least 20% or a risk of hip fracture of at least 3% according to the FRAX
tool.
osteoporotic fractures, although intravenous bisphosphonates can be used if patients are unable to use the
oral forms.
Supplementation of calcium (800–1000 mg) and vitamin D (400–800 IU) is also recommended.
Raloxifene and teriparatide are options when bisphosphonate therapy fails or is contraindicated (SOR A).
At a routine well child check, the mother of an 18-month-old female expresses concern about the
child’s development. Which one of the following should prompt consideration of a developmental
delay?
Approximately 90% of 18-month-olds say at least three words, and 50%–90% say six words.
The ability to point to body parts or pictures after they are named is expected at 2 years of age.
Not walking at 18 months would be a red flag for delay, but running well may not yet be
accomplished.
At 18 months a child would be expected to scribble spontaneously but not to copy a vertical line.
Which one of the following is the strongest indication for formal allergy testing?
Despite 10%–30% of the population being affected by allergic disease, allergy testing does have limitations and
is most useful in certain clinical situations. Allergy testing can be helpful in patients with persistent sinus
Allergy testing for insect stings is indicated only following systemic/anaphylactic or large local
Three days of fever followed by a diffuse urticarial rash likely represents a rash associated with a
Allergy testing for penicillin has a negative predictive value of 95%–98%. Testing for allergy to other
antibiotics has a much lower sensitivity and specificity but does have limited use to help guide
medication choices in patients with multiple allergies and when limited antibiotic options are
available.
Persistent epigastric pain following the ingestion of tomato products is more indicative of acid reflux
A 22-year-old male presents to your office the morning after falling onto his outstretched right hand as
he tripped while leaving a bar. He has a deep, dull ache in the right wrist on the radial side. The pain is
worsened by gripping and squeezing. On examination there is some wrist fullness and the wrist is
tender to palpation over the anatomic snuffbox. Radiographs of the wrist are negative.
The history, symptoms, and physical examination findings in this case suggest a scaphoid fracture. The
scaphoid bone is the most commonly fractured carpal bone and a fall on an outstretched hand can produce
enough force to cause this fracture. This fracture is most common in males 15–30 years of age.
The finding of anatomic snuffbox tenderness is highly sensitive but not specific for a scaphoid fracture. Initial
radiographs often do not demonstrate a fracture. When there is a high clinical suspicion for a scaphoid
fracture but radiographs are negative, it is reasonable to immobilize in a thumb spica splint and reevaluate in
2 weeks.
Treatment for a sprain with or without follow-up would not be ideal in a situation where a scaphoid fracture is
suspected. MRI or bone scintigraphy can be considered if the patient desires or needs an immediate
diagnosis, but CT and ultrasonography are not appropriate imaging modalities for this fracture.
A 54-year-old male develops chest pain while running. He is rushed to the emergency department of a
hospital equipped for percutaneous coronary intervention. An EKG shows 3 mm of ST elevation in the
anterior leads. He is diaphoretic and cool with ongoing chest pain. His blood pressure is 80/50 mm Hg,
his pulse rate is 116 beats/min, and his oxygen saturation is 98% on room air.
A) a ß-blocker
D) an intravenous vasopressor
This patient is likely experiencing an acute anterior wall myocardial infarction with possible
incipient cardiogenic shock. Along with initiating the hospital’s protocol for myocardial infarction, immediate
Given the possibility of cardiogenic shock, ß-blockers should not be used. Unless more than a 2-hour delay in
A 38-year-old female presents for follow-up of a second hospitalization in the past 3 months for acute
hepatitis, thrombocytopenia, and alcohol withdrawal symptoms treated with benzodiazepines. She says that
prior to her hospitalization a week ago she had been drinking a half pint of vodka daily. She reports that her
drinking has gradually increased over the past 10 years but increased significantly 6 months ago after she lost
her job at a bar and grill. She knows her alcohol consumption is causing damage to her liver and tells you that
her aunt died of alcoholic cirrhosis this year. Despite this knowledge she does not want to stop drinking at this
time. She has looked into several alcohol cessation programs in the area but does not think that they are a
She currently lives with her boyfriend who also uses alcohol and cocaine regularly. She is not currently
speaking to her mother because they “don’t see eye to eye.” She tells you that she has not consumed alcohol
since her discharge from the hospital 2 days ago. She reports that her abdominal pain, nausea, and vomiting
A) alcohol intoxication
B) alcohol withdrawal
C) alcohol use disorder in early remission
A
D) severe alcohol use disorder
This patient presents with 6 out of 11 symptoms of alcohol use disorder within a 12-month period, including
2.Recurrent alcohol use that has contributed to the inability to fulfill work obligations,
4.Continued alcohol use despite knowledge that it is causing physical damage to her liver,
Mild alcohol use disorder is defined by the presence of 2–3 of the 11 symptoms documented in the DSM-5,
whereas 3–5 symptoms indicate moderate alcohol use disorder and 6 or more symptoms indicate severe
alcohol use disorder. This patient has severe alcohol use disorder that is currently active.
Early remission is defined as the absence of symptoms for at least 3 months but less than 12
months.
She is not currently intoxicated, and she does not currently have withdrawal symptoms related to her
--
55
Q
2019.55
A 67-year-old male presents to your office because of fatigue and a syncopal episode. His vital signs in the
office are normal. An examination reveals a harsh systolic murmur best heard over the second right
intercostal space radiating to the neck. Echocardiography confirms your suspected diagnosis.
Which one of the following is the only treatment that improves mortality with this condition?
A) ß-Blockers
A
C) Aortic valve replacement (REVIEW: 2018.180 )
This patient has symptomatic severe aortic stenosis. The only treatment that improves this condition is aortic
valve replacement (SOR B). Transcutaneous aortic valve replacement may be an alternative for patients who
ß-Blockers must be used with caution due to the risk of depressing left ventricular systolic function. They have
Antimicrobial prophylaxis is not indicated unless a patient has undergone valve replacement or has a history
Atrial fibrillation is common in patients with aortic stenosis and rate control is important.
Symptomatic mitral valve regurgitation (MR) may require mitral valve intervention. However, these murmurs
are
1.holosystolic,
A ventricular septal defect (VSD) can cause a loud holosystolic murmur with an associated thrill heard best at
vesicles on the vulva. She does not have a past history of similar lesions. You make a presumptive diagnosis of
genital herpes.
A
B) a polymerase chain reaction (PCR) test
When genital herpes occurs during pregnancy, the best method of diagnosis is either a tissue culture or a
polymerase chain reaction (PCR) test, which is more sensitive. Enzyme-linked immunosorbent assays are
A 27-year-old white female with a history of mania sees you because of polyuria and increased thirst over the
past month. She has taken lithium, 1800 mg daily, for 3 years and her mania is well controlled. She has not lost
weight and there is no family history of her current problem. There are no orthostatic blood pressure changes.
Laboratory Findings
There is no significant change in urine osmolality in response to the administration of vasopressin. Which one
C) Panhypopituitarism
A
A) Drug-induced nephrogenic diabetes insipidus (REVIEW: 2018.139 )
Polyuria occurs in 20%–70% of patients on long-term lithium therapy, even when plasma lithium levels are in
the therapeutic range. This is a result of impaired renal concentrating ability that is resistant to
The diuresis associated with diabetes mellitus is a result of the osmotic effect of increased serum
Patients with hypothalamic or pituitary injuries may develop central diabetes insipidus, which
Psychogenic water drinking occurs in psychiatric patients, but would not be expected to cause
--
58
Q
2019.58
A 40-year-old female sees you because of burning upper abdominal and chest pain and an acidic taste in her
mouth after nearly every meal. She has pain at night that sometimes keeps her awake, but she does not have
any nausea, vomiting, difficulty swallowing, bloating, bloody stools, or weight loss. She does not smoke.
Which one of the following would be the most appropriate next step?
D) Schedule esophagogastroduodenoscopy
A
B) Start a 4- to 8-week trial of a proton pump inhibitor (REVIEW: 2018.183 )
Patients with symptoms typical for GERD can be treated conservatively initially unless there are warning signs
such as anemia, weight loss, evidence of bleeding or obstruction, dysphagia, or persistent symptoms despite
maximal treatment, or the patient is age 50 or over. In the absence of any of these concerns, medical therapy
with a proton pump inhibitor can be initiated. While H2 histamine blockers can also treat reflux symptoms
they are somewhat less effective, and stepwise therapy may increase costs.
Routine testing for Helicobacter pylori in patients with GERD alone is not recommended because treating H.
pylori has been shown in some studies to increase esophagitis and GERD symptoms. However, in the
presence of dyspepsia (fullness, bloating, nausea), which can be associated with GERD, testing for and treating
H. pylori is expected to be beneficial. This patient has classic signs and symptoms of GERD and abdominal
ultrasonography would not be likely to reveal any helpful findings. In the presence of warning signs,
intervention for GERD should be reserved for patients who fail maximal medical therapy or patients who are
developed a headache, nausea, and dizziness, but no respiratory difficulty. That night he had difficulty
sleeping. He asks for your recommendation on preventing a recurrence of the problem when he goes skiing
Which one of the following medications would you recommend he start the day before his ascent and
B) Aspirin
C) Dexamethasone (Decadron)
D) Tadalafil (Adcirca)
E) Zolpidem (Ambien)
A
A) Acetazolamide (Diamox Sequels)
Acetazolamide is the preferred agent for preventing acute mountain sickness (AMS). Multiple trials have
demonstrated its efficacy in preventing AMS. Dexamethasone is a first-line treatment for acute mountain
sickness of any severity but is a second-line drug for prevention because of its side-effect profile.
Tadalafil is advised as a second-line treatment after nifedipine for the prevention and treatment of
--
60
Q
2019.60
A 25-year-old female has a heart murmur on her postpartum visit. This was first noted at the age of 20. She
has been asymptomatic. The murmur is systolic and increases in intensity with Valsalva maneuvers. Further
questioning reveals that her two sisters died suddenly from cardiac problems in their early twenties.
A) dilated cardiomyopathy
B) hypertrophic cardiomyopathy
C) peripartum cardiomyopathy
D) restrictive cardiomyopathy
A
B) hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is the most common type of cardiomyopathy, with a prevalence of 1:500. It
involves left ventricular hypertrophy without chamber dilatation. It is caused by autosomal dominant genetic
Dilated cardiomyopathy is a leading cause of heart failure but most patients are symptomatic.
Peripartum cardiomyopathy may occur during and after pregnancy and presents as heart failure.
--
61
Q
2019.61
A 5-year-old female is brought to your office with a progressive rash on her legs (shown below) and buttocks.
No rash is noted above the level of the mid-torso. Her mother also reports that the child had two episodes of
bloody diarrhea 3 days ago. She also has abdominal pain and on examination she has abdominal tenderness
with no rigidity but some voluntary guarding. You also note swelling and tenderness in her left wrist and right
knee. A CBC, platelets, prothrombin time, and partial thromboplastin time are normal. A urinalysis reveals
B) Gianotti-Crosti syndrome
D) Henoch-Schönlein purpura
A
D) Henoch-Schönlein purpura
Henoch-Schönlein purpura (HSP) is an IgA vasculitis that is usually diagnosed clinically. It presents as palpable
purpura of the lower extremities without thrombocytopenia or coagulopathy. It is often associated with
3.renal dysfunction.
Erythema infectiosum (fifth disease) can be identified by an erythematous rash on the cheeks and a
1.hemolytic anemia,
2.thrombocytopenia, and
3.kidney injury.
--
62
Q
2019.62
A 52-year-old female sees you because of concerns about developing lung cancer. She reports that she quit
smoking last month after learning that her father has stage IV lung cancer. She had smoked a pack of
cigarettes per day since she was 18 years old. She has no history of cough, shortness of breath, or weight loss.
She is worried about developing lung cancer and wants to know how to “catch it early.”
Based on the recommendations of the U.S. Preventive Services Task Force, in addition to providing ongoing
smoking cessation support, which one of the following should you recommend?
A
C) Low-dose chest CT at age 55
The 2013 U.S. Preventive Services Task Force lung cancer screening guidelines recommend annual low-dose
CT screening for all adults between the ages of 55 and 80 who have a >30-pack-yearsmoking history and either
A 46-year-old female with a history of hyperthyroidism controlled with methimazole (Tapazole), 10 mg daily,
returns to your office after an absence of several years. She has new symptoms of palpitations, heat
intolerance, and hoarseness. A physical examination reveals an enlarged thyroid and a radioactive iodine
Which one of the following is the appropriate definitive treatment for this patient?
D) Radioactive iodine
E) Thyroidectomy
A
E) Thyroidectomy (REVIEW: 2018.208 )
This patient has a medical history, physical examination, and radioactive iodine uptake scan consistent
with toxic multinodular goiter, which is the second most common cause of hyperthyroidism in the United
States.
Although the addition of propranolol and an increase in methimazole may control her palpitations and other
symptoms of hyperthyroidism, these measures will not permanently eliminate the problem.
Radioactive iodine ablation and thyroidectomy with subsequent thyroid hormone replacement are both
appropriate treatments for toxic multinodular goiter, but thyroidectomy is indicated for this patient because
Which one of the following groups has the highest prevalence of syphilis?
A) Baby boomers
B) Incarcerated females
A
C) Men who have sex with men
Factors associated with increased prevalence rates for syphilis in the United States include a history of
incarceration or commercial sex work, living in the southern or western United States, residing in a major
metropolitan area, African-American ethnicity, and being a male younger than 29 years of age. The risk for
syphilis infection is highest among men who have sex with men and among persons who are HIV-positive.
--
65
Q
2019.65
Which one of the following is the counseling strategy in the Stages of Change Model?
A) Quickly establishing rapport with a patient to improve compliance with recommendations for change
B) Assessing the patient’s motivation for change and determining where they are in the process
A
B) Assessing the patient’s motivation for change and determining where they are in the process
The Stages of Change Model assesses the patient’s motivation for change and determines which stage of the
1.Precontemplation,
2.Contemplation,
3.Preparation,
4.Action, and
5.Maintenance.
Understanding this helps guide counseling strategies for each individual patient.
--
66
Q
2019.66
A 42-year-old female presents with a 2-week history of throbbing medial heel pain that is most painful when
she first steps out of bed in the morning. The pain improves after she walks around for several minutes.
A) Achilles tendinopathy
B) Calcaneal stress fracture
C) Neuroma
D) Plantar fasciitis
A
D) Plantar fasciitis (REVIEW: 2018.170 )
Plantar fasciitis is the most common cause of heel pain, affecting more than 2 million people each year. The
pain is typically worst when the patient first gets out of bed and improves with activity.
Calcaneal stress fractures follow an increase in activity, and the pain tends to worsen with activity
Achilles tendinopathy is an aching pain that also worsens with increased activity, and there is often
Neuromas present with a burning, tingling, or numb sensation and a painful lump.
--
67
Q
2019.67
A 55-year-old patient with a history of alcoholism is admitted through the emergency department with acute
pancreatitis. Which one of the following tests performed at the time of admission can best predict the severity
of pancreatitis?
A) Hematocrit
B) C-reactive protein
C) Serum amylase
D) Serum lipase
E) CT of the abdomen
A
A) Hematocrit
Knowing the severity of pancreatitis helps predict how aggressive management should be. Hematocrit, BUN,
and creatinine levels are the most useful predictors of the severity of pancreatitis, reflecting the degree
C-reactive protein is often elevated, but it is not as useful as hematocrit for predicting severity.
CT evidence of severe pancreatitis lags behind clinical and laboratory evidence, and early CT
--
68
Q
2019.68
According to state child abuse mandatory reporter laws, which one of the following is the threshold that must
be met for physicians to make a report to local child protective services or law enforcement?
B) If they consider the possibility of abuse or neglect, even if further evaluation indicates that it is unlikely
C) If they observe signs or symptoms that may occur in cases of abuse or neglect, but that are nonspecific for
abuse or neglect
A
D) If they suspect that a child has experienced abuse or neglect
Although each state has its own laws regarding obligations to report child abuse, all 50 U.S. states require
physicians, whether as a specified professional group or as a part of universal mandated reporting, to report a
suspicion of child abuse. The standard is generally suspicion or cause to believe that abuse has occurred.
If the possibility of abuse is briefly considered but rejected, or if nonspecific signs are present that do not
A 34-year-old male with sickle cell disease has a new onset of mild to moderate thirst and polyuria. He ate a
An examination reveals a BMI of 32 kg/m2. Results of a urinalysis performed by your staff include 3+ glucose
and no ketones. His blood glucose level is 288 mg/dL and his hemoglobin A1c is 5.2%.
Which one of the following would be most appropriate at this point to help diagnose and monitor this
D) Hemoglobin electrophoresis
E) Referral to an endocrinologist
A
A) A serum fructosamine level
This patient with sickle cell disease has a new onset of diabetes mellitus. Hemoglobinopathies falsely lower
Fructosamine correlates well with hemoglobin A1c levels and is recommended instead of
hemoglobin A1c for monitoring glucose control in patients with diabetes and hemoglobinopathies.
A 2-hour glucose tolerance test or hemoglobin electrophoresis would not provide useful information.
Referral to an endocrinologist is not indicated at this point because the patient has not failed primary care
management.
--
70
Q
2019.70
A 35-year-old male presents with a 2-week history of lower extremity edema. He is in good health and does
not take any medications. You note weight gain, and mild dyspnea with exertion. An examination is
unremarkable except for 2+ to 3+ pitting edema of the lower extremities to his knees bilaterally. A CBC and
metabolic panel are unremarkable except for a low albumin level. A urinalysis reveals 3+ protein on the
Which one of the following would be the most appropriate next step?
