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Primary Care -- AAFP

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

A. Strict bed rest at home and reexamination within 48 hours
B. Admitting the patient to the hospital for bed rest and frequent monitoring of blood pressure, weight, and proteinuria
C. Admitting the patient to the hospital for bed rest and monitoring, and beginning hydralazine (Apresoline) to maintain blood pressure below 140/90 mm Hg
D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section
D. Admitting the patient to the hospital, treating with parenteral magnesium sulfate, and planning prompt delivery either vaginally or by cesarean section. This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant.
Which one of the following is the most common cause of hypertension in children under 6 years of age? (check one)

A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caffeine use
C. Renal parenchymal disease. Although essential hypertension is most common in adolescents and adults, it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated.
A 70-year-old male with a history of hypertension and type 2 diabetes mellitus presents with a 2-month history of increasing paroxysmal nocturnal dyspnea and shortness of breath with minimal exertion. An echocardiogram shows an ejection fraction of 25%. Which one of the patients current medications should be discontinued? (check one)

A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)
B. Pioglitazone (Actos). According to the American Diabetes Association guidelines, thiazolidinediones (TZDs) are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy (SOR C). Older patients can be treated with the same drug regimens as younger patients, but special care is required when prescribing and monitoring drug therapy. Metformin is often contraindicated because of renal insufficiency or heart failure. Sulfonylureas and other insulin secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia, and injecting it requires good visual and motor skills and cognitive ability on the part of the patient or a caregiver. TZDs should not be used in patients with New York Heart Association class III or IV heart failure.
A 72-year-old African-American male with New York Heart Association Class III heart failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril (Prinivil, Zestril), 40 mg twice daily; carvedilol (Coreg), 25 mg twice daily; and furosemide (Lasix), 80 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 68 beats/min and regular. Findings include a few scattered bibasilar rales on examination of the lungs, an S3 gallop on examination of the heart, and no edema on examination of the legs. An EKG reveals a left bundle branch block, and echocardiography reveals an ejection fraction of 25%, but no other abnormalities. Which one of the following would be most appropriate at this time? (check one)

A. Increase the lisinopril dosage to 80 mg twice daily
B. Increase the carvedilol dosage to 50 mg twice daily
C. Increase the furosemide dosage to 160 mg daily
D. Refer for coronary angiography
E. Refer for cardiac resynchronization therapy
E. Refer for cardiac resynchronization therapy. This patient is already receiving maximal medical therapy. The 2002 joint guidelines of the American College of Cardiology, the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology endorse the use of cardiac resynchronization therapy (CRT) in patients with medically refractory, symptomatic, New York Heart Association (NYHA) class III or IV disease with a QRS interval of at least 130 msec, a left ventricular end-diastolic diameter of at least 55 mm, and a left ventricular ejection fraction (LVEF) ≤30%. Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously, overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA functional class III or IV despite maximal medical therapy for heart failure.
Of the following dietary factors recommended for the prevention and treatment of cardiovascular disease, which one has been shown to decrease the rate of sudden death? (check one)

A. Increased intake of plant protein
B. Increased intake of omega-3 fats
C. Increased intake of dietary fiber and whole grains
D. Increased intake of monounsaturated oils
E. Moderate alcohol consumption (1 or 2 standard drinks per day)
B. Increased intake of omega-3 fats. Omega-3 fats contribute to the production of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which inhibit the inflammatory immune response and platelet aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart Association guidelines state that omega-3 supplements may be recommended to patients with preexisting disease, a high risk of disease, or high triglyceride levels, as well as to patients who do not like or are allergic to fish. The Italian GISSI study found that the use of 850 mg of EPA and DHA daily resulted in decreased rates of mortality, nonfatal myocardial infarction, and stroke, with particular decreases in the rate of sudden death.
A 75-year-old male presents to the emergency department with a several-hour history of back pain in the interscapular region. His medical history includes a previous myocardial infarction (MI) several years ago, a history of cigarette smoking until the time of the MI, and hypertension that is well controlled with hydrochlorothiazide and lisinopril (Prinivil, Zestril). The patient appears anxious, but all pulses are intact. His blood pressure is 170/110 mm Hg and his pulse rate is 110 beats/min. An EKG shows evidence of an old inferior wall MI but no acute changes. A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT of the chest shows a dissecting aneurysm of the descending aorta that is distal to the proximal abdominal aorta but does not involve the renal arteries. Which one of the following would be the most appropriate next step in the management of this patient? (check one)

A. Immediate surgical intervention
B. Arteriography of the aorta
C. Intravenous nitroprusside (Nipride)
D. A nitroglycerin drip
E. Intravenous labetalol (Normodyne, Trandate)
E. Intravenous labetalol (Normodyne, Trandate). Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography. Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior beta-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain).
According to the U.S. Preventive Services Task Force, which one of the following patients should be screened for an abdominal aortic aneurysm? (check one)

A. A 52-year-old male with type 2 diabetes mellitus
B. An asymptomatic 67-year-old male smoker with no chronic illness
C. A 72-year-old male with a history of chronic renal failure
D. A 69-year-old female with a history of coronary artery disease
E. A 75-year-old female with hypertension and hypothyroidism
B. An asymptomatic 67-year-old male smoker with no chronic illness. The U.S. Preventive Services Task Force has released a statement summarizing recommendations for screening for abdominal aortic aneurysm (AAA). The guideline recommends one-time screening with ultrasonography for AAA in men 65-75 years of age who have ever smoked. No recommendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.
A 36-year-old white female presents to the emergency department with palpitations. Her pulse rate is 180 beats/min. An EKG reveals a regular tachycardia with a narrow complex QRS and no apparent P waves. The patient fails to respond to carotid massage or to two doses of intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be to administer intravenous (check one)

A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. flecainide (Tambocor)
D. propafenone (Rhythmol)
E. verapamil (Calan)
E. verapamil (Calan). If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of intravenous verapamil or a β-blocker. If that fails, intravenous propafenone or flecainide may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia.
A 60-year-old African-American female has a history of hypertension that has been well controlled with hydrochlorothiazide. However, she has developed an allergy to the medication. Successful monotherapy for her hypertension would be most likely with which one of the following? (check one)

A. Lisinopril (Prinivil, Zestril)
B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem)
E. Diltiazem (Cardizem). Monotherapy for hypertension in African-American patients is more likely to consist of diuretics or calcium channel blockers than β-blockers or ACE inhibitors. It has been suggested that hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in Caucasians.
A 60-year-old African-American male was recently diagnosed with an abdominal aortic aneurysm. A lipid profile performed a few months ago revealed an LDL level of 125 mg/dL. You would now advise him that his goal LDL level is: (check one)

A. <100 mg/dL
B. <130 mg/dL
C. <150 mg/dL
D. <160 mg/dL
A. <100 mg/dL. Most physicians realize that the goal LDL level for patients with diabetes mellitus or coronary artery disease is <100 mg/dL. Many may not realize that this goal extends to people with CAD-equivalent diseases, including peripheral artery disease, symptomatic carotid artery disease, and abdominal aortic aneurysm.
Cardiovascular Board Review Questions 02
An asymptomatic 3-year-old male presents for a routine check-up. On examination you notice a systolic heart murmur. It is heard best in the lower precordium and has a low, short tone similar to a plucked string or kazoo. It does not radiate to the axillae or the back and seems to decrease with inspiration. The remainder of the examination is normal. Which one of the following is the most likely diagnosis? (check one)

A. Eisenmenger's syndrome
B. Mitral stenosis
C. Peripheral pulmonic stenosis
D. Still's murmur
E. Venous hum
D. Still's murmur. There are several benign murmurs of childhood that have no association with physiologic or anatomic abnormalities. Of these, Still's murmur best fits the murmur described. The cause of Still's murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger's syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination.
A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which one of the following would most likely require a significant dosage adjustment from the standard protocol? (check one)

A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA)
A. Enoxaparin (Lovenox). Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours. Although some β-blockers require a dosage adjustment, metoprolol and carvedilol are metabolized by the liver and do not require dosage adjustment in patients with renal failure. Clopidogrel is currently recommended at the standard dosage for patients with renal failure and acute coronary syndrome. Thrombolytics like tPA are given at the standard dosage in renal failure, although hemorrhagic complications are increased.
A 55-year-old male who has a long history of marginally-controlled hypertension presents with gradually increasing shortness of breath and reduced exercise tolerance. His physical examination is normal except for a blood pressure of 140/90 mm Hg, bilateral basilar rales, and trace pitting edema. Which one of the following ancillary studies would be the preferred diagnostic tool for evaluating this patient? (check one)

A. 12-lead electrocardiography
B. Posteroanterior and lateral chest radiographs
C. 2-dimensional echocardiography with Doppler
D. Radionuclide ventriculography
E. Cardiac MRI
C. 2-dimensional echocardiography with Doppler. The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure.
A 23-year-old female sees you with a complaint of intermittent irregular heartbeats that occur once every week or two, but do not cause her to feel lightheaded or fatigued. They last only a few seconds and resolve spontaneously. She has never passed out, had chest pain, or had difficulty with exertion. She is otherwise healthy, and a physical examination is normal. Which one of the following cardiac studies should be ordered initially? (check one)

A. 24-hour ambulatory EKG monitoring (Holter monitor)
B. 30-day continuous closed-loop event recording
C. Echocardiography
E. Electrophysiologic studies
D. An EKG. The symptom of an increased or abnormal sensation of one's heartbeat is referred to as palpitations. This condition is common to primary care, but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of those who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval.
Which one of the following is most appropriate for the initial treatment of claudication? (check one)