C) Renal ultrasonography
D) Echocardiography
A
B) A spot urine protein/creatinine ratio (REVIEW: 2018.55)
Individuals with nephrotic syndrome often present with edema and fatigue with no evidence of severe liver
disease or heart failure. Hallmarks of this problem include heavy proteinuria, hypoalbuminemia,
While most of these cases are idiopathic, secondary causes such as diabetes mellitus, systemic lupus
To confirm proteinuria in the nephrotic range a spot urine protein/creatinine ratio is now suggested instead of
nephritis but subsequent studies have shown a lack of specificity and sensitivity.
Renal ultrasonography would be indicated if the glomerular filtration rate were reduced.
While a renal biopsy is often recommended, it is most useful in patients with suspected underlying
systemic lupus erythematosus or similar disorders when a biopsy can guide management decisions
and prognosis.
--
71
Q
2019.71
A 69-year-old female with hypertension, hyperlipidemia, and coronary artery disease had a myocardial
infarction 1 year ago that was treated with percutaneous stenting. She was recently diagnosed with atrial
fibrillation and takes diltiazem (Cardizem) for rate control. She is also taking lisinopril (Prinivil, Zestril),
Of the following, which option would be best for thromboembolism prevention in this patient?
A
C) Discontinue aspirin and begin apixaban (Eliquis)
CHA2DS2-VASc Score
Hypertension
Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and
This patient has a CHA2DS2-VASc score of 3 (hypertension, age 65–74, female), which classifies her as high risk
for thromboembolism.
Oral anticoagulation is indicated for patients with a score of 2 or more, who are at high risk for pulmonary
embolism/deep vein thrombosis (PE/DVT) (SOR C). Patients with a score of 0–1 have a low to medium risk and
In patients with atrial fibrillation and stable coronary artery disease, novel oral anticoagulants are preferred
(SOR A). They reduce the risk of reinfarction, stroke, and overall mortality in patients with a past history of
A 4-year-old male is brought to your office by his adoptive parents who are concerned about his poor behavior
and intellectual development. The patient is in the 7th percentile for height and weight. There have been some
Which one of the following facial dysmorphologies would be most consistent with a diagnosis of fetal alcohol
syndrome?
B) Low-set ears
C) A smooth philtrum
The classic facial dysmorphologies associated with fetal alcohol syndrome are a
1.Smooth philtrum,
Two out of these three characteristics are required for the diagnosis of fetal alcohol syndrome.
Low-set ears and a central chin dimple are not associated findings.
--
73
Q
2019.73
A 7-year-old female is brought to your office by her mother, who says that the child has developed underarm
odor and is beginning to develop acne. The patient has an unremarkable history, was born at full term, and
has no chronic medical problems. There is no family history of endocrine disorders or precocious puberty.
An examination reveals normal vital signs and a normal BMI, and her height is stable on the growth curve with
no increased velocity. Her sexual maturity rating is stage 1. She has some open and closed comedones on her
A
A) Reassurance and surveillance over the next 3–6 months
Premature adrenarche without development of secondary sex characteristics is usually idiopathic and does
Reassurance and surveillance over the next 3–6 months would be most appropriate at this time.
Laboratory studies and radiography warrant consideration if the patient develops secondary sex
characteristics before the age of 8, or if her height velocity increases rapidly during the surveillance period.
--
74
Q
2019.74
An otherwise asymptomatic 7-year-old male has a blood pressure above the 95th percentile for gender, age,
and height on serial measurements. Which one of the following studies would be most appropriate at this
time?
C) Renal ultrasonography
E) A sleep study
A
C) Renal ultrasonography
Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy
are the most common cause of hypertension in preadolescent children. Preadolescent children with
hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the
Renin and aldosterone levels are indicated if there is a reason to suspect primary
diagnose pheochromocytomas, which are rare and usually present with a triad of symptoms including
Doppler ultrasonography of the renal arteries is useful for diagnosing renal artery stenosis, which
especially women 19–39 years of age, who are more at risk for renal artery stenosis due to
fibromuscular dysplasia.
Sleep studies are indicated in patients who are obese or have signs or symptoms of obstructive sleep apnea.
--
75
Q
2019.75
A 58-year-old female presents to your office after being seen in the emergency department last weekend for
her first episode of renal colic. After undergoing CT urography she passed a calcium phosphate kidney stone.
Which one of the following medications in her current regimen places her at higher risk for kidney stone
formation?
A) Escitalopram (Lexapro)
B) Levothyroxine (Synthroid)
D) Metformin (Glucophage)
E) Topiramate (Topamax)
A
E) Topiramate (Topamax)
It is a carbonic anhydrase inhibitor, which induces a metabolic acidosis that leads to hypercalciuria and the
A 30-year-old female presents with pain over the proximal fifth metatarsal after twisting her ankle.
Which one of the following would be the most appropriate initial management?
E) Surgical fixation
A
B) A compressive dressing with weight bearing and range-of-motion exercises as tolerated
The fifth metatarsal has the least cortical thickness of all of the metatarsals. There are strong ligaments and
capsular attachments on the proximal fifth metatarsal that can put significant stress on this area of the bone,
leading to fractures.
Nondisplaced tuberosity fractures can generally be treated with compressive dressings such as
an Aircast or Ace bandage, with weight bearing and range-of-motion exercises as tolerated.
Minimally displaced (<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a short
that treatment of his underlying mood disorder is the best initial step.
A) Bupropion (Wellbutrin)
B) Citalopram (Celexa)
C) Nortriptyline (Pamelor)
D) Sertraline (Zoloft)
A
A) Bupropion (Wellbutrin)
When psychogenic erectile dysfunction (ED) coexists with depression, treatment of the underlying mood
An antidepressant that is LESS likely to worsen the ED, such as bupropion, mirtazapine, or fluvoxamine, should
be chosen.
Antidepressants that are more likely to cause sexual side effects should be avoided,
o Citalopram (Celexa)
o Escitalopram (Lexapro)
o Fluvoxamine (Luvox)
o Paroxetine (Paxil)
o Sertraline (Zoloft)
Phosphodiesterase-5 inhibitors are the first line of treatment for ED (SOR A) and can be used effectively in
A 14-year-old male sees you for a well child examination. He had one dose of HPV vaccine at his last well child
Which one of the following is true regarding HPV vaccine for this patient?
B) He should receive one dose of the vaccine now and no additional HPV vaccine in the future
A
B) He should receive one dose of the vaccine now and no additional HPV vaccine in the future
HPV vaccine is currently recommended for males and females at age 11 (first dose up to 15).
21 in males, and
26 in females.
Children who receive the first dose of the vaccine before the age of 15 and receive two doses are
If the first dose is given after age 15, a three-dose series is recommended.
--
79
Q
2019.79
Which one of the following is an indication for considering atrial ventricular nodal ablation in a patient
A) Hemodynamic instability
E) Persistent atrial fibrillation in a patient who has been successfully rate controlled and anticoagulated for
several years
A
D) Atrial fibrillation refractory to medical therapy
Atrial ventricular nodal ablation is recommended for patients whose atrial fibrillation is refractory to medical
therapy, and requires that patients be anticoagulated for at least 1 month prior to the procedure and for
Patients with atrial fibrillation who are hemodynamically unstable should be considered
Atrial ventricular nodal ablation is not necessary for patients successfully converted to sinus rhythm or for
those who are successfully treated with medical interventions for rate control and anticoagulation.
--
80
Q
2019.80
An otherwise healthy 42-year-old male presents to your office with low back pain that started a week ago after
he lifted a heavy box. Since the time of his injury he has been having consistent pain, numbness, and tingling
that radiates down the back of his right leg to his calf.
A) No imaging
B) Plain radiography
C) CT
D) MRI
A
A) No imaging
Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition and early imaging
is associated with worse overall outcomes and is likely to identify minor abnormalities even in asymptomatic
patients.
Imaging for acute low back pain should be reserved for cases that are suspicious for cauda equina
In the absence of red flags such as progressive motor or sensory loss, new urinary retention or
overflow incontinence, a history of cancer, a recent invasive spinal procedure, or significant trauma
relative to age, imaging is not warranted regardless of whether radiculopathy is present, unless
symptoms persist despite a trial of at least 6 weeks of medical management and physical therapy.
--
81
Q
2019.81
A 34-year-old female presents to your office after she was bitten on the hand by a neighbor’s fucking piece-of-
shit cat. The patient has no allergies and has been in good health. You decide to treat the patient with a
prophylactic antibiotic.
A) Amoxicillin/clavulanate (Augmentin)
B) Azithromycin (Zithromax)
C) Cephalexin (Keflex)
D) Clindamycin (Cleocin)
E) Metronidazole (Flagyl)
A
A) Amoxicillin/clavulanate (Augmentin)
Prophylactic antibiotics should be given for all closed-fist injuries unless the skin has not been penetrated, and
for puncture wounds caused by cat bites. The antibiotic should have both aerobic and anaerobic activity and
include
If the patient is allergic to penicillin, clindamycin plus levofloxacin or moxifloxacin, which has anaerobic
Azithromycin, cephalexin, and metronidazole are not first-line antibiotics following a cat bite.
--
82
Q
2019.82
A 25-year-old female was involved in a motor vehicle accident 2 weeks ago. A chest radiograph to assess for
rib fractures revealed bilateral hilar lymphadenopathy. She thinks that her mother had a similar finding when
she was younger. Records from the emergency department reveal that a CBC, comprehensive metabolic
The patient has never been sexually active, does not take any medications, and does not smoke or use any
illicit drugs. Her rib pain has since resolved and she has no other symptoms. She does not have a cough,
dyspnea, weight loss, or skin lesions. Spirometry in the office today is normal.
Which one of the following would be the most appropriate next step?
A
A) A follow-up visit and a repeat chest radiograph in 6 months (REVIEW: 2018.112 )
Given this patient’s age, lack of symptoms, and possible family history, the presence of asymptomatic bilateral
Because the patient does not have any symptoms and stage 1 sarcoidosis resolves in most cases, the most
prudent course is to reevaluate her in 6 months with a careful history, a physical examination, and a chest
radiograph.
Given the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a
lung biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but
would be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.
--
83
Q
2019.83
A healthy 49-year-old female presents to your office for a routine health maintenance visit. Since her last visit
a year ago she has had only two menstrual periods. She reports sudden sensations of extreme heat in her
face, neck, and chest that last just a few minutes but occur throughout the day. These symptoms are very
Which one of the following would you recommend to relieve her symptoms?
A) Black cohosh
D) Micronized progesterone
E) Testosterone
A
B) Combined estrogen and progesterone
This patient presents with typical vasomotor symptoms that can begin in perimenopause and affect sleep
quality. Hormone therapy is the gold standard for treatment of vasomotor symptoms.
Combination estrogen and progesterone therapy is highly effective for vasomotor symptoms and
Although micronized progesterone decreases vasomotor symptoms there are no long-term studies to assess
Compounded bioidentical hormone therapy creates safety concerns and is not a first-line therapy due to
limited government regulation and monitoring, the potential for overdosing and underdosing, impurities or
Testosterone alone is not FDA-approved for use in women. Additionally, it has not been shown to be beneficial
for treatment of vasomotor symptoms in combination with hormone therapy and is associated with significant
side effects. It may be useful for hypoactive sexual desire in postmenopausal women.
There is insufficient data to recommend the use of herbal remedies such as black cohosh.
--
84
Q
2019.84
A 30-year-old female presents for follow-up after an emergency department visit for an episode
one of the following would be most appropriate for the initial long-term management of this patient?
A) Adenosine (Adenocard)
B) Amiodarone (Cordarone)
C) Diltiazem (Cardizem)
D) Metoprolol
E) Catheter ablation
A
E) Catheter ablation
Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White
syndrome (WPW). Catheter ablation has a very high immediate success rate (96%–98%). The most significant
risk associated with the procedure is permanent atrioventricular block, which occurs in approximately 0.4% of
procedures. Adenosine and amiodarone are used for the acute management of supraventricular tachycardia,
but not for long-term management. Node-blocking medications such as diltiazem and metoprolol should not
be used for the long-term treatment of WPW, due to the increased risk of ventricular fibrillation.
--
85
Q
2019.85
A 7-year-old male received one dose of trivalent inactivated influenza vaccine at another health care facility 5
weeks ago. This was the first time he received influenza vaccine, and it resulted in soreness at the injection
site. His mother reports that he has had mild hives after eating peanuts and eggs in the past. Your office has
A
B) Immunization now with quadrivalent inactivated vaccine
The CDC’s Advisory Committee on Immunization Practices recommends that patients with egg allergy receive
influenza vaccination.
Previously unvaccinated patients ages 6 months to 8 years should receive two doses of either trivalent or
A 93-year-old female presents to your office after a choking episode. She also says she has had
gradually worsening difficulty with swallowing over the past several months. A modified barium swallow and
A) Cervical web
B) Pharyngeal neoplasm
C) Schatzki ring
D) Tracheoesophageal fistula
E) Zenker’s diverticulum
A
E) Zenker’s diverticulum
A Zenker’s diverticulum is an oropharyngeal structural lesion and is most common in the elderly population,
The pathogenesis involves stenosis of the cricopharyngeus and increased hypopharyngeal pressure
The radiographic findings in this case are consistent with a Zenker’s diverticulum.
A cervical web or Schatzki ring would be identified by a short segment of narrowing without diverticula.
Three weeks after he had knee surgery, a 64-year-old male presents for follow-up of an emergency
department visit for a pulmonary embolism. He has no previous history of pulmonary embolism and is
A) 1 month
B) 3 months
C) 6 months
D) 9 months
E) 12 months
A
B) 3 months
Patients who have a venous thromboembolism (VTE) require anticoagulation therapy for treatment and
prevention of recurrence. The risk of recurrence is greatest in the first year after the event and remains
elevated indefinitely. The risk for VTE recurrence is dependent on patient factors, such as active cancers and
thrombophilia. Current guidelines recommend treatment for at least 3 months. In patients who have
a reversible provoking factor such as surgery, anticoagulation beyond 3 months is not recommended.
--
88
Q
2019.88
A 21-year-old male presents to your office with excessive sweating in the axillae, palms, and soles. This has
been a problem for several years and interferes with his ability to participate in daily activities without
discomfort and embarrassment. After ruling out possible secondary causes you diagnose primary focal
hyperhidrosis.
B) Topical 2% glycopyrrolate
C) Oral oxybutynin
E) Sympathetic denervation
A
A) Topical 20% aluminum chloride (Drysol)
The recommended first-line treatment for primary focal hyperhidrosis is topical 20% aluminum chloride. It
should be applied to affected areas nightly for 6–8 hours and works by obstructing the eccrine sweat glands
Iontophoresis and botulinum toxin are alternative first- or second-line therapies for palmar and
plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or face.
Topical 2% glycopyrrolate must be compounded by a pharmacy and is indicated only for craniofacial
hyperhidrosis.
Oral anticholinergics such as oxybutynin can be considered if other first-line treatments fail.
However, up to 10% of patients will stop taking these medications due to side effects such as dry
Microwave technology is a newer treatment option that has shown some promising results but should not be
Sympathetic denervation should be used only if other less invasive therapies have already been tried.
--
89
Q
2019.89
A 67-year-old male who recently had an ST-elevation myocardial infarction (STEMI) and underwent placement
of a circumflex artery stent presents for hospital follow-up. His past medical history also includes
hypertension, obesity, stage 3a chronic kidney disease, and coronary artery disease. He is feeling well today
but his cardiologist told him he probably has diabetes mellitus and should see you to discuss treatment
options. The cardiologist told the patient that there are new medications for diabetes that will help lower his
risk for future myocardial infarctions and he is interested in starting one of these.
A physical examination is unremarkable. The patient weighs 145 kg (320 lb) and his BMI is 44 kg/m 2. His blood
TSH……………………………………….. normal
Based on American Diabetes Association guidelines, in addition to lifestyle modifications, which one of the
A) No pharmacologic therapy
B) Empagliflozin (Jardiance)
D) Liraglutide (Victoza)
E) Metformin (Glucophage)
A
E) Metformin (Glucophage)
With the advent of new medications to treat diabetes mellitus, including many medications that help lower
Unless there are contraindications, however, metformin is still the initial medication of choice for patients
If this patient’s hemoglobin A1c were >10%, it would be reasonable to start insulin therapy.
If it becomes necessary to add an additional antidiabetic agent it would be reasonable to consider a GLP-1
receptor agonist or a DPP-4 inhibitor in addition to metformin at that time, given the patient’s history of
PPC 4-5
--
90
Q
2019.90
A 30-year-old female sees you for a routine health maintenance visit. She has myopia and says she is
D) prevention of presbyopia
A
C) satisfactory improvement of vision in almost all patients
LASIK corrective vision surgery has become increasingly common over the last 20 years. A laser is used to cut a
flap the size of a contact lens consisting of corneal epithelium and stroma. This flap is repositioned and heals
without sutures.
It is important to counsel patients on realistic expectations. Vision following the procedure may not be as clear
as with glasses or contact lenses and some individuals still require external correction. Up to 40% of patients
experience dry eyes following the surgery (SOR B). These symptoms may be worse in patients with chronic
pain syndromes such as fibromyalgia, migraine, and irritable bowel syndrome (SOR C). Glares, halos, and
starbursts may affect up to 20% of patients following LASIK. This may be especially bothersome at night (SOR
B).
LASIK does not correct age-related presbyopia (SOR C). Reading glasses may be necessary if this develops in
certain patients. Overall, however, most patients are satisfied with their results and only 3% are unhappy with
A 58-year-old female with COPD asks what she can do to avoid hospitalization. She does not have any other
medical problems.