A. Regular exercise
B. Chelation
C. Vasodilating agents
D. Warfarin (Coumadin)
A. Regular exercise. Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved by rest. It affects 10% of persons over 70 years of age. However, up to 90% of patients with peripheral vascular disease are asymptomatic. Initial treatment should consist of vigorous risk factor modification and exercise. Patients who follow an exercise regimen can increase their walking time by 150%. A supervised program may produce better results. Risk factors include diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional treatments such as chelation have not been shown to be effective. Vasodilating agents are of no benefit. There is no evidence that anticoagulants such as aspirin have a role in the treatment of claudication.
In a patient who presents with symptoms of acute myocardial infarction, which one of the following would be an indication for thrombolytic therapy? (check one)

A. New-onset ST-segment depression
B. New-onset left bundle branch block
C. New-onset first degree atrioventricular block
D. New-onset Wenckebach second degree heart block
E. Frequent unifocal ventricular ectopic beats
B. New-onset left bundle branch block. In patients with ischemic chest pain, the EKG is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction - they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy.
A 68-year-old female has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. The most appropriate treatment at this time would be (check one)

A. lisinopril (Prinivil, Zestril)
B. clonidine (Catapres)
C. propranolol (Inderal)
D. amlodipine (Norvasc)
E. hydrochlorothiazide
E. hydrochlorothiazide. Randomized, placebo-controlled trials have shown that isolated systolic hypertension in the elderly responds best to diuretics and to a lesser extent, β-blockers. Diuretics are preferred, although long-acting dihydropyridine calcium channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. Thiazide diuretics may also improve osteoporosis, and would be the most cost-effective and useful agent in this instance.
A 31-year-old healthy female is admitted to the hospital from the emergency department after presenting with aching in her right shoulder and swelling in the ipsilateral forearm and hand. The only precipitating event that she can recall is digging strenuously in the back yard to put in a new garden. Ultrasonography is remarkable for a thrombus in the axillosubclavian vein. She has no prior history of clotting, takes no medications, and has no previous history of medical or surgical procedures involving this extremity. The most likely etiology for this patient's condition is (check one)

A. a hypercoagulable state
B. a compressive anomaly in the thoracic outlet
C. use of injection drugs
D. Budd-Chiari syndrome
B. a compressive anomaly in the thoracic outlet. Thrombosis of the upper extremity accounts for about 10% of all venous thromboembolism (VTE) cases. However, axillosubclavian vein thrombosis (ASVT) is becoming more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in young, healthy individuals. The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet. These anomalies are often bilateral, and the other upper extremity at similar risk for thrombosis. While a hypercoagulable state also may contribute to the thrombosis, it is much less common. Budd-Chiari syndrome refers to thrombosis in the intrahepatic, suprahepatic, or hepatic veins. It is not commonly associated with spontaneous upper-extremity thrombosis.
A 56-year-old white male presents with a 2-week history of intermittent pain in his left leg. The pain usually occurs while he is walking and is primarily in the calf muscle or Achilles region. Sometimes he will awaken at night with cramps in the affected leg. He has no known risk factors for atherosclerosis. Which one of the following would be the best initial test for peripheral vascular occlusive disease? (check one)

A. Ankle-brachial index
B. Arterial Doppler ultrasonography
C. Arteriography
D. Magnetic resonance angiography (MRA)
E. Venous ultrasonography
A. Ankle-brachial index. The ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD) in this patient. The ABI is the ratio of systolic blood pressure measured in the ankle to systolic pressure using the standard brachial measurement. A ratio of 0.9-1.2 is considered normal. Severe disease is defined as a ratio <0.50. More invasive and expensive testing using Doppler ultrasonography, arteriography, or magnetic resonance angiography may be useful if the ABI suggests an abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous thrombosis, which is another common etiology for calf pain.
A 69-year-old male has a 4-day history of swelling in his left leg. He has no history of trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is unremarkable except for a diffusely swollen left leg. A CBC, chemistry profile, prostate-specific antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography of the extremity reveals a clot in the proximal femoral vein. He has no past history of venous thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the American College of Chest Physicians recommends that warfarin (Coumadin) be instituted now and continued for at least (check one)

A. 1 month
B. 3 months
C. 6 months
D. 12 months
B. 3 months. For patients with a first episode of unprovoked deep venous thrombosis, evidence supports treatment with a vitamin K antagonist for at least 3 months (SOR A). The American College of Chest Physicians recommends that patients be evaluated at that point for the potential risks and benefits of long-term therapy (SOR C).
Cardiovascular Board Review Questions 03
A 35-year-old African-American female has just returned home from a vacation in Hawaii. She presents to your office with a swollen left lower extremity. She has no previous history of similar problems. Homan's sign is positive, and ultrasonography reveals a noncompressible vein in the left popliteal fossa extending distally. Which one of the following is true in this situation? (check one)