Which one of the following interventions has been shown to reduce respiratory-related hospital admissions in
A
A) Written self-management plans that include smoking cessation plans
Written self-management plans have been shown to decrease respiratory-related hospitalizations in patients
with COPD.
Although regular physical activity has clear health benefits, the methods are so varied in studies of physical
activity that there is currently no strong evidence to show it reduces hospitalizations in COPD patients.
Although FEV1 is important for predicting hospitalizations for a population, it is not accurate enough to be
Daily oxygen therapy does not help to postpone the first hospitalization.
Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep apnea, but not those with
COPD alone.
--
92
Q
2019.92
You suspect that a 28-year-old female patient may have a somatic symptom disorder, specifically a conversion
disorder. Which one of the following is the most appropriate pharmacologic treatment of this disorder?
A) Bupropion (Wellbutrin)
B) Clozapine
C) Selegiline (Eldepryl)
D) Sertraline (Zoloft)
E) Topiramate (Topamax)
A
D) Sertraline (Zoloft)
Somatic symptom disorders account for approximately 5% of primary care visits. Effective pharmacologic
treatment includes sertraline and other SSRI-based therapy in addition to cognitive-behavioral therapy (SOR
B).
Effective – Escitalopram
Sadness – Sertraline
Panic – Paroxetine
Compulsions – Citalopram
Bupropion, monoamine oxidase inhibitors such as selegiline, anticonvulsants such as topiramate, and
A 30-year-old gravida 2 para 1 in her second trimester is evaluated for hypothyroidism. The normal TSH range
in pregnancy is
The TSH reference range is lower during pregnancy because of the cross-reactivity of the alpha-subunit of
hCG.
Levels of hCG peak during weeks 7–13 of pregnancy, and hCG has mild TSH-like activity, leading to
slightly high free T4 levels in early pregnancy. This leads to a feedback decrease in TSH.
--
94
Q
2019.94
A 69-year-old male presents for an annual health maintenance examination. His medical history is significant
for hypertension and worsening back pain over the last 6 months. Laboratory studies reveal a hemoglobin
level of 8.6 g/dL (N 14.0–18.0) and a mean corpuscular volume of 88 um3 (N 80–94). The remainder of the CBC
is normal. A peripheral smear and a ferritin level are both normal. A comprehensive metabolic panel is normal
Which one of the following would be the most appropriate next step in the evaluation of this patient?
B) A haptoglobin level
D) Flow cytometry
A
C) Serum protein electrophoresis
This patient’s laboratory results and back pain suggest multiple myeloma (MM).
He has a normocytic anemia and evidence of renal insufficiency, which can indicate MM.
The laboratory findings along with worsening back pain indicate a need to order serum protein
Flow cytometry is generally used in patients with an elevated WBC count and suspected lymphoma.
The remainder of this patient’s CBC is normal, which makes a bone marrow issue less likely.
His mean corpuscular volume is also normal, making vitamin B12 deficiency less likely.
A haptoglobin level could be ordered, but protein electrophoresis is a better choice because
--
95
Q
2019.95
A 60-year-old female has recently moved to your area from another state and sees you to establish care. Her
past records are not available at the time of her visit but she has a history of ER+/PR+ breast cancer diagnosed
2 years ago. She was treated with lumpectomy, radiation, and chemotherapy. She does not have any current
symptoms and there is no family history of breast or ovarian cancer. Her last visit with a physician was 6
months ago. She had a mammogram at that time. A breast MRI was done at the time of her cancer diagnosis.
B) A Pap test
C) Mammography
D) Breast MRI
E) Echocardiography
A
A) A history and physical examination only
Breast cancer survivors should undergo a history and physical examination every 3–6 months for the first 3
Papanicolaou testing guidelines do not change for patients with a history of breast cancer. Screening should
be repeated every 3–5 years according to American Society for Colposcopy and Cervical Pathology (ASCCP)
guidelines.
Mammograms of both breasts or the remaining breast are recommended no more often than yearly (SOR A).
Breast MRI is not recommended on a regular basis unless the patient has a high risk of recurrence, a
significant family history of breast or ovarian cancer, or a personal history of Hodgkin’s disease (SOR C).
While it is important to be alert for signs of cardiotoxicity due to prior chemotherapy, echocardiography is
indicated only if the patient has cardiac symptoms. Routine echocardiography is not recommended (SOR C).
--
96
Q
2019.96
A 17-year-old female presents for acute care after tripping and falling on her right knee when stepping off her
electric scooter. An examination does not reveal gross deformity or notable effusion. Range of motion in the
right knee is limited to 100° of flexion. There is tenderness over the proximal tibia. She can only take two steps
Which one of the following findings on the patient’s history and examination should prompt you to order
A) Her age
B) Her sex
A
E) The inability to take more than two steps (REVIEW: 2018.7 )
Several decision support tools can help guide the decision to order imaging of an injured knee, such as the
Ottawa Knee Rule, the Pittsburgh Knee Rule, and American College of Radiology (ACR) criteria. The inability to
take four or more steps immediately after an injury or in the emergency setting is an indication for
Age is an indication for radiography in acute knee pain in patients over 55 years of age according to the
Ottawa rule, or under 12 or over 50 years of age according to the Pittsburgh rule. The patient’s sex does not
Bony tenderness is an indication for imaging according to the ACR and Ottawa rules, but only if isolated over
the proximal fibula or over the patella without other bony tenderness. The inability to flex the knee to 90° is
also an indication for imaging according to the ACR and Ottawa rules.
--
97
Q
2019.97
For urinary stones 5–10 mm in diameter, which one of the following has been proven effective in facilitating
A) Ciprofloxacin (Cipro)
B) Naproxen
C) Nitrofurantoin (Macrodantin)
D) Promethazine
E) Tamsulosin (Flomax)
A
E) Tamsulosin (Flomax)
Tamsulosin promotes passage of ureter stones that are 5–10 mm in diameter. The number needed to
treat is five patients to cause the expulsion of one stone (SOR B).
There was no difference in the percentage of patients passing stones smaller than 5 mm when comparing
tamsulosin to placebo, as these stones have a high rate of spontaneous passage without any intervention.
Naproxen and promethazine are sometimes used for the management of pain and nausea associated with
stones, but they have not been shown to facilitate stone expulsion.
Ciprofloxacin and nitrofurantoin are used to treat urinary tract infections but have not been shown to facilitate
stone expulsion.
--
98
Q
2019.98
A 67-year-old male is admitted to the hospital for community-acquired pneumonia. An examination reveals a
temperature of 40.0°C (104.0°F), a respiratory rate of 50/min, a pulse rate of 110 beats/min, a blood pressure
of 90/50 mmHg, and an oxygen saturation of 88% on room air. The patient is confused and requires
aggressive fluid resuscitation for hypotension and he is transferred to the intensive-care unit. He has no
In addition to treatment with ceftriaxone and azithromycin (Zithromax), which one of the following
A) Clindamycin (Cleocin)
B) Levofloxacin (Levaquin)
C) Methylprednisolone (Medrol)
D) Oseltamivir (Tamiflu)
A
C) Methylprednisolone (Medrol)
This patient has severe community-acquired pneumonia based on clinical criteria, including an elevated
respiratory rate, confusion, and hypotension requiring aggressive fluid resuscitation. Corticosteroids such as
methylprednisolone have been shown to improve clinical outcomes such as length of stay, duration of
antibiotic treatment, and the risk of developing adult respiratory distress syndrome. The preferred choice of
antibiotic treatment for patients in the intensive-care unit is a ß-lactam antibiotic (ceftriaxone, cefotaxime) or
The addition of levofloxacin is not necessarily preferred over just ceftriaxone and azithromycin.
Clindamycin is not indicated in the absence of risk factors for anaerobic infection such as aspiration
or alcoholism.
--
99
Q
2019.99
A 32-year-old female presents with heat intolerance, excessive weight loss, and anxiety. She gave birth 6
months ago and recently stopped breastfeeding. On examination her thyroid gland is slightly
diffusely enlarged and nontender. Laboratory studies reveal a decreased TSH level and elevated free T3 and
Which one of the following tests would be most useful to confirm the diagnosis?
C) Thyroid ultrasonography
A
A) Radioactive iodine uptake
Postpartum thyroiditis is defined as a transient or persistent thyroid dysfunction that occurs within 1 year of
diagnosis.
Thyroid peroxidase antibody levels are elevated with chronic autoimmune thyroiditis
routine thyroid ultrasonography in patients with abnormal thyroid function tests if there is no
--
100
Q
2019.100
A 79-year-old female comes to your office with her daughter to discuss concerns about the mother’s
endurance. The daughter thinks her mother is losing strength more quickly than she should. The patient’s past
medical history includes osteoporosis and hypertension. She is using a cane when needed for support but has
not fallen. She is not sleeping well and her insomnia seems to have worsened over the last year. They both
agree she is not depressed, and her PHQ-2 score today is 0. After a discussion with the patient and her
daughter and a physical examination, you are concerned that the patient is at risk for frailty-related health
outcomes.
Which one of the following interventions would you recommend as most important to improve this patient’s
A) Aerobic exercise
B) Resistance training
C) Nutritional counseling
D) Vitamin D
E) Mirtazapine (Remeron)
A
B) Resistance training
Frailty is an increasingly common problem in the geriatric population, especially as individuals are living
longer. The current literature supports resistance training to improve physical function before aerobic
exercise is introduced.
Although there was hope that nutritional counseling would improve outcomes, it does not seem to have an
effect.
Mirtazapine is on the Beers list, and without a compelling indication such as weight loss with depression it
A patient comes to your outpatient clinic with a persistent migraine that she has been unable to treat
effectively at home. The symptoms began several hours ago and are typical for her. She has already tried her
usual treatments of ibuprofen, 800 mg, and rizatriptan (Maxalt), 10 mg, but they have not provided any relief.
She took a second dose of rizatriptan 2 hours later without benefit. She is in significant pain, which is causing
D) Intramuscular morphine
E) Intramuscular prochlorperazine
A
E) Intramuscular prochlorperazine
Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute
migraine beyond their effect on nausea. Most outpatient clinics do not have the ability to
administer intravenous metoclopramide, which is the preferred treatment. However, most clinics do have the
Due to concerns about oversedation, misuse, and rebound, treatment with parenteral opiates is discouraged
Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of success in the
A 42-year-old male with a history of alcohol abuse was admitted to the hospital last night with mid-epigastric
pain and tenderness. The hospital evaluation included an elevated lipase level and a normal ultrasound
examination. He was diagnosed with acute pancreatitis, placed on NPO status, and started on intravenous
fluids and pain control. This morning he still has moderate epigastric pain and tenderness, and mild nausea
The American Gastroenterological Association guidelines on acute pancreatitis recommend initiating oral
feedings early in the course in order to protect the gut-mucosal barrier, which may limit infectious
complications and does not increase hospital length of stay or other complications.
Nasogastric or nasojejunal tube feeding may be considered at 3–5 days if oral feedings are not tolerated. Total
parenteral nutrition is indicated only when enteral feedings cannot supply adequate caloric intake or are not
possible for other reasons. The incidence of single or multiple organ failure or infected necrosis is significantly
A 57-year-old female who spends a lot of time working in her yard has pigmented areas on sun-exposed skin.
She has several of these and would like to address them for cosmetic reasons. An examination is consistent
with solar lentigines. One of these on her posterior leg has increased in size more rapidly.
Which one of the following would be the most appropriate next step for the lesion on the posterior leg?
B) A topical retinoid
C) Cryotherapy
D) Laser therapy
E) A biopsy
A
E) A biopsy
Solar lentigines occur on sun-exposed skin and are known commonly as liver spots. A biopsy should be
performed if they grow rapidly, change rapidly, are painful, itch, bleed easily, heal poorly, or have
therapy with hydroquinone or retinoids, or ablative therapy with chemical peels, cryotherapy, intense pulsed
According to U.S. Preventive Services Task Force guidelines, which one of the following interventions is
recommended after 12 weeks gestation in women who are at high risk for preeclampsia?
A) Aspirin, 81 mg daily
A
A) Aspirin, 81 mg daily
For women at high risk of developing preeclampsia, the U.S. Preventive Services Task Force (USPSTF)
While calcium appears to be helpful in preventing preeclampsia for women with a diet deficient in calcium, the
The USPSTF recommendation does not address the use of fish oil, magnesium gluconate, vitamin C, or vitamin
you for follow-up. He started running on his neighborhood streets 3 months ago to train for a 10K race. The
pain limits his training significantly. His symptoms improved when he began taking ibuprofen and took 2
weeks off from running a month ago. A radiograph of the left foot 4 weeks ago was normal. There is no other
On examination you note that his left heel is slightly swollen compared to the right and very tender when
squeezed on the sides. The anterior aspect and Achilles tendon insertion of the heel are nontender. There is
no erythema or warmth and the remainder of the left lower extremity examination is normal. His vital signs
are normal.
C) A repeat radiograph
D) Ultrasonography
E) MRI
A
E) MRI
This patient has a calcaneal stress fracture as suggested by the history of increased running on a hard surface,
improvement with rest, and a positive calcaneal squeeze on examination. A delay in diagnosis increases the
MRI is the preferred imaging modality because radiographs often do not detect a calcaneal stress
fracture.
A C-reactive protein level could be indicated if there were symptoms or signs of infection or autoimmune
illness.
The clinical picture does not suggest a neurologic condition, so nerve conduction velocity testing is not
appropriate.
While there are some case reports of the diagnosis of stress fractures using ultrasonography, this is not the
A 48-year-old female presents with the nail findings shown below. Her past medical history is significant for
A) clubbing
B) koilonychia
C) leukonychia
D) onychomycosis
Koilonychia, also known as spoon nail, is a finding that can be associated with multiple systemic conditions
Clubbing of the nails involves thickening of the soft tissue proximal to the nail.
Leukonychia is a white discoloration of the nail plate and can be a normal variant.
morphology.
--
107
Q
2019.107
A 38-year-old female presents for evaluation of infertility after being unable to conceive for the past 14
months. She has a history of type 2 diabetes, obesity, and hypothyroidism, and takes metformin (Glucophage)
and levothyroxine (Synthroid) daily. A review of systems is notable for menses that occur once every 35–50
days and persistent dark hair growth on her chin and areolae. An examination is remarkable only for a blood
pressure of 142/95 mm Hg, a BMI of 37 kg/m2, and the hair growth described by the patient.
Which one of the findings in this patient is a required diagnostic criterion for polycystic ovary syndrome?
A) Hyper-androgenism
B) Hypertension
C) Hypothyroidism
D) Infertility
E) Obesity
A
A) Hyper-androgenism
Several professional organizations have published criteria for the diagnosis of polycystic ovary syndrome
(typically oligomenorrhea), and the presence of at least one polycystic ovary by imaging criteria. Hypertension,
hypothyroidism, infertility, and obesity are common symptoms in patients with PCOS but are not diagnostic.
The National Institutes of Health advises that patients must have both
presence of two of the following: hyperandrogenism, ovulatory dysfunction, and at least one polycystic ovary.
The Androgen Excess and PCOS Society says that patients must have hyperandrogenism plus either
--
108
Q
2019.108
A 63-year-old male sees you after carotid ultrasonography at a local health fair showed a 50% occlusion of his
left proximal internal carotid artery. He has no significant past medical history and has never had a TIA or
stroke.
D) statin therapy and referral to a vascular surgeon for consideration of a carotid artery stent
E) statin therapy and referral to a vascular surgeon for consideration of carotid endarterectomy
A
C) statin therapy, and repeat ultrasonography in 1 year
Asymptomatic carotid artery disease is considered a coronary artery disease risk equivalent; therefore, statin
therapy is indicated. Repeating ultrasonography annually to monitor for progression of the disease and to
According to the 2014 guidelines for the primary prevention of stroke issued by the American Heart
in highly selected asymptomatic patients with >70% carotid stenosis, but the effectiveness of this
intervention compared with statin therapy alone is not well established. The guidelines also state
that it is reasonable to consider carotid endarterectomy for asymptomatic patients with >70%
--
109
Q
2019.109
A previously healthy 45-year-old female presents with upper abdominal pain and dysphagia. An upper GI
series reveals no significant reflux. On esophagogastroduodenoscopy the esophagus has a ringed appearance
and a biopsy reveals >15 eosinophils/hpf. Helicobacter pylori testing is negative. She does not currently take
any medications.
A
A) Budesonide oral suspension, 1 mg twice daily
The clinical presentation and esophagogastroduodenoscopy findings indicate eosinophilic esophagitis (EoE) in
this patient. In the absence of other causes of eosinophilia, the presence of >15 eosinophils/hpf is
considered diagnostic.
Application of corticosteroids to the esophagus is generally the treatment of choice, either in the
form of an oral suspension of budesonide or an inhaled corticosteroid sprayed into the mouth
and swallowed.
Although EoE can occur in patients with other atopic illnesses, this patient does not have any symptoms of
A 34-year-old female has posttraumatic stress disorder that started 6 months ago after she was a victim of an
armed robbery. She also has nightmares, anxiety, hypervigilance, and some paranoia and has been
reexperiencing the robbery. She has been receiving psychotherapy but would now like to start a medication.
Which one of the following would be the most appropriate medication to start?
A) Bupropion (Wellbutrin)
B) Buspirone
C) Lorazepam (Ativan)
D) Risperidone (Risperdal)
A
E) Venlafaxine (Effexor XR)
It is important for patients with posttraumatic stress disorder (PTSD) to receive psychotherapy. For those who
continue to have symptoms it is appropriate to initiate medications. SSRIs and venlafaxine are considered
The use of benzodiazepine medications is not recommended because of the high risk of misuse.
Antipsychotic medications would be appropriate in patients with disabling symptoms and behaviors
--
111
Q
2019.111
At a routine health maintenance visit a 36-year-old female reports that she had pharyngitis while she was in
high school and within 1–2 days of starting a course of penicillin she developed a nonpruritic rash. The
penicillin was stopped and she was given an alternative antibiotic and told she had an allergy to penicillin. Six
weeks ago she was inadvertently treated with amoxicillin in an evening clinic and had no adverse reaction.
B) She should have skin testing to determine her penicillin allergy status
C) She should have RAST testing to determine her penicillin allergy status
D) She does not have a penicillin allergy and can use penicillin and its derivatives in the future
A
D) She does not have a penicillin allergy and can use penicillin and its derivatives in the future
This patient was inadvertently challenged with amoxicillin and did not develop an allergic reaction. Her
Although a low-risk history allows for an amoxicillin challenge in the clinic under medical observation, patients
with moderate-risk histories of an urticarial or other pruritic rash should undergo skin testing.
If that testing is negative, it should be followed with an amoxicillin challenge under observation.
An 83-year-old female tells you she has had pain in her knees for the past 15 years, although she has never
discussed this problem with you before. After a thorough history and physical examination you diagnose
osteoarthritis.
Which one of the following would you recommend as the most appropriate first-line treatment to reduce this
patient’s pain?
A) Vitamin D
E) Supervised exercise
A
E) Supervised exercise
The goals of osteoarthritis therapy are to minimize pain and improve function. The American Academy of
Orthopedic Surgery and the American College of Rheumatology have agreed that first-line treatment includes
aerobic exercise, resistance training, and weight loss. For patients with osteoarthritis of the knee, supervised
exercise was found to reduce pain and improve physical function and quality of life (SOR A).
Vitamin D is not currently recommended, and glucosamine and chondroitin are less effective than placebo.
If patients have an inadequate response to these agents other treatments to consider include tramadol, other
B) carry the pregnancy to term and place the baby for adoption
A
A) carry the pregnancy to term and keep the baby
While recent data is not available, 45% of pregnancies in the United States in 2011 were unintentional. About
42% of pregnant women with unintended pregnancies chose to terminate the pregnancy by one means or
another. Of the 58% that chose to carry the pregnancy to term, only about 1% placed the infant for adoption.
--
114
Q
2019.114
A 72-year-old female presents for a routine health maintenance visit. Which one of the following medications
A) Atorvastatin (Lipitor)
B) Hydrochlorothiazide
C) Metformin (Glucophage)
D) Phenytoin (Dilantin)
E) Ranitidine (Zantac)
A
D) Phenytoin (Dilantin)
Medications reported to be associated with osteoporosis and increased fracture risk include
antiepileptic drugs,
long-term heparin,
cyclosporine,
tacrolimus,
aromatase inhibitors,
glucocorticoids,
thiazolidinediones,
SSRIs,
parenteral nutrients,
medroxyprogesterone contraceptives,
methotrexate, and
aluminum antacids.
Atorvastatin, hydrochlorothiazide, metformin, and ranitidine are not associated with osteoporosis.
--
115
Q
2019.115
Which one of the following is the greatest risk factor for abdominal aortic aneurysm (AAA)?
A) Male sex
B) Female sex
C) White race
A
D) A long duration of smoking
The following factors have been found to increase the risk for developing an abdominal aortic aneurysm
(AAA): a history of smoking, advanced age, above-average height, having a first degree relative with an AAA, a
personal history of atherosclerosis, high cholesterol levels, and hypertension. Smokers have a seven times
greater risk of developing an AAA compared with nonsmokers. This single factor outweighs all of the other risk
factors except age. Although women are less likely to develop an AAA, they have a 2–3 times greater chance of
In addition to significantly increasing the risk for AAA development, current smoking increases the risk for
further AAA expansion and rupture. Epidemiologic studies suggest that the duration of smoking influences the
risk for AAA significantly more than the total number of cigarettes smoked. The U.S. Preventive Services Task
Force currently recommends one-time screening for AAA in males between the ages of 65 and 75 who have
ever smoked (B recommendation). There was not enough evidence to determine the risk and benefits of
During an outbreak of head lice at a local school the principal asks you for advice to send home to the parents.
In addition to treatment with topical permethrin (Nix), which one of the following would you recommend?
D) Washing clothing and bedding in hot water and drying with hot air
A
D) Washing clothing and bedding in hot water and drying with hot air (REVIEW: 2018.137 )
The appropriate recommendation for head lice is to wash any recently used bedding and clothing with hot
water or expose them for 5 minutes to a temperature >130°F to kill lice and eggs.
Items that cannot be washed or dried in this manner or dry-cleaned should be sealed in a plastic bag for 2
weeks.
Additional or alternative treatments include topical ivermectin, benzoyl alcohol, malathion, and spinosad.
Other recommended measures include removal of any visible nits (eggs) with a nit comb, not a
brush.
Conditioners can interfere with the action of permethrin, decreasing its effectiveness.
Human head lice are specific to humans, so pets are not affected.
--
117
Q
2019.117
A 42-year-old bricklayer was diagnosed with acute bronchitis at an urgent care center 6–7 weeks ago. A chest
radiograph was negative for pneumonia but revealed a solitary pulmonary nodule. No previous chest
radiograph was available, so a follow-up chest radiograph was ordered for 4–6 weeks after the initial one. He
The patient’s bronchitis has since resolved, and he feels well. He has no significant past medical history and
does not take any medications. He has no constitutional symptoms and a physical examination today is within
normal limits. He has a 10-pack-year cigarette smoking history and quit 15 years ago.
If a lesion is noted on the chest radiograph, which one of the following characteristics would be most
A) A diameter of 5 mm
B) Concentric calcifications
E) Smooth borders
A
D) A nonsolid “ground glass” appearance
Characteristics that are more commonly associated with malignant lesions include
3.noncalcified lesions,
4.a lesion size or volume doubling time between 1 month and 1 year, and
Findings on a chest radiograph that are more commonly associated with benign lesions include
Other diagnostic imaging modalities are also utilized, including CT and PET, and a biopsy is sometimes
necessary to establish the diagnosis. Chest radiographs are still useful for monitoring patients with multiple
findings that correlate most often with benign lesions. Informed decision making by the patient and family
physician can sensibly guide the follow-up of patients with solitary pulmonary nodules without automatically
Immunotherapy can prevent recurrence of severe allergic reactions triggered by which one of the following
common allergens?
A) Penicillin
B) Poison ivy
C) Shellfish
D) Tree nuts
E) Wasp stings
A
E) Wasp stings
Wasp stings, penicillin, shellfish, and tree nuts are all relatively common causes of severe allergic reactions,
including anaphylaxis. Immunotherapy is available and recommended for the stings of insects, including
It is not available for penicillin, poison ivy, shellfish, or tree nut allergens. Poison ivy typically causes a type 4
A 46-year-old male who uses injectable heroin daily presents to establish primary care. He reports no
symptoms and feels well overall. He does not smoke cigarettes, use alcohol, or use any drugs other than
heroin. He works as an accountant for the federal government and has not had any arrests for illegal activity.
In addition to assessing his readiness for treatment of his addiction, you should order testing for
A) HIV only
A
D) HIV, hepatitis A, hepatitis B, hepatitis C, and TB
HIV,
hepatitis A,
hepatitis B,
hepatitis C, and
latent tuberculosis.
These patients should be screened at the initial visit and treated for any conditions found, according to routine
guidelines. If titers are low or absent for hepatitis A or B, the patient should be vaccinated.
Although gonorrhea and Chlamydia screening is recommended for females under 25 years of age who
A 13-year-old female is brought to your office by her father for evaluation of left knee pain. It has been slowly
worsening over the past several weeks and she does not recall any inciting injury or event. She plays soccer
and participates in practice 3 days a week with games on the weekends. She is finding it increasingly difficult
to participate fully due to pain. She notes some swelling and tenderness just below her kneecap. She has tried
icing the area after activity and has recently started taking ibuprofen with moderate relief of the pain.
On examination you note prominence of the tibial tubercle with tenderness to palpation. The remainder of the
Which one of the following is indicated at this time to further assess this condition?
A) No imaging
B) Radiography
C) Ultrasonography
D) CT
E) MRI
A
A) No imaging
This patient has Osgood-Schlatter disease, a common cause of knee pain in active children with immature
skeletons. It occurs as a result of abnormal development, injury, or overuse of the growth plate and the
Osteochondrosis is a more general term for this condition, which can occur at growth plates around other
joints, including the hip, foot, elbow, and back. In Osgood-Schlatter disease repetitive traction of the patellar
tendon on the tibial tubercle ossification center leads to inflammation and pain. Imaging is not required to
make the diagnosis when patients present with typical symptoms and physical examination findings.
Radiographs may be obtained if there is uncertainty about the diagnosis. Radiographic findings in Osgood-
Schlatter disease include soft-tissue swelling and fragmentation of the tibial tubercle.
This condition is self-limited and treatment consists of activity modification and the use
of acetaminophen or NSAIDs.
A 3-month-old white male is brought to your office for evaluation of three lesions on his buttocks. The lesions
began as vesicles that quickly progressed to flaccid bullae with sharp margins and no surrounding erythema.
The lesions ruptured and formed yellow crusts, which oozed yellowish liquid.
E) Topical nystatin
A
D) Topical mupirocin (Bactroban)
Bullous impetigo is caused by Staphylococcus aureus, which produces a toxin responsible for flaccid
This usually resolves within 3 weeks without scarring. Impetigo, either bullous or nonbullous, may be
Because of emerging drug resistance, oral azithromycin and other macrolides should not be used.
Oral penicillin is no longer recommended because it is less effective than other antibiotics such as
A 27-year-old gravida 3 para 2 presents in her first trimester for obstetric care. Her previous two pregnancies
did not have any complications. She asks which immunizations she needs during this pregnancy.
A) Hepatitis B
B) MMR
C) PCV13
D) Tdap
E) Varicella
A
D) Tdap (REVIEW: 2018.114 )
Maternal vaccination helps prevent disease in newborn infants. Currently, two vaccines are recommended for
Pneumococcal vaccine is currently being studied for this use but is not recommended.
--
123
Q
2019.123
A 75-year-old male nursing home resident is brought to the emergency department with a cough and fever.
His past medical history is significant for coronary artery disease, COPD, hypertension, and osteoarthritis. On
examination he has a blood pressure of 145/90 mm Hg, a pulse rate of 84 beats/min, and an oxygen
saturation of 89% on room air. A physical examination is remarkable for mildly labored breathing and crackles
in his left lower lung field. A chest radiograph confirms left lower lobe pneumonia. He is admitted to the
Which one of the following would be the most appropriate antibiotic treatment?
A) Cefdinir only
A
C) Ceftriaxone and azithromycin (Zithromax)
Current recommendations state that nursing home–acquired pneumonia should be treated as community-
acquired pneumonia unless patients have severe illness, chronic wounds, foreign bodies in the airway, a
history of antibiotic use in the last 90 days or recent hospitalization, colonization with multidrug-resistant
pathogens, or very low functional status, or reside in a facility with a high prevalence of multidrug-resistant
pathogens.
A 67-year-old male presents with a 3-month history of a worsening cough, shortness of breath, and
paroxysmal nocturnal dyspnea. On examination he has a heart rate of 78 beats/min, a blood pressure of
138/88 mm Hg, a respiratory rate of 18/min, and an oxygen saturation of 94% on room air. A physical
examination reveals jugular venous distention, bibasilar crackles, 2+ pitting ankle edema, and a displaced
apical impulse. An echocardiogram shows normal valvular structure and function with a left ventricular
Which one of the following would be most appropriate for this patient?
A
A) Furosemide (Lasix), 20 mg daily
This patient has diastolic heart failure, also called heart failure with preserved ejection fraction (HFpEF).
Patients who have HFpEF with active fluid overload should be treated with diuretics such as furosemide (SOR
B).
If concomitant hypertension is present along with HFpEF, the patient’s blood pressure should be treated
Although this patient’s blood pressure is elevated, a diagnosis of hypertension has not been confirmed, so
A 13-year-old who was assigned at birth as a female has been diagnosed with gender dysphoria. He presents
to your office after relocating because of bullying at school. The patient’s parents are present, with past
medical records, and fully support the desire of their child to affirm his gender as a male. On examination the
Which one of the following steps would be appropriate for optimal support and therapy for this patient?
A) Encourage conversion of the patient’s gender identity to be congruent with the gender assigned at birth
B) Recommend delaying gender-affirming treatment until he is at least 18 years old to prevent adverse
C) Order genetic testing and ultrasonography to confirm the gender assigned at birth
A
D) Offer gonadotropin-releasing hormone analogue treatment
Hormonal intervention therapy should not be offered prior to puberty. However, stage 2 or 3 of sexual
maturity is an appropriate time to consider gonadotropin-releasing hormone analogue therapy (SOR B).
Individuals who receive hormone therapy often report less anxiety, increased self-esteem, and better quality
unethical and against recommended guidelines to convert a person’s gender identity to the sex assigned at
This patient has brought medical records to the appointment, making it unnecessary to order confirmatory
testing, which may also induce emotional harm and additional medical costs.
--
126
Q
2019.126
A 38-year-old female presents for a health maintenance examination. Her laboratory results are unremarkable
and she has no acute symptoms. She has no family history of cancer.
According to the U.S. Preventive Services Task Force, this patient should be screened for which one of the
following?
A) Breast cancer
B) Colon cancer
C) Ovarian cancer
E) Hepatitis C
A
D) Intimate partner violence
Intimate partner violence and the abuse of older or vulnerable adults are common in the United States.
Immediate effects such as injury and death and other health consequences, including mental health
conditions, substance abuse, sexually transmitted infections, unintended pregnancies, and chronic pain, often
affect the traumatized individual. The U.S. Preventive Services Task Force recommends screening for intimate
Screening for breast cancer, colon cancer, ovarian cancer, or hepatitis C is not appropriate for this patient at
this time.
--
127
Q
2019.127
A 56-year-old male with a history of hepatitis C cirrhosis is admitted to the hospital with gastrointestinal (GI)
bleeding. The patient has been stable, taking only furosemide (Lasix) and spironolactone (Aldactone). Upper GI
endoscopy confirms variceal bleeding and the gastroenterologist performs appropriate variceal banding.
A nurse calls you because laboratory studies that were ordered in the emergency department reveal a serum
ammonia level of 120 g/dL (N 39–90). The patient has no signs of confusion, insomnia, or decreased mental
Which one of the following would be most appropriate for addressing the elevated ammonia level?
A) No additional treatment
B) Lactulose (Kristalose)
C) Methotrexate
D) Neomycin
E) Prednisone
A
A) No additional treatment
portosystemic shunting,
gastrointestinal bleeding,
shock,
renal disease,
heavy exercise,
smoking,
parenteral nutrition,
salicylate intoxication,
alcohol use.
In patients with chronic liver disease, hepatic encephalopathy is diagnosed based on the overall clinical
presentation and not on ammonia levels. A normal ammonia level does not exclude the diagnosis of hepatic
encephalopathy, nor does an elevated ammonia level establish the diagnosis. This patient had an elevated
serum ammonia level that was found incidentally during his hospital admission for gastrointestinal bleeding.
Because there was no clinically significant encephalopathy, treatment based on ammonia levels is not
indicated. The patient’s elevated ammonia level was probably from diuretic use.
A 22-year-old gravida 1 para 1 presents with her 4-day-old male infant for follow-up after an uncomplicated
vaginal delivery at term. She is exclusively breastfeeding and the child’s weight is currently 7% below his birth
weight and 2% below his weight at hospital discharge 2 days ago. You observe her breastfeeding technique in
Which one of the following would raise concerns that the mother or infant may be having difficulty with
breastfeeding?
An infant’s dimpled cheeks during breastfeeding is a sign of a poor latch, with the infant not getting enough of
With a good latch, most or all of the mother’s areola is completely in the infant’s mouth and thus not
The infant’s chin, not the nose, should be against the breast.
Inverted (rather than everted) or very large nipples may be problematic and require additional
lactation support.
The transition of the infant stool from dark meconium stools to yellow stools is a sign that the infant
is digesting milk.
--
129
Q
2019.129
A 35-year-old female is admitted to the hospital with fever, tachycardia, and hypotension. Her medical history
Which one of the following is the most common infection in patients such as this?
A) Cellulitis
B) Endocarditis
C) Osteomyelitis
D) Pneumonia
E) Pyelonephritis
A
A) Cellulitis (REVIEW: 2019.189 )
The most common complications for patients who inject drugs are skin and soft-tissue infections. These are
This patient is also at risk for endocarditis, osteomyelitis, pneumonia, and pyelonephritis, but these infections
A 37-year-old female presents with a 3-day history of left thumb pain. She first noted diffuse pain in her left
thumb after a fall while skiing. She does not recall the mechanism of injury. The pain is greatest at the medial
metacarpophalangeal joint, but there is no mass or instability. A radiograph does not show any fractures.
An examination reveals mild laxity in her ulnar collateral ligament with 30° of joint opening when abduction
stress is applied to the distal thumb while stabilizing the metacarpal. The right side has only 15° of joint
opening.
C) Immobilization of the left thumb in a thumb spica cast or brace for 6 weeks
A
C) Immobilization of the left thumb in a thumb spica cast or brace for 6 weeks (REVIEW: 2017.12 )
Ulnar collateral ligament (UCL) disruption, or “skier’s thumb,” should be suspected in traumatic thumb injuries.