A. Monotherapy with an initial 10-mg loading dose of warfarin (Coumadin) would be appropriate
B. Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day
C. The incidence of thrombocytopenia is the same with low-molecular-weight heparin as with unfractionated heparin
D. The dosage of warfarin should be adjusted to maintain the INR at 2.5-3.5
E. Anticoagulant therapy should be started as soon as possible and maintained for 1 year to prevent deep vein thrombosis (DVT) recurrence
B. Enoxaparin (Lovenox) should be administered at a dosage of 1 mg/kg subcutaneously twice a day. The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low-molecular-weight heparin is lower than with conventional heparin. The INR should be maintained at 2.0-3.0 in this patient. The 2.5-3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3-6 months in a patient with a first DVT related to travel.
Which one of the following historical features is most suggestive of congestive heart failure in a 6-month-old white male presenting with tachypnea? (check one)

A. Diaphoresis with feeding
B. Fever
C. Nasal congestion
D. Noisy respiration or wheezing
E. Staccato cough
A. Diaphoresis with feeding. Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive. Older children may have symptoms more similar to adults, but the infant's greatest exertion is related to feeding. Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis.
Which one of the following procedures carries the highest risk for postoperative deep venous thrombosis? (check one)

A. Abdominal hysterectomy
B. Coronary artery bypass graft
C. Transurethral prostatectomy
D. Lumbar laminectomy
E. Total knee replacement
E. Total knee replacement. Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy <5%, and after abdominal hysterectomy approximately 16%.
A 13-year-old male is found to have hypertrophic cardiomyopathy. His father also had hypertrophic cardiomyopathy, and died suddenly at age 38 following a game of tennis. The boy's mother asks you for advice regarding his condition. What advice should you give her? (check one)

A. He may participate in noncontact sports
B. He should receive lifelong treatment with beta-blockers
C. His condition usually decreases lifespan
D. His hypertrophy will regress with age
E. His siblings should undergo echocardiography
E. His siblings should undergo echocardiography. Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta-blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal.
A 70-year-old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches: (check one)

A. 3.5 cm
B. 4.5 cm
C. 5.5 cm
D. 6.5 cm
E. 7.5 cm
C. 5.5 cm. Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Small Aneurysm Trial, failed to show any benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risks of aneurysm rupture were 1% or less in both studies, with 6-year cumulative survivals of 74% and 64%, respectively. Interestingly, the risk for aneurysm rupture was four times greater in women, indicating that 5.5 cm may be too high, but a new evidence-based threshold has not yet been defined.
Which one of the following drug classes is preferred for treating hypertension in patients who also have diabetes mellitus? (check one)

A. Centrally-acting sympatholytics
B. Alpha-blocking agents
C. Beta-blocking agents
D. ACE inhibitors
E. Calcium channel blockers
D. ACE inhibitors. ACE inhibitors have proven beneficial in patients who have either early or established diabetic renal disease. They are the preferred therapy in patients with diabetes and hypertension, according to guidelines from the American Diabetes Association, the National Kidney Foundation, the World Health Organization, and the JNC VII report.
A 75-year-old Hispanic male presents with dyspnea on exertion which has worsened over the last several months. He denies chest pain and syncope, and was fairly active until the shortness of breath slowed him down recently. You hear a grade 3/6 systolic ejection murmur at the right upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with a mean transvalvular gradient of 55 mm Hg and a calculated valve area of 0.6 cm2. Left ventricular function is normal. Which one of the following is appropriate management for this patient? (check one)

A. Aortic valve replacement
B. Aortic balloon valvotomy
C. Medical management with beta-blockers and nitrates
D. Watchful waiting until the gradient is severe enough for treatment
E. Deferring the decision pending results of an exercise stress test
A. Aortic valve replacement. Since this patient's mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is not larger than 1 cm2, it is likely that his symptoms are due to aortic stenosis. As patients with symptomatic aortic stenosis have a dismal prognosis without treatment, prompt correction of his mechanical obstruction with aortic valve replacement is indicated. Medical management is not effective, and balloon valvotomy only temporarily relieves the symptoms and does not prolong survival. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.
Which one of the following is considered a contraindication to the use of beta-blockers for congestive heart failure? (check one)

A. Mild asthma
B. Symptomatic heart block
C. New York Heart Association (NYHA) Class III heart failure
D. NYHA Class I heart failure in a patient with a history of a previous myocardial infarction
E. An ejection fraction <30%
B. Symptomatic heart block. According to several randomized, controlled trials, mortality rates are improved in patients with heart failure who receive beta-blockers in addition to diuretics, ACE inhibitors, and occasionally, digoxin. Contraindications to beta-blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma. Beta-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification.
Which one of the following is the leading cause of death in women? (check one)

A. Breast cancer
B. Lung cancer
C. Ovarian cancer
D. Osteoporosis
E. Cardiovascular disease
E. Cardiovascular disease. Cardiovascular disease is the leading cause of death among women. According to the CDC, 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common.
A 72-year-old African-American male comes to your office for surgical clearance to undergo elective hemicolectomy for recurrent diverticulitis. The patient suffered an uncomplicated acute anterior-wall myocardial infarction approximately 18 months ago. A stress test was normal 2 months after he was discharged from the hospital. Currently, the patient feels well, walks while playing nine holes of golf three times per week, and is able to walk up a flight of stairs without chest pain or significant dyspnea. Findings are normal on a physical examination. Which one of the following would be most appropriate for this patient prior to surgery? (check one)

A. A 12-lead resting EKG
B. A graded exercise stress test
C. A stress echocardiogram
D. A persantine stressed nuclear tracer study (technetium or thallium)
E. Coronary angiography
A. A 12-lead resting EKG. The current recommendations from the American College of Cardiology and the American Heart Association on preoperative clearance for noncardiac surgery state that preoperative intervention is rarely needed to lower surgical risk. Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with no stress testing or coronary angiography for an elective minor or intermediate-risk operation such as the one this patient is to undergo. A resting 12-lead EKG is recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.
Cardiovascular Board Review Questions 04
A 73-year-old male with COPD presents to the emergency department with increasing dyspnea. Examination reveals no sign of jugular venous distention. A chest examination reveals decreased breath sounds and scattered rhonchi, and the heart sounds are very distant but no gallop or murmur is noted. There is +1 edema of the lower extremities. Chest radiographs reveal cardiomegaly but no pleural effusion. The patient's B-type natriuretic peptide level is 850 pg/mL (N <100) and his serum creatinine level is 0.8 mg/dL (N 0.6-1.5). Which one of the following would be the most appropriate initial management? (check one)

A. Intravenous heparin
B. Tiotropium (Spiriva)
C. Levalbuterol (Xopenex) via nebulizer
D. Prednisone, 20 mg twice daily for 1 week
E. Furosemide (Lasix), 40 mg intravenously
E. Furosemide (Lasix), 40 mg intravenously. B-type natriuretic peptide (BNP) is secreted in the ventricles and is sensitive to changes in left ventricular function. Concentrations correlate with end-diastolic pressure, which in turn correlates with dyspnea and congestive heart failure. BNP levels can be useful when trying to determine whether dyspnea is due to cardiac, pulmonary, or deconditioning etiologies. A value of less than 100 pg/mL excludes congestive heart failure as the cause for dyspnea. If it is greater than 400 pg/mL, the likelihood of congestive heart failure is 95%. Patients with values of 100-400 pg/mL need further investigation. There are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute left ventricular dysfunction will have. If these problems can be ruled out, then individuals with levels between 100-400 pg/mL most likely have congestive heart failure. Initial therapy should be a loop diuretic. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance.
A 25-year-old female at 36 weeks gestation presents for a routine prenatal visit. Her blood pressure is 118/78 mm Hg and her urine has no signs of protein or glucose. Her fundal height shows appropriate fetal size and she says that she feels well. On palpation of her legs, you note 2+ pitting edema bilaterally. Which one of the following is true regarding this patient's condition? (check one)

A. You should order a 24-hr urine for protein
B. A workup for possible cardiac abnormalities is necessary
C. Her leg swelling requires no further evaluation
D. She most likely has preeclampsia
E. She most likely has deep venous thrombosis
C. Her leg swelling requires no further evaluation. Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema with no signs of elevated blood pressure will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient's presentation, as are cardiac or renal conditions.
A 72-year-old male with a history of previous inferior myocardial infarction sees you prior to surgery for symptomatic gallstones. He denies chest pain or dyspnea. His current medications include aspirin, 81 mg daily; ramipril (Altace), 10 mg daily; and pravastatin (Pravachol), 40 mg daily. He is in good health otherwise and has no other health complaints. He has been cleared for surgery by his cardiologist. Which one of the following should be considered before and after surgery, assuming no contraindications? (check one)