It is important to recognize and treat this injury because it can lead to joint instability and a weak pincer grip if
untreated.
Initial treatment of UCL disruption involves immobilization of the affected thumb in a thumb spica
A Stener lesion (entrapment of the UCL outside of the adductor aponeurosis) would usually present
with joint instability and a tender mass and would necessitate an orthopedic referral.
--
131
Q
2019.131
Which one of the following laboratory tests is best for assessing thyroid function?
A) Free T3
B) Reverse T3
C) Free T4
D) TSH
The best laboratory assessment of thyroid function is a serum TSH test, which is the preferred test for
diagnosing primary hypothyroidism. If an elevated serum TSH level is detected and hypothyroidism is
Which disorder of sexual development is associated with an increased risk of endometrial cancer, celiac
D) Klinefelter syndrome
E) Turner syndrome
A
E) Turner syndrome
endometrial cancer,
Physicians providing primary care to patients with Turner syndrome should recognize these increased risks
and provide testing for celiac disease and serial screening for cardiac and/or aortic defects, and should also
Klinefelter syndrome carry increased risks of other conditions, but not endometrial cancer, celiac disease, or
A 25-year-old male presents to your office with a nearly 3-month history of a persistent, mildly productive
cough. He does not have any fevers, myalgias, or night sweats but is often congested. He has never smoked
and is normotensive. An examination is notable for a normal weight and vital signs, clear lungs, a mildly
Which one of the following is the most likely cause of this patient’s chronic cough?
A) Bronchogenic carcinoma
B) Chronic aspiration
D) Tuberculosis
A
E) Upper airway cough syndrome (REVIEW: 2018.205 )
2.tobacco use,
3.GERD,
4.asthma, and
Given the patient’s lack of tobacco use and normal blood pressure, bronchogenic carcinoma and obstructive
sleep apnea are less likely. There are no risk factors in this patient’s history to suggest chronic aspiration or
tuberculosis.
--
134
Q
2019.134
A 52-year-old male sees you for follow-up after his third episode of acute gout in the last year. The patient has
otherwise been in good health with recent normal laboratory results, including normal renal function. You
To reduce the risk of recurrent gout episodes, you also initiate therapy with which one of the following for the
next 6 months?
A) Colchicine (Colcrys)
B) Methotrexate
C) Prednisone
D) Probenecid
A
A) Colchicine (Colcrys) (REVIEW: 2018.209 )
Strong evidence suggests that prophylaxis with either colchicine or NSAIDs reduces the risk for acute gout
The optimal duration of such prophylactic therapy is unknown, but moderate evidence suggests that it should
Although prednisone would be helpful it is not the preferred agent in this patient with normal renal function.
A 65-year-old female with hypertension, osteoporosis, and GERD presents to your office for a well woman
visit. She reports no new symptoms or concerns. A review of laboratory work performed prior to her visit
reveals lipid levels at goal, normal glucose and sodium levels, a calcium level of 10.6 mg/dL (N 8.6–10.3), an
albumin level of 4.1 g/dL (N 3.6–5.1), and a 25-hydroxyvitamin D level of 35 ng/mL (N 20–50). Her calcium level
The patient’s medications include hydrochlorothiazide, 12.5 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily;
alendronate (Fosamax), 70 mg weekly; omeprazole (Prilosec), 20 mg daily as needed; and vitamin D, 2000 IU
In addition to ordering follow-up laboratory studies and scheduling a follow-up visit in 1 month, which one of
A) Discontinue alendronate
B) Discontinue hydrochlorothiazide
C) Discontinue lisinopril
A
B) Discontinue hydrochlorothiazide (REVIEW: 2018.198 )
Alendronate, lisinopril, and omeprazole do not cause hypercalcemia. A high vitamin D level can cause
hypercalcemia, so increasing vitamin D is not appropriate at this point. A laboratory evaluation can help
A 17-year-old male presents with right lateral ankle pain after twisting his ankle in a basketball game earlier
today. The area is mildly swollen. A radiograph shows soft-tissue edema but no evidence of fracture.
Which one of the following would be the most appropriate management of this condition?
B) Prolonged use of a patellar tendon strap to help unload the ankle joint
A
A) Use of a functional ankle brace with early mobilization
Early mobilization leads to better outcomes with ankle sprains, and using a functional ankle brace such as a
semi-rigid air stirrup brace or a soft lace-up ankle brace will protect the ankle from inversion and eversion
sprains while still allowing for mobility during physical activity. These braces lead to improved functional
outcomes at 1 month when compared to elastic compression taping. Patellar tendon straps relieve the pain
associated with patellar tendinopathy but are not indicated with acute ankle sprains. Use of a semi-rigid air
stirrup splint has been shown to be superior to neuromuscular training for prevention of recurrent ankle
sprains.
--
137
Q
2019.137
A 60-year-old patient is admitted to the hospital for a COPD exacerbation. For this patient, which one of the
A
A) 40 mg daily for 5 days
For patients with a COPD exacerbation, systemic glucocorticoids can improve FEV1, improve oxygenation,
shorten recovery time, and reduce the length of hospitalization (level of evidence A).
Prednisone, 40 mg daily for 5 days, is recommended for COPD exacerbations. Studies have shown
that oral administration is equally efficacious compared to the intravenous route. The duration of
therapy should not be longer than 5–7 days (level of evidence A).
--
138
Q
2019.138
Which one of the following is the most common cause of iron deficiency anemia in premenopausal women?
A) Blood donation
C) Hematuria
E) Colon cancer
A
D) Abnormal uterine bleeding
Abnormal uterine bleeding is the most common cause of iron deficiency anemia in premenopausal women,
accounting for 20%–30% of cases. Gastrointestinal causes are less common but should be considered if the
gynecologic evaluation is normal or the anemia fails to resolve with iron supplementation. Blood donation and
A 52-year-old female sees you because of hair loss. An examination reveals diffuse thinning of the hair along
the vertex, with sparing of the frontal hairline. Follicular orifices are still visible.
Which one of the following is the most likely explanation for these findings?
A) Alopecia areata
B) Anagen effluvium
C) Androgenetic alopecia
D) Tinea capitis
E) Trichorrhexis nodosa
A
C) Androgenetic alopecia
Androgenetic alopecia is associated with bitemporal thinning of the frontal and vertex scalp in men, but in
women the frontal hairline is spared and hair thinning is most apparent at the vertex.
There is often a family history of hair loss in patients with androgenetic alopecia. Alopecia areata results in
Anagen effluvium results in diffuse hair loss days to weeks after exposure to chemotherapeutic
Tinea capitis is a dermatophyte infection of the hair shaft and follicles that results in patchy hair loss
Trichorrhexis nodosa is characterized by breaks in the hair secondary to trauma or because of fragile
hair, often due to excessive brushing, heat application, or hairstyles that lead to pulling on hairs.
--
140
Q
2019.140
A 17-year-old female presents to your office with open and closed comedones on her nose, forehead, and
chin. No cystic lesions are noted and the acne does not extend to her back or chest.
A
A) Topical adapalene (Differin) and benzoyl peroxide
Acne affects 85% of 12- to 25-year-olds in the United States. This patient has mild acne as evidenced by the
Topical retinoids are first-line treatment for any level of severity of acne (SOR A).
Benzoyl peroxide is also very effective in the control of acne because it reduces the concentration of
cystic acne with no risk of bacterial resistance. The combination of a topical retinoid and benzoyl
Topical antibiotics such as clindamycin and erythromycin should not be used as monotherapy due to high
rates of microbial resistance. There is little evidence that salicylic acid is effective in combating acne despite its
widespread use.
Tazarotene is effective in the treatment of acne but is teratogenic (pregnancy category X) and should
Combined oral contraceptives can be effective, but norethindrone and other first-generation
A 52-year-old male business executive sees you for a routine health maintenance examination. He reports
good health and does not have any chest pain, shortness of breath, or fatigue. He has no family history of
premature vascular disease. A screening test for diabetes mellitus was normal 2 years ago. His lifestyle is
sedentary, and you note that his weight is up 4 kg from last year with a current BMI of 33 kg/m 2. He smokes an
occasional cigar. The patient tells you he wants his heart checked out thoroughly because a friend suffered a
major heart attack this year. In addition to counseling on diet, fitness, and healthy weight, you would
recommend
A) no EKG
C) a resting EKG and, if the findings are abnormal, follow-up with a stress EKG
A
A) no EKG
The U.S. Preventive Services Task Force (USPSTF) recommends against screening with either resting or stress
EKGs to prevent cardiovascular disease (CVD) events in asymptomatic individuals at low risk of CVD events (D
recommendation).
Potential harms of EKG screening include invasive confirmatory testing and treatment. The USPSTF concluded
that current evidence is insufficient to determine the balance of benefits and harms of screening with resting
or stress EKGs to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events (I
recommendation).
--
142
Q
2019.142
Which one of the following is higher on average in rural areas compared to urban areas?
A
D) The percentage of the population age 65 and older
Americans who live in rural areas face many health challenges compared to their counterparts who live in
urban areas. This includes health care workforce shortage problems. The number of primary care and
specialty care physicians, physician assistants, advanced practice nurses, registered nurses, dentists, and
People who live in rural areas are also affected by socioeconomic factors. They tend to be older and poorer on
average, with a higher percentage living below the poverty level. Rural areas also have higher unemployment
rates. In 2017, 18.1% of rural populations were over the age of 64 compared to 14.3% of urban populations.
Residents of rural areas are more likely to be uninsured and rely more heavily on the Supplemental Nutrition
Assistance Program (SNAP) and Medicaid. Fewer 18- to 24-year-olds in rural areas have high school diplomas.
Tobacco use is higher among rural youth, including cigarette smoking and smokeless tobacco use.
Health inequity issues are also challenges in rural areas, including higher rates of diabetes mellitus and
coronary heart disease. Deaths related to drug overdoses have been rising and in 2017 overtook the death
rate for people who live in urban areas. Family physicians are only 15% of the U.S.
--
143
Q
2019.143
A 48-year-old male is brought to the medical tent of a marathon after he became confused and dizzy in the
A
D) Full-body immersion in an ice bath
Heatstroke can be nonexertional from prolonged exposure to a high heat index, or it can be exertional, as in
this case. A core temperature >40°C (104°F) is consistent with heatstroke. In treating patients with either
clinical variant of heatstroke, cold or ice-water immersion is the most effective treatment and should be
initiated as soon as possible, without delaying for transfer to the hospital setting (SOR A).
Treatment should continue until the core body temperature is <39°C (102°F). If cold water immersion is not
possible other forms of cooling such as cold intravenous fluids, ice packs, cold water immersion of the
extremities, and evaporative cooling have been shown to have some benefit.
Once the body temperature is decreased patients should be transferred to a hospital for evaluation for known
complications of heatstroke, including coagulopathy, renal and hepatic dysfunction, hypoglycemia, electrolyte
An adult male sees you for follow-up of metabolic syndrome associated with type 2 diabetes and
hyperlipidemia. Routine laboratory findings include an AST level of 73 U/L (N 10–59) and an ALT level of 62 U/L
(N 13–40). These levels are persistently elevated 3 months later. He states that he drinks 1–2 glasses of wine
per week and does not use acetaminophen. His medications include metformin (Glucophage) and atorvastatin
(Lipitor).
A) Discontinue atorvastatin
B) Discontinue metformin
A
C) Screen for hepatitis and hemochromatosis
This patient most likely has nonalcoholic fatty liver disease (NAFLD). The initial evaluation should include
studies to rule out uncommon, but not rare, causes of liver disease. This would include viral hepatitis studies,
Discontinuing statin therapy is generally not necessary because statins have been shown to be safe
If NAFLD is determined to be the most likely cause, an NAFLD fibrosis score should be calculated to preclude
A 25-year-old landscaper presents with a 1-day history of pain and swelling in his left hand. Three days ago he
sustained a puncture wound in the palm of the hand when he was stuck by a large thorn. He has generalized
achiness and chills in addition to the hand pain. He has no significant past medical history.
On examination the patient’s temperature is 37.9°C (100.2°F). His left third finger is diffusely swollen,
erythematous, and held in flexion. There is tenderness along the third tendon in the palm. A radiograph of the
Which one of the following would be the most appropriate next step?
A
E) Urgent surgical consultation
Pyogenic flexor tenosynovitis usually develops 2–5 days after a penetrating hand injury. The flexor tendon
sheath has a poor vascular supply and the synovial fluid is a prime growth medium for bacteria. Flexor
Treatment includes prompt intravenous antibiotics and surgical debridement and irrigation.
Flexor tenosynovitis requires urgent surgical consultation and treatment. Patients with suspected flexor
tenosynovitis should be seen by a surgeon within 72 hours of symptom onset (SOR C).
Oral antibiotics and splinting of the hand alone are insufficient treatments for the condition.
Incision and drainage would also not be sufficient to clear the infection.
Ordering MRI can unnecessarily delay surgical consultation, although the surgeon may obtain one to
guide treatment.
--
146
Q
2019.146
An 85-year-old male with mild dementia, stage 4 chronic kidney disease, and insulin-dependent diabetes
mellitus has received a letter from his gastroenterologist stating that he is due for his next colonoscopy. He
had a normal colonoscopy 10 years ago and has no known high-risk indications for surveillance beyond those
C) overscreening
D) overdiagnosis
E) overtreatment
A
C) overscreening
Overscreening is defined as the use of screening tests at ages younger or older than the range recommended
Current guidelines from the U.S. Preventive Services Task Force recommend screening for colon
The decision to screen adults 76–85 years of age should be an individual one, taking into account the patient’s
overall health and prior screening history (C recommendation). In this case ordering a screening colonoscopy
would be an example of overscreening because the patient is above the recommended upper age of 75 and
he has multiple comorbid conditions that limit his life expectancy. Overscreening can result in increased cost,
morbidity, and/or mortality, especially in older individuals. Overdiagnosis is when a diagnosis is made
correctly, but the diagnosis is irrelevant because it will never cause symptoms or death during a patient’s
Which one of the following would be an indication for emergency contraception after unprotected
intercourse?
A) Being 2 days late for a depot medroxyprogesterone acetate (Depo-Provera) injection, which was given 1
B) Forgetting to change an etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) when the current ring has
C) Missing one dose of a combined oral contraceptive pill in the month prior to a sexual encounter
D) Failure to use backup protection such as a condom when using a progestin-only mini-pill with no missed
doses
A
B) Forgetting to change an etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) when the current ring has
In patients who use the etonogestrel/ethinyl estradiol vaginal ring, emergency contraception is recommended
if they have intercourse when the same ring has been in place for >5 weeks.
Backup protection is advised until the new ring has been in place for 1 week.
Backup protection is generally unnecessary with the depot medroxyprogesterone injection unless the patient
is more than 2 weeks late for her injection. Backup protection is then recommended for 7 days after the
injection.
Emergency contraception is recommended for women who miss two or more doses of
their combined contraceptive in 1 month, especially if these doses were missed during the first
week and unprotected intercourse occurs during that week. Backup protection should continue
until the oral contraceptive pill has been taken for 7 consecutive days.
Emergency contraception is generally only recommended up to 5 days after unprotected intercourse.
The progestin-only mini-pill is effective alone for contraception when taken as prescribed.
--
148
Q
2019.148
A 45-year-old African-American male with a several-month history of fatigue and anorexia with weight loss is
found to be anemic, with a hemoglobin level of 9.2 g/dL (N 14.0–18.0). Which one of the following microscopic
findings on a peripheral blood smear would be most characteristic of vitamin B12 deficiency anemia in this
patient?
E) Schistocytes
A
D) Hypersegmented polymorphonuclear WBCs
Vitamin B12 deficiency, which is most commonly related to a deficiency of intrinsic factor that is produced by
the gastric mucosa and is necessary for absorption of vitamin B12 in the terminal ileum, is manifested as
In addition to an elevated mean corpuscular volume, the classic finding on microscopy of the peripheral smear
is the presence of multiple (usually five or more) segments in the WBC nuclei. Vitamin B 12 levels are low and a
high methylmalonic acid level helps to confirm the diagnosis. A methylmalonic acid level is recommended in
patients who have borderline low vitamin B12 levels but are at risk for deficiency. Risk factors include chronic
proton pump inhibitor use; chronic metformin therapy; chronic malnutrition due to alcoholism, chronic
gastritis, or peptic ulcer disease; and diseases of the terminal ileum, such as Crohn’s disease. People who have
had gastric bypass surgery are also at risk for vitamin B12 deficiency, which is why supplementation should be
Microcytic, hypochromic RBCs are typical of iron deficiency anemia but may also be seen in anemia of chronic
disease. Sickled or crescent-shaped cells are seen with sickle cell anemia, and basophilic stippling may be seen
in anemia associated with lead toxicity. Schistocytes are seen in hemolytic anemia.
--
149
Q
2019.149
You are administering a mental status examination to a 92-year-old male with suspected dementia. You give
the patient a pencil and ask him to show how it is used. He gives you a bewildered look and eventually puts
A) executive functioning
B) gnosia
C) orientation
D) praxis
E) visuospatial proficiency
A
D) praxis
Praxis is the ability to carry out intentional motor acts and is commonly assessed by giving the patient a
common object such as a hairbrush or pencil and asking the patient to show how it is used. A patient unable
to carry out such motor acts is referred to as having apraxia (SOR C). Several other common components of
Executive functioning is the ordering and implementation of cognitive functions necessary to engage
in appropriate behavior and is often assessed by asking a patient to draw a clock with the hands
object such as a pen, watch, or stethoscope and asking whether he or she can identify it and describe how it is
used.