A. Atenolol (Tenormin)
B. Verapamil (Calan, Isoptin)
C. Digoxin
D. Transdermal nitroglycerin
E. Intravenous nitroglycerin
A. Atenolol (Tenormin). A recent development in the prophylaxis of surgery-related cardiac complications is the use of beta-blockers perioperatively for patients with cardiac risk factors. In a randomized, double-blind, placebo-controlled trial involving 200 patients who were undergoing elective noncardiac surgery that required general anesthesia, the effect of atenolol on perioperative cardiac complications was evaluated. Patients were eligible for beta-blocker therapy if they had known coronary artery disease or two or more risk factors. Atenolol was not used if the resting heart rate was <55 beats/min, systolic blood pressure was <100 mm Hg, or there was evidence of congestive heart failure, third degree heart block, or bronchospasm. A 5-mg dose of intravenous atenolol was given 30 minutes before surgery and then again immediately after surgery. Oral atenolol, 50-100 mg, was then given until hospital discharge or 7 days postoperatively. The results of the study showed that mortality from cardiac causes was 65% lower in the patients receiving atenolol. Another study showed similar perioperative benefit using the beta-blocker bisoprolol.
In prescribing an exercise program for elderly, community-dwelling patients, it is important to note that: (check one)

A. Graded exercise stress testing should be done before beginning the program
B. Target heart rates should be 80% of the predicted maximum
C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial
D. Treadmill walking is especially beneficial to patients with peripheral neuropathy
C. The initial routines can be as short as 6 minutes repeated throughout the day and still be beneficial. Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%-75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet.
A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an LDL cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be screened for: (check one)

A. Hyperthyroidism
B. Hypothyroidism
C. Addison's disease
D. Cushing's disease
E. Pernicious anemia
B. Hypothyroidism. According to the Summary of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III Report of 2001, any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications.
A 56-year-old African-American male with longstanding hypertension and a 30-pack-year smoking history has a 2-day history of dyspnea on exertion. Physical examination is unremarkable except for rare crackles at the bases. Which one of the following serologic tests would be most helpful for detecting left ventricular dysfunction? (check one)

A. Beta-natriuretic peptide (BNP)
B. Troponin-T
C. C-reactive protein (CRP)
D. D dimer
E. Cardiac interleukin-2
A. Beta-natriuretic peptide (BNP). Beta-natriuretic peptide (BNP) is a 32-amino acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. The major source of BNP is the cardiac ventricles, and because of its minimal presence in storage granules, its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram.
Patients with Wolff-Parkinson-White syndrome who have episodic symptomatic supraventricular tachycardia or atrial fibrillation benefit most from: (check one)

A. Episodic intravenous digoxin
B. Long-term oral digitalis
C. Episodic beta-blockers
D. Radiofrequency catheter ablation of bypass tracts
D. Radiofrequency catheter ablation of bypass tracts. Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. Intravenous and oral digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract.
A 72-year-old male with class III congestive heart failure (CHF) due to systolic dysfunction asks if he can take ibuprofen for his "aches and pains." Appropriate counseling regarding NSAID use and heart failure should include which one of the following? (check one)

A. NSAIDs are a good choice for pain relief, as they decrease systemic vascular resistance
B. NSAIDs are a good choice for pain relief, as they augment the effect of his diuretic
C. High-dose aspirin (325 mg/day) is preferable to other NSAIDs for patients taking ACE inhibitors
D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention
D. NSAIDs, including high-dose aspirin, should be avoided in CHF patients because they can cause fluid retention. If possible, NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure. NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less likely to cause these negative effects.
A 72-year-old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has hypertension, but no history of congestive heart failure or structural heart disease. He is otherwise healthy and active. The best INITIAL approach to his atrial fibrillation would be: (check one)

A. Rhythm control with antiarrythmics and warfarin (Coumadin) only if he cannot be consistently maintained in sinus rhythm
B. Rhythm control with antiarrythmics and warfarin regardless of maintenance of sinus rhythm
C. Ventricular rate control with digoxin, and warfarin for anticoagulation
D. Ventricular rate control with digoxin, and aspirin for anticoagulation
E. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation
E. Ventricular rate control with a calcium channel blocker or beta-blocker, and warfarin for anticoagulation. Five recent randomized, controlled trials have indicated that in most patients with atrial fibrillation, an initial approach of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT have a morbidity or mortality benefit and were more likely to suffer from adverse drug effects and increased hospitalizations. The most efficacious drugs for rate control are calcium channel blockers and beta-blockers. Digoxin is less effective for rate control and should be reserved as an add-on option for those not controlled with a beta-blocker or calcium channel blocker, or for patients with significant left ventricular systolic dysfunction. In patients 65 years of age or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm.
Cilostazol (Pletal) has been found to be a useful drug for the treatment of intermittent claudication. This drug is contraindicated in patients with: (check one)

A. Congestive heart failure
B. A past history of stroke
C. Diabetes mellitus
D. Third degree heart block
E. Hyperlipidemia
A. Congestive heart failure. Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with congestive heart failure. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block.
Cardiovascular Board Review Questions 05
A 35-year-old white male with known long QT syndrome has a brief episode of syncope requiring cardiopulmonary resuscitation. Which one of the following is most likely responsible for this episode? (check one)

A. Sinus tachycardia
B. Atrial flutter with third degree block
C. Asystole
D. Torsades de pointes
D. Torsades de pointes. Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have either torsades de pointes or ventricular fibrillation. Sinus tachycardia would not explain the syncope, and atrial flutter and asystole are not usual in long QT syndrome.
An 83-year-old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medications except occasional acetaminophen for knee pain. She has never been in the hospital and has not had any operations. She says that she feels well. The examination is normal, with expected age-related changes, except that her blood pressure on three different readings averages 175/70 mm Hg. These readings are confirmed on a subsequent follow-up visit. In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this patient's hypertension? (check one)

A. An alpha-blocker
B. An ACE inhibitor
C. A beta-blocker
D. An angiotensin receptor blocker
E. A thiazide diuretic
E. A thiazide diuretic. Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 160 mm Hg. (Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg.) The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy. Alpha-blockers are not recommended. ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g., in a patient with diabetes or who has had a myocardial infarction.
Of the following, the INITIAL treatment of choice in the management of severe hypertension during pregnancy is: (check one)

A. Labetalol (Trandate, Normodyne) intravenously
B. Reserpine (Serpasil) intramuscularly
C. Nifedipine (Procardia, Adalat) sublingually
D. Enalapril (Vasotec) intravenously
A. Labetalol (Trandate, Normodyne) intravenously. In pregnant women with severe hypertension, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. Intravenous hydralazine, intravenous labetalol, or oral nifedipine may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACE inhibitors are never indicated for hypertensive therapy during pregnancy.
Which one of the following has been shown to decrease mortality late after a myocardial infarction? (check one)

A. Nitrates
B. Beta-blockers
C. Digoxin
D. Thiazide diuretics
E. Calcium channel antagonists
B. Beta-blockers. Beta-blockers and ACE inhibitors have been found to decrease mortality late after myocardial infarction. Aspirin has been shown to decrease nonfatal myocardial infarction, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after myocardial infarction.
Which one of the following is preferred for chronic treatment of congestive heart failure due to left ventricular systolic dysfunction? (check one)

A. Diuretics
B. Digoxin
C. Calcium channel blockers
D. ACE inhibitors
E. Hydralazine (Apresoline) plus isosorbide dinitrate (Isordil, Sorbitrate)
D. ACE inhibitors. ACE inhibitors are the preferred drugs for congestive heart failure due to left ventricular systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms.
Which one of the following is most predictive of increased perioperative cardiovascular events associated with noncardiac surgery in the elderly? (check one)

A. An age of 80 years
B. Left bundle-branch block
C. Atrial fibrillation with a rate of 80 beats/min
D. A history of previous stroke
E. Renal insufficiency (creatinine 2.0 mg/dL)
E. Renal insufficiency (creatinine 2.0 mg/dL). Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as unstable coronary syndrome (acute or recent myocardial infarction, unstable angina), decompensated congestive heart failure, significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease. Intermediate predictors are mild angina, previous myocardial infarction, compensated congestive heart failure, diabetes mellitus, and renal insufficiency. Minor predictors are advanced age, an abnormal EKG, left ventricular hypertrophy, left bundle-branch block, ST and T-wave abnormalities, rhythm other than sinus, low functional capacity, history of stroke, and uncontrolled hypertension.
The use of automated external defibrillators by lay persons in out-of-hospital settings: (check one)

A. Has been frustrated by liability concerns
B. Has been hampered by an unwillingness to place the devices in public areas
C. Has been shown to contribute to significant gains in full neurologic and functional recovery
D. Has been eclipsed by the widespread use of internal cardiac defibrillators in high-risk patients
C. Has been shown to contribute to significant gains in full neurologic and functional recovery. The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity. At present, 45 states have passed Good Samaritan laws covering the use of AEDs by well-intentioned lay persons. There are initiatives for widespread placement of AEDs, to include commercial airlines and other public facilities. Implantable cardioverter defibrillators (ICDs) are useful in known at-risk patients, but the use of AEDs is for the population at large.
A 74-year-old white male complains of pain in the right calf that recurs on a regular basis. He smokes 1 pack of cigarettes per day and is hypertensive. He has a history of a previous heart attack but is otherwise in fair health. Which one of the following findings would support a diagnostic impression of peripheral vascular disease? (check one)

A. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf
B. Pain that begins immediately upon walking and is unrelieved by rest
C. Doppler waveform analysis showing accentuated waveforms at a point of decreased blood flow
D. Treadmill arterial flow studies showing a 20-mm Hg decrease in ankle systolic blood pressure immediately following exercise
E. An ankle-brachial index of 1.15
D. Treadmill arterial flow studies showing a 20-mm Hg decrease in ankle systolic blood pressure immediately following exercise. Peripheral vascular disease (PVD) is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent decrease in the ankle-brachial index from baseline following exercise, and usually a 20-mm Hg or greater decrease in systolic blood pressure. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker's cysts. Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ankle-brachial index is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, ankle-brachial indices in the range of 0.91-1.30 are thought to be normal.
In a 34-year-old primigravida at 35 weeks' gestation, which one of the following supports a diagnosis of MILD preeclampsia rather than severe preeclampsia? (check one)