Orientation is the ability of the patient to recognize his or her place in time and space. Orientation is
commonly assessed by asking a patient the date, the current location, his or her name, and his or
Visuospatial proficiency is the ability to perceive and manipulate objects and shapes in space. It is often
assessed by asking the patient to copy intersecting pentagons or a three-dimensional cube on paper.
--
150
Q
2019.150
A 58-year-old male with well controlled type 2 diabetes presents for follow-up of ongoing exertional chest pain
that has been present for months with no significant change. He has a remote history of myocardial infarction
and recently underwent cardiac catheterization, which showed non-obstructing coronary artery disease with a
left ventricular ejection fraction of 60%. His current medications include aspirin, 81 mg; atorvastatin (Lipitor),
80 mg; lisinopril (Prinivil, Zestril), 40 mg; metoprolol succinate (Toprol-XL), 100 mg; and metformin
(Glucophage), 1000 mg twice daily. Home blood pressure monitoring shows an average blood pressure of
examination, is unremarkable.
Which one of the following medications would be the best addition to his current regimen?
A
A) Amlodipine (Norvasc), 2.5 mg daily
This patient has a blood pressure that is elevated according to all major current guidelines. Amlodipine, a long-
acting dihydropyridine calcium channel blocker (CCB), is the best pharmacologic choice because it will lower
blood pressure and treat angina without the risk of heart block.
Short-acting CCBs such as non–extended-release nifedipine may cause reflex tachycardia and are not
recommended.
Nondihydropyridine CCBs such as diltiazem would put this patient at risk for heart block because he is
already taking long-acting metoprolol and his heart rate is in the 50s.
Long-acting nitrates and ranolazine are options to treat stable angina but would not be effective
--
151
Q
2019.151
A 28-year-old male presents to your office in January with a 1-day history of cough and nasal congestion. He
has not had any fever, shortness of breath, or chest pain. An examination reveals some rhinorrhea and
hoarseness. A lung examination is normal. The patient asks you to prescribe albuterol (Proventil, Ventolin)
Which one of the following would be the most appropriate evidence-based response to the patient’s request?
A
A) Do not prescribe albuterol
In a Cochrane review of five trials of 2-agonist therapy in adults, there was no significant difference between 2-
agonists and placebo in cough reduction. Based on reports of adverse effects, the number needed to harm is
2. It is important to set reasonable expectations for cough duration after an acute respiratory illness.
--
152
Q
2019.152
An 8-year-old male was brought to your office 7 months ago because of frequent diarrhea and abdominal
discomfort that had been present for 1.5–2 years. An examination revealed no abnormalities. A CBC, a serum
iron level, and a metabolic panel were normal. Serology was consistent with celiac disease and a duodenal
biopsy confirmed the diagnosis. The patient’s symptoms resolved after his parents took him to a nutritionist
who recommended a gluten-free diet. Today you see the child for preventive care and he remains
asymptomatic.
In addition to normal well child care, which one of the following would you recommend?
A) No further testing
A
D) IgA tissue transglutaminase antibody
Celiac disease affects approximately 1% of the U.S. population and can affect all ages. Individuals with
northern European ancestry are most commonly affected. The condition is caused by autoimmunity induced
Untreated celiac disease is associated with anemia, malabsorption, osteoporosis, weight loss, and
gastrointestinal lymphomas.
The World Gastroenterology Organisation recommends annual monitoring of children and adolescents with
The preferred serology is IgA antibody to tissue transglutaminase (IgA anti-tTG) due to its balance of
Failure of IgA anti-tTG titers to decrease in 6 months suggests continued ingestion of gluten.
Repeat duodenoscopy with a biopsy would be unnecessary and would subject the child to potential harm.
--
153
Q
2019.153
A 24-year-old female sees you for a routine wellness examination. She tells you that she and her husband
A) Folic acid
B) Vitamin B6
C) Vitamin B12
D) Vitamin C
E) Vitamin D
A
A) Folic acid (REVIEW: 2018.202 )
Women of reproductive age should take a daily supplement of 0.4–0.8 mg of folic acid starting before
conception in order to reduce the risk of neural tube defects. A higher folic acid dosage of 4 mg daily starting 1
month prior to conception is recommended for women who have a high risk of pregnancy complicated by a
neural tube defect. This includes women with a previous pregnancy with a neural tube defect, a personal or
family history of neural tube defects, type 1 diabetes, or a seizure disorder. Vitamin B6, vitamin B12, vitamin C,
An unimmunized child is brought to the local health department and diagnosed with measles. All individuals
at the day care facility that the child attends were exposed to this child about 48 hours prior to the diagnosis.
Which one of the following should be given the MMR vaccine as postexposure prophylaxis?
B) A 5-year-old child with asthma who received a second dose of MMR 2 weeks ago
C) A pregnant 24-year-old day care staff member who received two doses of MMR as a child
D) A pregnant 36-year-old day care staff member who had one dose of MMR vaccine last year when she
E) A 52-year-old nurse who works part-time at the day care facility and received two doses of MMR as an adult
A
A) An otherwise healthy 9-month-old child who is up to date on all age-appropriate immunizations
Measles outbreaks are becoming more common and the CDC has outlined who should receive postexposure
prophylaxis with the MMR vaccine. To be effective as postexposure prophylaxis the vaccine must be
Infants <12 months of age are considered to be at high risk for complications from measles and should
Children who are otherwise fully vaccinated do not need additional prophylaxis.
Pregnant women cannot receive the MMR vaccine due to fetal risk, but they should receive intravenous
previously.
--
155
Q
2019.155
A 13-year-old male is admitted to the hospital with diabetic ketoacidosis. Aggressive fluid resuscitation with
normal saline was initiated in the emergency department and the following laboratory results were obtained:
Glucose……………… 400mg/dL
Bicarbonate……….. 15mEq/L(N22–29)
Aniongap……………. 14mEq/L(N10–20)
In addition to continued fluid resuscitation, which one of the following would be the most appropriate next
B) Potassium replacement
A
B) Potassium replacement
Correcting the potassium level is the best treatment choice for this patient. A low serum potassium level in
diabetic ketoacidosis (DKA) indicates a significant potassium deficiency, placing the patient at risk for a cardiac
Potassium deficiency is usually the product of urinary losses due to glucose osmotic diuresis and
secondary hyperaldosteronism. However, serum potassium can remain normal when there is a whole body
deficiency, as a result of movement of potassium out of cells in response to the acidosis, insulin deficiency,
and hyperosmolality. This patient’s serum potassium is low, which indicates severe deficiency.
Sodium bicarbonate can be used in some cases of DKA but is not the most important next step in this case. If
insulin therapy is initiated prior to potassium replacement the insulin can force more potassium into cells,
worsening the serum deficiency. If the serum potassium level is <3.3 mEq/L potassium should be replaced
prior to insulin therapy. Ketone measurement can also be part of DKA management but is not the most
A 25-year-old male presents to your office with anxiety. During questioning he reveals that he struggles with
opioid addiction since he underwent an appendectomy 2 years ago, and is anxious because of random drug
screens in his workplace. He averages using about 30 mg of hydrocodone daily and goes through cycles of use
and withdrawal. Screening is negative for alcohol and substance use disorders other than opioids, and for
depression or other mental health disorders. You consider maintenance treatment for opioid use disorder
with buprenorphine.
B) should not be combined with naloxone therapy because of potential side effects
A
D) can be initiated only after inpatient detoxification (REVIEW: 2018.157 )
Buprenorphine therapy is an important option for maintenance therapy for patients with opioid use disorder.
It can be initiated in the outpatient setting but should be done when the patient is in mild to
moderate withdrawal in order to avoid the risk of precipitated withdrawal (SOR C).
Buprenorphine therapy is more convenient than methadone maintenance therapy and is equally as effective.
Buprenorphine/naloxone combinations are preferred over buprenorphine monotherapy due to lower abuse
potential, except when naloxone is contraindicated such as in patients who are pregnant or breastfeeding
(SOR C).
Because relapse rates are higher in patients who discontinue medication-assisted therapy for opioid use
A 64-year-old female with a long-standing history of COPD presents with a 1-day history of dizziness and
Which one of the following is the most likely cause of her symptoms?
A) Atrial fibrillation
C) Myocardial infarction
D) Pulmonary embolism
A
A) Atrial fibrillation
Atrial fibrillation is characterized by an irregularly irregular rhythm, without any discernible P waves. In
multifocal atrial tachycardia the P waves show varying morphology, and this rhythm is typically seen in
patients with underlying lung disease, especially COPD. Acute ST-segment elevation myocardial infarction is
characterized by the presence of hyperacute ST-segment and T-wave changes in contiguous EKG leads,
tachycardia (a heart rate 100 beats/min), nonspecific ST-T changes, and new-onset right bundle branch block
(SOR C).
--
158
Q
2019.158
A 50-year-old female with diabetes mellitus presents with an insidious onset of right shoulder pain. She does
not recall any injury. The pain is a dull ache that is difficult for her to localize. She has noticed a decreased
range of motion, particularly with reaching overhead, and it seems to be getting progressively worse. She has
not had any fevers, chills, numbness, weakness, or other joint involvement.
There is no tenderness to palpation anywhere, including the acromion, acromioclavicular joint, or biceps
tendon. The patient has a marked loss of active and passive range of motion in shoulder flexion, abduction,
A) Acromioclavicular arthropathy
B) Adhesive capsulitis
C) Glenohumeral arthritis
E) Subacromial bursitis
A
B) Adhesive capsulitis
Risk factors for adhesive capsulitis include female sex, age between 40 and 60 years of age, diabetes mellitus,
and hypothyroidism.
This is a clinical diagnosis of exclusion that is based on physical findings of loss of active and passive
range of motion.
Glenohumeral arthritis may present with similar findings but is ruled out by normal radiographs.
A patient with acromioclavicular arthritis will have radiographic findings and a painful cross-arm test.
Rotator cuff disease and bursitis typically present with painful active range of motion but preserved passive
An 85-year-old female presents to your office to establish care. She has a history of essential hypertension,
bilateral osteoarthritis of the knees, depression, and hypothyroidism. The patient feels well and has only mild
pain from her osteoarthritis. A recent basic metabolic panel showed a sodium level of 132 mEq/L (N 135–145)
but was otherwise unremarkable. A TSH level was 1.07 uU/mL (N 0.45–4.50).
Which one of the medications in this patient’s current regimen is most likely causing the hyponatremia?
A) Acetaminophen
B) Hydrochlorothiazide
C) Levothyroxine (Synthroid)
E) Vitamin D
A
B) Hydrochlorothiazide (REVIEW: 2019.135 )
Hyponatremia is an extremely common condition, affecting 4%–7% of the ambulatory population. While a
number of medications can cause hyponatremia, among the most common offenders are SSRIs and thiazide
diuretics. Acetaminophen and metoprolol are not known to affect sodium levels. Vitamin D deficiency has also
been linked to hyponatremia so supplementation would likely improve rather than worsen hyponatremia.
--
160
Q
2019.160
A 58-year-old female presents to your office to discuss a new diagnosis of COPD. She has a 40-pack-year
smoking history, and she quit using tobacco 18 months ago. Spirometry performed last week showed an
FEV1/FVC ratio of 0.62 with an FEV1 that is 75% of predicted. She was first treated for an exacerbation last
month and has never required hospitalization for any respiratory illness. You administer a COPD assessment
test and she rates herself at 16/40, which is a moderately high score.
Which one of the following inhaled medications would be appropriate to initiate today?
B) Fluticasone (Flovent)
C) Fluticasone/salmeterol (Advair)
D) Ipratropium (Atrovent)
E) Tiotropium (Spiriva)
A
E) Tiotropium (Spiriva) (REVIEW: 2019.91, 2019.137, 2018.216 )
This patient has airflow obstruction consistent with a diagnosis of COPD, evidenced by an FEV1/FVC ratio <0.7.
An evidence-based standard approach to COPD is found in the annual guidelines published by the Global
According to the 2019 report, this patient’s FEV1 of 75% of predicted puts her in the GOLD grade
Patients in this category have symptoms that bother them regularly without having frequent COPD
exacerbations. Patients in this category benefit from daily use of long-acting bronchodilators, either
Long-acting agents such as tiotropium (a LAMA) or salmeterol (a LABA) are preferred over the short-acting
agents ipratropium and albuterol for patients in this category of disease severity.
Patients with persistent symptoms while using one of these agents may benefit from a combination of a LABA
and a LAMA.
Monotherapy with inhaled corticosteroids has not been shown to improve mortality or prevent a
The combination of an inhaled corticosteroid plus a LABA has evidence of superiority over either agent alone
for improving lung function and health status, and for reducing exacerbations in patients who have more
Pregnancy increases the risk for all of the following dental disorders EXCEPT
A) dental caries
B) loose teeth
C) gingivitis
D) impacted molars
E) periodontitis
A
D) impacted molars
Impacted molars are a mechanical problem where the tooth does not emerge properly because of abnormal
angulation or not enough room in the mouth. Pregnant women may experience impacted third molars
(wisdom teeth) because they typically emerge in the late teens or early twenties, but pregnancy itself does not
However, the risk of dental caries, loose teeth, gingivitis, and periodontitis all increase during pregnancy.
Pregnant women are at higher risk for dental caries because the oral cavity is exposed to
more gastric acidity due to vomiting with morning sickness, and acid reflux due to a lax esophageal
Increased levels of estrogen and progesterone during pregnancy can relax the ligaments and bones
Gingivitis and periodontitis increase during pregnancy because of a fluctuation in estrogen and
progesterone levels in combination with changes in oral flora and a decreased immune response.
Periodontitis is of particular concern during pregnancy and should be treated because of its
--
162
Q
2019.162
A 38-year-old female has a 4-year history of intermittent abdominal pain occurring several days per week. She
went to an urgent care clinic over the weekend and has brought her laboratory results for you to review. A
comprehensive metabolic panel, CBC, and TSH level are all normal. She states that her stools have become
harder and difficult to pass, with frequent straining and pain. She reports now having a bowel movement only
2–3 times a week. She tells you that she tried psyllium but it resulted in abdominal bloating. She is concerned
Her past and family medical histories are otherwise negative. Her vital signs are normal and her weight is
unchanged from a previous wellness visit 6 months ago. An abdominal examination is notable for generalized
pain with deep palpation. She does not have any masses, hepatosplenomegaly, or rebound tenderness. A
A) Celiac disease
B) Colon cancer
C) Hyperparathyroidism
A
E) Irritable bowel syndrome
The Rome IV criteria for irritable bowel syndrome are symptom-based diagnostic criteria used to identify
patients with irritable bowel syndrome (IBS). According to these criteria, IBS is defined as:
1.recurrent abdominal pain at least 1 day per week for at least 3 months.
The diagnosis can be made from the patient history, a physical examination, and a minimal laboratory
This patient does not have any “alarm” symptoms (a positive family history of colorectal cancer, rectal bleeding
in the absence of documented bleeding hemorrhoids or anal fissures, unintentional weight loss, or anemia) so
colon cancer would be unlikely. Celiac disease and inflammatory bowel disease are unlikely in a patient with
constipation-predominant IBS. Serologic and inflammatory marker testing would be warranted in patients
with predominant diarrhea or mixed types of IBS. Hyperparathyroidism does not usually present with this
A 67-year-old male presents with a 12-hour history of the inability to urinate. He also reports mild symptoms
of benign prostatic hyperplasia that he has tolerated for the last couple of years. Today he has significant
discomfort in his suprapubic area, and his bladder is palpable. He has not had any fever or recent painful
Which one of the following would be the initial treatment for this patient’s acute urinary retention?
A) An oral alpha-blocker followed by urethral catheter placement if he is unable to void within 24 hours
B) Urethral catheter placement with immediate removal after draining the bladder
A
C) Urethral catheter placement followed by continuous drainage for 3 days
Acute symptomatic urinary retention should be treated with immediate urethral catheterization. The catheter
During this time the patient should be evaluated for underlying causes of the retention, such as infection, and
prescribed or over-the-counter medications. Starting an alpha-blocker while the catheter is in place should be
considered, but initial treatment with an alpha-blocker without catheterization is not indicated. Suprapubic
catheter placement should only be used when urethral catheterization is unsuccessful. Transurethral
resection of the prostate may be necessary later but is not the initial treatment.
--
164
Q
2019.164
A 45-year-old female presents with pain in her right hand and wrist. She is right hand–dominant and most
symptoms are in the right hand and wrist. She has been awakening at night with numbness of the hand that
improves after she shakes her wrist. Her work as a software engineer involves lots of typing.
On examination you note a positive Tinel’s sign at the right wrist consistent with carpal tunnel syndrome. She
has an important project at work over the next several months and will not be able to take any time off.
Which one of the following treatments has the best evidence for delaying the need for definitive surgical
therapy?
A) Night splints
B) Physical therapy
C) Therapeutic ultrasound
D) Oral corticosteroids
E) Corticosteroid injection
A
E) Corticosteroid injection (REVIEW: 2018.127)
Carpal tunnel syndrome of mild to moderate severity can be treated nonsurgically. Patients with severe
symptoms or nerve damage seen on electromyography should be referred for surgical therapy. Nonsurgical
management options include splinting, physical therapy, therapeutic ultrasound, and corticosteroids (oral or
injection). Oral prednisone, 20 mg daily, for 10–14 days improves symptoms and function compared with
placebo, for up to 8 weeks, but oral corticosteroids are less effective than corticosteroid injections. In a 2013
double-blind, placebo-controlled, randomized clinical trial comparing methylprednisolone injection (40 mg and
80 mg) to saline injection, patients in the 80-mg injection group were less likely to have surgery at 12 months.
While corticosteroid injections have the best evidence for delaying the need for surgery, night splints, physical
therapy, and therapeutic ultrasound have some evidence of benefit. Splinting was found to be effective in a
Cochrane review. It is low cost and safe and especially recommended in pregnancy-related disease. Limited
evidence supports the use of physical therapy to treat carpal tunnel syndrome. Nerve glide exercises are
simple hand and finger movements that are easy to learn, can be performed at home, and can be combined
with other treatments such as splinting. Therapeutic ultrasound also has limited evidence of benefit. It
requires an experienced therapist and requires multiple sessions, typically 5 days/week for 2–4 weeks.
--
165
Q
2019.165
A 46-year-old female presents to your office with a 24-hour history of moderate pleuritic chest pain. She does
not take any medications and has been in excellent health. A physical examination is normal, including pulse
oximetry, and a chest radiograph is also normal. You diagnose viral pleurisy.
A) Colchicine (Colcrys)
B) Ibuprofen
C) Prednisone
D) Tramadol (Ultram)
A
B) Ibuprofen
NSAIDs such as ibuprofen should be used as first-line treatment for the control of pleuritic pain (SOR B).
NSAIDs do not have the analgesic potency of narcotics, but they do not cause respiratory suppression and do
not change the patient’s sensorium. Corticosteroids should be reserved for patients who cannot take NSAIDs.
A 43-year-old female comes to your office to establish care. She reports a long history of uncontrolled
hypertension. She is taking several medications that have been prescribed over the years.
Which one of the following medications should be discontinued 4–6 weeks prior to obtaining a plasma
A) Hydralazine
B) Potassium chloride
C) Spironolactone (Aldactone)
D) Terazosin (Hytrin)
E) Verapamil (Calan)
A
C) Spironolactone (Aldactone) (REVIEW: 2019.135, 2019.159 )
Patients with secondary hypertension frequently take several medications and are classified as having
“resistant” hypertension. It is important to recognize that many antihypertensive medications can affect the
aldosterone levels and should be discontinued 4–6 weeks before obtaining a ratio.
Angiotensin receptor blockers and ACE inhibitors can increase renin levels.
Oral potassium supplements should be continued or started in patients with hypokalemia, since
Medications such as hydralazine, terazosin, and verapamil may be continued or started for blood
An 88-year-old female hospice patient is experiencing significant agitation and delirium. After attempting
conservative treatments and ruling out reversible causes of her symptoms, which one of the following
A) Alprazolam (Xanax)
B) Amitriptyline
C) Diphenhydramine (Benadryl)
D) Risperidone (Risperdal)
A
D) Risperidone (Risperdal)
Agitation and delirium are common end-of-life symptoms. It is important to assess for treatable causes,
including constipation, urinary retention, uncontrolled pain, and adverse medication effects. The antipsychotic
medication risperidone is effective for treating agitation and nausea at this stage, but dosing is much lower
Benzodiazepines can provoke increased agitation and should be used with caution; however, they
Generally, a longer-acting form such as lorazepam would be a better choice than short-acting
alprazolam.
Amitriptyline and diphenhydramine can both cause urinary retention, potentially leading to delirium
and agitation.
--
168
Q
2019.168
You are evaluating a 2-year-old white male who was seen in the emergency department 1 week ago for a
generalized seizure. The seizure lasted approximately 45 seconds and was followed by a postictal state, but
there have been no recurrences. A CBC, electrolyte levels, MRI of the brain, and an EEG were all normal.
The parents of the child ask your advice regarding drug therapy. You should inform the parents that
antiepileptic drugs
A
A) are not indicated at this time
For patients who experience a seizure, the risk factors for recurrent seizures include two unprovoked seizures
more than 24 hours apart, epileptiform abnormalities on an EEG, abnormal brain imaging results, severe head
trauma, and a syndrome associated with epilepsy. In children who do not have any of these risk factors,
antiepileptic drug therapy is not indicated after a first unprovoked seizure. When there are no risk factors
there is no difference in 1- to 2-year seizure remission rates if antiepileptic drug therapy is started after a
second seizure as opposed to starting it after the first seizure. If therapy is indicated, monotherapy should be
the initial approach. The risk of adverse effects of drug therapy are as high as 50%. This includes subtle
A 15-year-old male presents for a sports preparticipation examination. His family history includes
hypertension in his mother. There are no other concerns. He does not take any medications or supplements.
An examination shows a BMI at the 75th percentile for his age. His weight is 59 kg (130 lb) and his blood
pressure is 130/88 mm Hg. On repeat measurements 30 minutes apart, his blood pressure is 132/90 mm Hg
and 132/88 mm Hg. The remainder of the examination, including vital signs, is normal.
Which one of the following would you recommend at this time?
A
A) Therapeutic lifestyle changes with close follow-up in 2–3 weeks
This patient has stage 1 hypertension based on his average blood pressure of 131/88 mm Hg after three
measurements. He is asymptomatic so the initial recommendation is therapeutic lifestyle changes and close
If his blood pressure remains elevated, an evaluation for secondary hypertension would be appropriate.
Medication would be appropriate for stage 1 hypertension with either evidence of end-organ disease or
persistent hypertension after a trial of therapeutic lifestyle changes or progression to stage 2 hypertension
(SOR C).
Thiazide diuretics or ACE inhibitors would be appropriate choices for initial treatment.
ß-Blockers are no longer considered first-line treatment for hypertension in adolescents or children.
This patient would need blood pressure monitoring at every visit due to his elevated blood pressure.
--
170
Q
2019.170
Which one of the following is an indication to consider ultrasonography to screen for developmental dysplasia
E) A female infant with a first degree relative with developmental dysplasia of the hip
A
E) A female infant with a first degree relative with developmental dysplasia of the hip
Screening for developmental dysplasia of the hip (DDH) is somewhat controversial because the benefit of
treatment remains somewhat unclear. Despite the widespread practice of screening for DDH, ethical newborn
practices are difficult to determine. The American Academy of Family Physicians and the U.S. Preventive
Services Task Force have found insufficient evidence to recommend routine screening for DDH. The American
Academy of Pediatrics, however, recommends routine screening of all newborns with physical examination
maneuvers, and targeted screening ultrasonography for infants who were breech in the third trimester, have a
family history of DDH, or have a personal history of instability. Given this, decisions should be individualized.
Additional risk factors include female sex, firstborn status, oligohydramnios, and a large-for-gestational-age
infant.
--
171
Q
2019.171
A) Supplementation for all children whose primary water source is well water
B) Starting supplementation at 6 months of age if the primary water supply is fluoride deficient
C) Starting supplementation at 2 years of age even in children who have received topical fluoride varnish
D) No supplementation if fluoride varnish is applied once all primary teeth have come in or by 3 years of age,
The U.S. Preventive Services Task Force recommends oral fluoride supplementation for the prevention of
dental caries beginning at age 6 months for children whose primary water supply is fluoride deficient (B
recommendation). Well water may be fluoridated naturally depending on the aquifer, but the water is highly
variable and should be tested before deciding on the need for supplementation. Testing well water is also
advisable because excessive fluoride may lead to fluorosis of the bones. Bottled water is variable, making it
varnish, is effective in preventing tooth decay in children and can be used in addition to properly fluoridated
water. Twice-yearly application of fluoride varnish to primary teeth should begin when the first tooth comes in
A 10-year-old male is brought to the emergency department with a history of group A ß-hemolytic
Streptococcus confirmed with a throat culture 2 weeks ago. His parents gave him antibiotics for 3 days then
stopped them because his symptoms were gone. He now has a temperature of 38.9°C (102.0°F), a heart rate
of 122 beats/min, and right hip and left knee pain with swelling.
Which one of the following would be the most appropriate initial pharmacologic therapy for acute rheumatic
A) Acetaminophen
B) Gabapentin (Neurontin)
C) Hydrocodone
D) Naproxen
A
D) Naproxen
Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be
Acetaminophen has not been shown to be a superior analgesic for acute rheumatic fever.
Gabapentin is not indicated, especially considering that the pain does not have a neuropathic
etiology.
Opioids would not be considered first-line treatment because of their adverse effects and the
--
173
Q
2019.173
A 67-year-old female who recently moved to your city presents to your office as a new patient. Over the past
year she has experienced wheezing and shortness of breath during her morning walks. She has a 35-pack-year
smoking history and has been treated with antibiotics at least four times in the past year for respiratory
infections. You suspect COPD and perform spirometry before and after a bronchodilator treatment.
Which one of the following pulmonary function test results would confirm COPD in this patient?
A
C) An irreversible FEV1/FVC ratio <65%
A large cohort study indicated that the Global Initiative for Chronic Obstructive Lung Disease
criterion (FEV1/FVC ratio <70%) is more sensitive for COPD in individuals 65 years and older compared to the
A 90-year-old male presents to the emergency department with chest pain, dyspnea, and diaphoresis. He has
experienced these symptoms intermittently since his wife died last week. An EKG shows ST elevation in the
anterior leads, and cardiac enzymes are elevated. An echocardiogram shows apical ballooning of the left
ventricle. Cardiac catheterization does not reveal coronary vascular disease. You plan to discharge the patient
Which one of the following would be the most appropriate management of this patient’s stress-induced
C) A diuretic, ACE inhibitor, and ß-blocker until his symptoms and the abnormalities seen on the
echocardiogram resolve
E) Pacemaker placement
A
C) A diuretic, ACE inhibitor, and ß-blocker until his symptoms and the abnormalities seen on the
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, can develop following emotional
distress and is characterized by the abrupt onset of dysfunction of the left ventricle.
The clinical presentation and laboratory studies can mirror acute coronary syndrome and should be treated
similarly. Once symptoms and cardiac abnormalities resolve, treatment is no longer indicated and may be
indicated.
Ambulatory cardiac monitors are not indicated for this patient with a known diagnosis of Takotsubo
cardiomyopathy.
--
175
Q
2019.175
Among patients prescribed metered-dose inhaler treatments, technical errors in using the device are most
likely in patients
A
D) >75 years of age
Studies have documented an increased rate of metered-dose inhaler (MDI) use errors in certain patient
subgroups that could adversely affect the efficacy of treatment. For patients over the age of 15, the ability to
demonstrate correct MDI use drops significantly with increasing age. One large study of MDI technique, after a
minimum of 3 months of prescribed use, confirmed error frequencies of 61% in patients 15–30 years of age,
70% in patients 30–60 years of age, 77% in patients 60–75 years of age, and 86% in patients >75 years of age.
Other patient characteristics also affect MDI error rates. A higher level of education and a diagnosis of asthma
rather than COPD are both associated with fewer errors, whereas the frequency of errors is higher for females
and lower-income patients. Disease severity and the presence of comorbidities has also been found to affect
MDI use. The error rate is lower for patients who have had prior training, and the rate of proper usage relates
A 2-year-old male is brought to your office by his mother. The child has a 2-day history of a runny nose and
mild cough associated with a subjective fever. The cough worsened last night. The patient has had a reduced
On examination the child has an axillary temperature of 37.4°C (99.3°F), a heart rate of 120 beats/min, a
respiratory rate of 26/min, a weight of 16 kg (35 lb), and an oxygen saturation of 96% on room air. He appears
mildly ill but is alert and does not show any signs of distress, and has a prominent high-pitched barking cough.
You note that he has clear rhinorrhea, the tympanic membranes are normal, and the oropharynx is moist and
clear. Auscultation reveals inspiratory stridor, but there are no signs of respiratory distress. The patient’s skin
Which one of the following would be the most appropriate next step in the management of this child?
A
A) Administration of dexamethasone, 0.6 mg/kg orally in a single dose (REVIEW: 2018.131 )
Hospitalization is not necessary if the child is stable. Racemic epinephrine, which has been shown to reduce
symptoms at 30 minutes but not at 2 hours or 6 hours, is recommended for the treatment of moderate to
severe croup when patients are being observed in a medical setting such as the emergency department or
hospital (SOR A). Amoxicillin and albuterol are not indicated in the management of croup.
--
177
Q
2019.177
A 47-year-old male presents to your office in a small town in Massachusetts. He has fevers, chills, and muscle
and joint aches. He does not have any joint swelling, numbness, tingling, headache, or chest pain. He says he
was working outside last Saturday and his wife removed a tick from his back that evening.
On examination he is febrile and appears moderately ill. The examination is notable for an erythematous
Which one of the following would be the most appropriate next step?
B) A Western blot
A
D) Doxycycline, 100 mg twice daily for 10 days
erythema migrans,
fever,
myalgias, and
arthralgias.
Longer treatment periods are required for Lyme arthritis and patients may require intravenous
antibiotics.
With this patient’s clinical presentation, antibiotic treatment would be recommended and serologic
testing is not needed. In clinical scenarios where diagnostic testing is needed, testing for early Lyme
disease should be performed with a two-tier test starting with an enzyme immunoassay and, if
--
178
Q
2019.178
You and your office educator are preparing printed educational materials for patients, families, and
caregivers. Based on current recommendations, the educator advises that these should be written at or below
A) First grade
B) Fifth grade
C) Eighth grade
D) Tenth grade
E) Twelfth grade
A
B) Fifth grade
It is recommended that all printed patient education information be written at or below a fifth- to sixth-grade
reading level. This aligns with universal health literacy precautions in which easy-to-understand concepts and
terms are used for all patients instead of focusing on those with low literacy. These literacy precautions are
recommended by professional organizations such as the American Medical Association and the Agency for
The American Academy of Pediatrics recommends measuring a child’s hemoglobin level at what age?
A) 6 months
B) 12 months
C) 18 months
D) 2 years
E) 5 years
A
B) 12 months
Multiple reports have associated iron deficiency with impaired neurodevelopment and it is therefore essential
to ensure adequate iron intake. Based on expert opinion, the American Academy of Pediatrics recommends
A 48-year-old female presents to your office for follow-up of painful rectal bleeding with bowel movements.
She has increased her fiber consumption and is using a stool softener as you recommended at her last visit 2
weeks ago. She reports that her pain has worsened since yesterday and she is very uncomfortable. An
examination reveals a firm and tender right posterior hemorrhoid below the dentate line.
Which one of the following would be the most appropriate next step in providing relief for this thrombosed
hemorrhoid?
A) Topical corticosteroids
B) Bioflavonoid supplements
C) Oral antibiotics
E) Excision
A
E) Excision
This patient has tried first-line treatment for hemorrhoids with increased fiber intake but has returned with
symptoms of a thrombosed external hemorrhoid. Office-based surgical excision of the thrombosed external
hemorrhoid within 2–3 days of symptom onset may provide significant symptomatic relief (SOR B) and result
in a lower risk of recurrence. While conservative treatment with topical therapies such as corticosteroids may
Bioflavonoids are used outside the United States for symptomatic treatment of hemorrhoids but
evidence is lacking and they are not approved by the FDA for this use.
Oral antibiotic therapy has no role in the treatment of thrombosed external hemorrhoids but may be
beneficial in treating an abscess, which would present with a gradual onset of pain and a fluctuant
rectal mass.
Rubber band ligation is an appropriate treatment for grades I–III internal hemorrhoids (SOR A).
--
181
Q
2019.181
A 39-year-old female presents to your office with progressive swelling in the right leg that has spread over the
past 2 days. She feels well otherwise. Her past medical history is significant for adrenal insufficiency treated
with oral prednisone, 5 mg daily, and fludrocortisone, 0.1 mg daily. An examination reveals a temperature of
37.8°C (100.0°F), a pulse rate of 88 beats/min, a blood pressure of 105/62 mm Hg, and redness, warmth, and
swelling in the right lower extremity. You diagnose cellulitis and prescribe appropriate antibiotics.
Which one of the following would be the most appropriate management of her corticosteroid regimen?
D) Stop prednisone until the infection resolves but continue fludrocortisone at the current dosage
A
B) Increase prednisone to 15 mg daily and continue fludrocortisone at the current dosage
Patients with chronic adrenal insufficiency, either primary or secondary, may not be able to mount a stress
response to infection or surgical procedures. Common practice during minor infections is to increase the
corticosteroid supplementation (SOR C). Fludrocortisone should be continued, but stress dosing is not
necessary.
--
182
Q
2019.182
A 71-year-old male is hospitalized for community-acquired pneumonia. He has a past medical history of
Which one of the following antibiotics is likely to increase the risk of rupture of this patient’s aneurysm?
A) Aztreonam (Azactam)
B) Ceftriaxone
C) Doxycycline
D) Levofloxacin
A
D) Levofloxacin
The FDA issued a warning that systemic fluoroquinolones can increase the occurrence of aortic
dissections or ruptures.
Drugs in this group should be avoided in patients with an existing aortic aneurysm or in patients at increased
risk for developing an aortic aneurysm unless there are no other treatment options available. Patients at
hypertension,
Marfan syndrome, or
Ehlers-Danlos syndrome.
Aztreonam, ceftriaxone, and doxycycline are not associated with this side effect (SOR A).
--
183
Q
2019.183
A 75-year-old male presents to your office with the growth shown below that has developed under his eye
over the past several months. He says the growth is painless but appears to be slowly enlarging.
A) Actinic keratosis
D) Sebaceous hyperplasia
E) Seborrheic keratosis
A
C) Nodular basal cell carcinoma
This patient has a nodular basal cell carcinoma, which has a pearly papular appearance with telangiectasia.
Basal cell carcinoma is the most common cutaneous malignancy. The incidence increases with age and occurs
most commonly in skin types 1 and 2. The tumors occur most frequently on the face, scalp, ears, and neck,
and less frequently on the torso and extremities. While locally destructive, basal cell carcinoma rarely
metastasizes.
The skin becomes slightly rough with actinic keratosis, and a slight scale forms gradually. Sebaceous
hyperplasia begins as elevated papules that eventually become dome-shaped and umbilicated. It consists of
small tumors made up of sebaceous glands. Fibrous papule of the face is a variant of angiofibroma. It is
usually 1–5 mm in diameter and most often appears on the nose. Seborrheic keratoses are benign skin
neoplasms that are tan or black, well circumscribed, and have a stuck-on appearance.
--
184
Q
2019.184
An otherwise healthy 55-year-old male who is visiting from Arizona presents to your office with a 4-week
history of intermittent fevers, night sweats, dry cough, weight loss, and myalgia. The patient has no other
A) blastomycosis
B) coccidioidomycosis
C) cryptococcosis
D) histoplasmosis
E) mucormycosis
A
B) coccidioidomycosis
Knowledge of endemic fungi capable of causing infection in otherwise healthy patients can be very helpful in
symptoms in this patient, coccidioidomycosis can also present with a rash such as erythema
nodosum.
Histoplasmosis is most common in the Midwest and with low-level exposure symptoms are usually mild or
absent.
Blastomycosis is also present in the Midwest, as well as in the Atlantic and southeastern states.
Symptoms include an abrupt onset of fever, chills, pleuritic chest pain, arthralgias, and myalgias.
Cryptococcosis and mucormycosis are more opportunistic infections occurring in immunocompromised hosts.
--
185
Q
2019.185
A 15-year-old male presents with a 2-day history of dark-colored urine, lower extremity edema, and fatigue.
Approximately 2 weeks ago he said he had a “bad sore throat” that was treated empirically with amoxicillin.
On examination his blood pressure is 144/92 mm Hg, his pulse rate is 76 beats/min, and his other vital signs
are normal. Other than mild dependent edema there are no additional significant physical examination
Which one of the following findings on microscopic evaluation of the urine sediment would help to confirm
B) RBC casts
C) WBC casts
D) Eosinophils
E) Oxalate crystals
A
B) RBC casts (REVIEW: 2018.160 )
This is a classic presentation for acute post-streptococcal glomerulonephritis (APSGN), with the onset of gross
hematuria associated with hypertension and systemic edema. This is most commonly seen in school-age
children, usually 1–2 weeks after an episode of pharyngitis or 3–4 weeks after an episode of impetigo, caused
by so-called nephritogenic strains of Group A ß-hemolytic Streptococcus. The hematuria is caused by immune
complex–mediated glomerular injury. The classic finding on microscopic urinalysis for acute
Bacteriuria may be seen in both upper and lower urinary tract infections, but may also be a spurious
blood pressure and edema with a thiazide or a loop diuretic. The prognosis for resolution and full recovery of
the vast majority of patients with APSGN is excellent, especially in the pediatric age group.
--
186
Q
2019.186
A 59-year-old plumber presents with swelling of his left elbow. An examination reveals swelling over the
olecranon but no erythema or warmth. His uric acid levels are normal and he has no history of inflammatory
disease. He has not had a fever. The swollen area is not painful and he has a normal range of motion.
Which one of the following would be the most appropriate next step?
B) Empiric antibiotics
C) Bursal aspiration
D) Plain radiographs
E) Orthopedic referral
A
A) Padding, ice, and elevation (REVIEW: 2018.118 )
This patient has olecranon bursitis, which is a superficial bursitis caused by chronic microtraumas to the
affected area. The initial management for this condition includes conservative measures such as padding,
elevation, icing, and analgesics (SOR B). If significant pain is associated with the swelling, or a decrease in
range of motion is present due to severe swelling, aspiration should be offered. This is not indicated in this
particular case and should be avoided to reduce the risk of septic bursitis. Septic bursitis would require
empiric antibiotics to cover common skin organisms (SOR B). Aspiration should be performed if infection is
suspected and the aspirate should be sent for a cell count, Gram stain, culture, glucose measurement, and
crystal analysis (SOR C). Plain radiographs are indicated only if there is acute trauma and concern that a
fracture may be present. If recurrent superficial bursitis occurs, a referral for surgery is indicated.
--
187
Q
2019.187
A 58-year-old male sees you for follow-up of diabetic gastroparesis. He has tried managing his symptoms with
more frequent meals and taking in more calories in semisolid or liquid form. These approaches have been
Which one of the following would be considered first-line pharmacotherapy for this patient?
A) Metoclopramide (Reglan)
B) Nortriptyline (Pamelor)
C) Omeprazole (Prilosec)
D) Ondansetron (Zofran)
E) Ranitidine (Zantac)
A
A) Metoclopramide (Reglan)
Diabetic gastroparesis is a delay in the emptying of food from the upper gastrointestinal tract in the absence
of a mechanical obstruction of the stomach or duodenum. Metoclopramide is the only prokinetic agent that
has been studied specifically for long-term use in gastroparesis and is considered first-line therapy (SOR B). It
Nortriptyline is a prokinetic agent but has not been shown to be more effective than placebo for
Proton pump inhibitors such as omeprazole, histamine H2-receptor antagonists such as ranitidine,
and ondansetron delay gastric emptying and should be withheld in patients with gastroparesis
whenever possible.
--
188
Q
2019.188
You have diagnosed a Chlamydia infection in a 24-year-old male. He reports having three sexual partners in
the last month. He does not feel comfortable revealing their names or genders at this time.
In almost all U.S. states, which one of the following would be the most appropriate plan for timely treatment
B) One prescription in the patient’s name and instructions to the patient to inform his partners
D) One prescription in the patient’s name and three prescriptions for expedited partner therapy
A
E) One prescription in the patient’s name and three blank prescriptions
Expedited partner therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with
Chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner
without the health care provider first examining the partner. When patients have been diagnosed with
gonorrhea or Chlamydia, EPT has been shown to reduce the overall burden of disease in a given population
when the partners cannot be linked to care. In this case, as the partners’ identities are unknown, it is
impossible for the clinician to examine them or even contact them, so four prescriptions should be written,
one with the patient’s name and the other three for EPT. The CDC states that EPT is particularly effective in
treating the female partners of infected males. The CDC considers having the partners visit a health care
provider to be the optimal course of treatment but this is not often practically feasible due to a lack of
Although conventional practice is to treat only the patient, this does not provide timely treatment for the
patient’s partners. A prescription written to “EPT” can be filled at the pharmacy without the individual’s name
or date of birth. Kentucky and South Carolina are the only states that do not allow this practice. A prescription
with three refills would be unethical, as presumably the physician would be advising the patient to distribute
medications that had been prescribed to only the patient. Blank prescriptions would require the partners to
reveal their identities, which may lead to a reluctance to fill the prescriptions.
--
189
Q
2019.189
Which one of the following calculated values is most useful for evaluating the effectiveness of a clinical
intervention?
C) Specificity
E) P-value
A
A) Number needed to treat
A basic understanding of statistics is essential to evaluate clinical evidence. The number needed to treat, which
represents the number of patients that must be treated to result in one positive outcome, is one of the most
intuitive statistical concepts in explaining the power or relative lack thereof of an intervention.
Relative risk reduction in particular can be misleading, since a seemingly large relative risk reduction
may result in a very small absolute risk reduction if the prevalence of the disorder in question is
low.
Specificity indicates the ability of a test to accurately identify a condition but does not indicate the
effectiveness of an intervention.
A 95% confidence interval relates to statistical variation and the relationship of an outcome to
chance.
P-value deals with statistical significance but not magnitude of the effect.
--
190
Q
2019.190
A patient is brought to your office by his spouse because of anger issues over the last 6 weeks that are
affecting his marriage and his work. He tells you he has started running 5 miles per day, but is sleeping poorly,
and that his mind has been racing during this period. He recently went on a shopping spree and reached the
maximum spending limit on his credit card. He has been using alcohol to calm down. He refuses to see a
psychiatrist.
A) bupropion (Wellbutrin)
B) lithium
C) lorazepam (Ativan)
D) sertraline (Zoloft)
E) trazodone (Oleptro)
A
B) lithium
lithium,
trazodone could possibly help the patient sleep, but these medications are ineffective for treating a
manic/hypomanic episode.
--
191
Q
2019.191
Which one of the following is the most common cause of hirsutism in premenopausal women?
A) Idiopathic hirsutism
C) Androgen-secreting tumors
A
B) Polycystic ovary syndrome
The most common cause of hirsutism in premenopausal women is polycystic ovary syndrome, which accounts
Other causes are rare, but should be considered when evaluating new cases of hirsutism.
--
192
Q
2019.192
To reduce overuse of antibiotics, the CDC promotes antibiotic stewardship. The recommended intervention is
the implementation of an antibiotic time-out to improve outcomes when prescribing antibiotics in hospitals.
When should an antibiotic time-out be scheduled when prescribing an antibiotic at the time a patient is
A
C) 48 hours after the initial antibiotic order
For patients started on empiric antibiotic therapy at hospital admission, the CDC recommends an antibiotic
time-out 48 hours after the initial order to determine if it can be stopped or needs to be changed.
The rationale is that antibiotics are often ordered empirically at the time of admission, while cultures and
other studies are also being ordered. The original empiric order should be reassessed, incorporating the
results of these studies while considering the evolving clinical status of the patient. Studies show this
A 24-year-old male presents with swelling of the right testicle. The pain started yesterday and has persistently
worsened. A physical examination reveals swelling on the right side of his scrotum. His entire testicle is
painful, and elevation of the scrotum improves his pain. Ultrasonography reveals hyperemia, swelling, and
A) Doxycycline
B) Levofloxacin (Levaquin)
C) Trimethoprim/sulfamethoxazole (Bactrim)
A
D) Doxycycline plus ceftriaxone
This patient presents with acute epididymitis. Typical symptoms develop gradually over 1–2 days with
posterior scrotal pain and swelling. Additional symptoms may include fever, hematuria, dysuria, and urinary
frequency. The pain may radiate to the lower abdomen. Physical examination findings may include tenderness
of the epididymis and testis along with swelling of the scrotum. Elevation of the scrotum may decrease the
pain (Prehn sign). Typical ultrasound findings include hyperemia, swelling, and increased blood flow to the
epididymis.
With testicular torsion the pain is often sudden in onset and severe, with associated nausea and vomiting and
no other urologic symptoms. A physical examination often demonstrates a high-riding testis that may lie
transversely in the scrotum. The cremasteric reflex may be absent. Ultrasound findings would demonstrate
In sexually active adults <35 years of age, gonorrhea and Chlamydia are the most common causative
organisms of acute epididymitis. Ceftriaxone, 250 mg intramuscularly or intravenously once, with oral
doxycycline, 100 mg twice daily for 10 days, would be the appropriate treatment for acute epididymitis (SOR
C). In men over the age of 35 or those with a history of recent urinary tract surgery or instrumentation, enteric
organisms are the most likely cause and monotherapy with oral levofloxacin or ofloxacin for 10 days would be
A 43-year-old female presents to your office with a 3-month history of left low back and posterior hip pain. She
does not recall an injury but says she was very active during a move to a new home prior to the onset of the
pain. An examination reveals that her gait, lower extremity strength, straight leg resistance, and hip and knee
range of motion are normal. A log roll test is also normal. A flexion, abduction, external rotation (FABER) test
A) Femoroacetabular impingement
C) Osteoarthritis
D) Piriformis syndrome
A
E) Sacroiliac joint dysfunction
The cause of hip pain is generally determined from the patient’s history and physical examination. A
positive flexion, abduction, external rotation (FABER) test that produces pain at the sacroiliac joint, lumbar
The log roll test involves passive supine internal and external rotation of the hip. When this test is
While femoroacetabular impingement may be associated with a positive FABER test, it would
Greater trochanteric pain syndrome results in lateral hip pain rather than posterior pain.
Osteoarthritis is usually associated with a limited range of motion and groin pain.
--
195
Q
2019.195
A 2-year-old female is brought to your office for a well child check. She had an episode of coughing and mild
bronchospasm 3 months ago that was successfully treated with albuterol (Proventil, Ventolin). The mother
asks you if there are any factors that would increase the patient’s risk of asthma.
Which one of the following factors would increase this patient’s risk of asthma?
A
B) Exposure to respiratory syncytial virus
Immunologic profiles of patients with asthma are influenced by environmental exposures. Those who are
exposed to respiratory syncytial virus (RSV) as an infant have an increased risk, whereas those who are
exposed to a high microbial environment have a lower risk than those without such exposure.
Otitis media and lactose intolerance are not known to be associated with asthma risk.
--
196
Q
2019.196
A 57-year-old long-time patient presents for an annual wellness visit. He has a BMI of 46 kg/m2, type 2
diabetes, obstructive sleep apnea, hypertension, and cardiomyopathy. He is adherent to his medication
regimen and CPAP therapy, and these problems have been controlled.
As you discuss lifestyle modification recommendations, he tells you that he wants to address his obesity this
year. You have counseled him on low-carbohydrate and low-calorie diets over the years. He has had difficulty
following these recommendations due to his work obligations. He states that he has tried multiple fad diets,
A) Worksite intervention
B) Exercise therapy
C) Behavioral therapy
D) Pharmacotherapy
E) Bariatric surgery
A
E) Bariatric surgery (REVIEW: 2018.177 )
This patient presents with morbid obesity complicated by several obesity-related conditions. Bariatric surgery
has been shown to result in greater weight loss compared to nonsurgical interventions (SOR A). It has also
been shown to be highly effective in treating obesity-related comorbid conditions such as diabetes mellitus
(SOR A). Patients with a BMI >40 kg/m2 should be referred for consideration of bariatric surgery (SOR B).
While worksite intervention, exercise therapy, behavioral therapy, and pharmacotherapy are appropriate
treatments for obesity, these interventions are all less effective than bariatric surgery.
--
197
Q
2019.197
Lymphadenopathy is associated with the highest risk of malignancy in which one of the following locations?
A) Axillary
B) Inguinal
C) Posterior cervical
D) Preauricular
E) Supraclavicular
A
E) Supraclavicular
In primary care practice the annual incidence of unexplained lymphadenopathy is only 0.6%. Only 1.1% of
these cases are related to malignancy. This percentage increases with age. Supraclavicular adenopathy is
associated with a high risk of intra-abdominal malignancy in both adults and children, with studies finding
34%–50% of these patients having a malignancy. Lymphadenopathy in the other locations listed is associated
A 63-year-old male with a history of controlled hypertension and benign prostatic hyperplasia presents to your
office after an emergency department visit for a closed, displaced left clavicle fracture. The injury occurred
when he slipped on ice while shoveling snow. His orthopedist has recommended surgery and has requested a
preoperative evaluation.
The patient’s blood pressure is 128/82 mm Hg and cardiovascular and pulmonary examinations are normal.
You determine that his risk for a major adverse cardiac event is <1% for this nonurgent and low-risk surgical
intervention. He does not have any chest pain or shortness of breath. He has pain with movement of his left
A) No further testing
B) An EKG
D) A chest radiograph
E) Echocardiography
A
A) No further testing
This asymptomatic patient is at low risk for a major adverse cardiac event (<1%) and requires no further
testing prior to undergoing a low-risk, nonurgent surgical intervention. A routine preoperative EKG does not
provide any benefit for asymptomatic patients undergoing low-risk surgical procedures (level of evidence 2). A
preoperative EKG may be considered for asymptomatic patients without known coronary artery disease who
are undergoing intermediate and high-risk surgeries (SOR B). A preoperative EKG is reasonable for patients
who have known heart disease, peripheral artery disease, or cerebrovascular disease who are undergoing
Exercise stress testing for noncardiac surgery is not useful for patients at low risk but may be helpful for
patients with an elevated risk and unknown functional capacity (SOR B). Routine chest radiography has no role
in the preoperative evaluation. Routine preoperative echocardiography to assess left ventricular function is
not recommended in asymptomatic patients (SOR B). It is reasonable for patients with dyspnea of unknown
etiology and patients with worsening heart failure symptoms to undergo preoperative evaluation of left
ventricular function (SOR C). Preoperative echocardiography is recommended for patients with known or
A 69-year-old female presents to your office to discuss the results of a recent lung biopsy. While informing the
A) limiting the number of family members that are present while delivering the bad news
B) making your best educated guess for how much time the patient has left to live
C) using layman’s terms to describe detailed treatment options and the prognosis
D) allowing adequate time to deliver the diagnosis in a private setting with limited interruptions
A
D) allowing adequate time to deliver the diagnosis in a private setting with limited interruptions
Physicians should respect the patient’s individual preferences for receiving bad news and allow adequate time
After delivering the news it is best to avoid extensive treatment details and making estimates of the patient’s
Patients should be allowed to have as few or as many family members and friends present as they desire at
the time of communication, and this often varies depending on the patient’s cultural background.
--
200
Q
2019.200
A 70-year-old female comes to your office with a 10-day history of a subjective fever at home, facial and tooth
pain, sinus pressure, and a green nasal discharge. There has been no change in her symptoms. The patient
has a history of allergic rhinitis treated with immunotherapy, and a history of developing hives while taking
In addition to nasal saline and analgesics, which one of the following would be the most appropriate
management?
B) High-dose amoxicillin/clavulanate
C) Azithromycin (Zithromax)
D) Doxycycline
A
D) Doxycycline (REVIEW: 2018.185 )
This patient has a history of symptoms consistent with acute bacterial rhinosinusitis that have persisted for 10
reaction to penicillin.
Macrolides and trimethoprim/sulfamethoxazole are not recommended as empiric therapy because of high
rates of resistance.