A. A blood pressure of 150/100 mm Hg
B. A 24-hr protein level of 6 g
C. A platelet count <100,000/mm3
D. Liver enzyme elevation with epigastric tenderness
E. Altered mental status
A. A blood pressure of 150/100 mm Hg. The criteria for severe preeclampsia specify a blood pressure of 160/110 mm Hg or above on two occasions, 6 hours apart. Other criteria include proteinuria above 5 g/24 hr, thrombocytopenia with a platelet count <100,000/mm3, liver enzyme abnormalities, epigastric or right upper quadrant pain, and alteration of mental status.
A 72-year-old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or deep vein thrombosis. She takes no routine medications. Which one of the following is most appropriate for prophylaxis against deep vein thrombosis? (check one)

A. No prophylaxis if there are no surgical complications
B. Aspirin, 325 mg daily
C. Unfractionated heparin, 5000 U subcutaneously every 12 hours
D. Thigh-high compression stockings
E. Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours
E. Enoxaparin (Lovenox), 30 mg subcutaneously every 12 hours. Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low-molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression.
Endocrine Board Review Questions 01
A 49-year-old female who takes multiple medications has a chemistry profile as part of her routine monitoring. She is found to have an elevated calcium level. All other values on the profile are normal, and the patient is not currently symptomatic. Follow-up testing reveals a serum calcium level of 11.2 mg/dL (N 8.4-10.2) and an intact parathyroid hormone level of 80 pg/mL (N 10-65). Which one of the following should be discontinued for 3 months before repeat laboratory evaluation and treatment? (check one)

A. Lithium
B. Furosemide (Lasix)
C. Raloxifene (Evista)
D. Calcium carbonate
E. Vitamin D
A. Lithium. Lithium therapy can elevate calcium levels by elevating parathyroid hormone secretion from the parathyroid gland. This duplicates the laboratory findings seen with mild primary hyperparathyroidism. If possible, lithium should be discontinued for 3 months before reevaluation (SOR C). This is most important for avoiding unnecessary parathyroid surgery. Vitamin D and calcium supplementation could contribute to hypercalcemia in rare instances, but they would not cause elevation of parathyroid hormone. Raloxifene has actually been shown to mildly reduce elevated calcium levels, and furosemide is used with saline infusions to lower significantly elevated calcium levels.
Which one of the following medications should be discontinued in a patient with diabetic gastroparesis? (check one)

A. Exenatide (Byetta)
B. Benazepril (Lotensin)
C. Metformin (Glucophage)
D. Hydrochlorothiazide
E. Prochlorperazine maleate
A. Exenatide (Byetta). Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including amylin analogues (e.g., pramlintide) and glucagon-like peptide 1 (e.g., exenatide). Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia. In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting occurred in 19%, which led to the cessation of treatment in about one-third of patients. The other medications listed do not cause delayed gastric emptying.
A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose level, which he rarely checks, is typically over 200 mg/dL. His serum creatinine level is 1.9 mg/dL. He also has had several episodes of heart failure. His current medications include glipizide (Glucotrol), lisinopril (Prinivil, Zestril), and furosemide (Lasix). Which one of the following would be most appropriate to add to this patients regimen to treat his diabetes mellitus? (check one)

A. The American Diabetes Association 1800-calorie/day diet
B. Metformin (Glucophage)
C. Pioglitazone (Actos)
D. Exenatide (Byetta)
E. Insulin glargine (Lantus)
E. Insulin glargine (Lantus). For geriatric patients in long-term care facilities, the predictable glucose control of glargine is the best approach to consider initially. The American Diabetes Association does not recommend a strict diet for frail diabetic patients in nursing homes. Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea. Heart failure precludes the use of pioglitazone, and renal failure precludes the use of metformin.
A 54-year-old female takes levothyroxine (Synthroid), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU/mL (N 0.5-5.0). Which one of the following would you recommend? (check one)

A. Decrease the dosage of levothyroxine
B. Increase the dosage of levothyroxine
C. Order a free T4 level
D. Order a TRH stimulation test
E. Repeat the TSH level in 3 months
C. Order a free T4 level. Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.
A 55-year-old white male sees you for a routine annual visit. His fasting blood glucose level is 187 mg/dL. Repeat testing 1 week later reveals a fasting glucose level of 155 mg/dL and an HbA1c of 9.4%. His BMI is 30 kg/m2. He does not seem to have any symptoms of diabetes mellitus. In addition to lifestyle changes, which one of the following would you prescribe initially? (check one)

A. Metformin (Glucophage)
B. Glyburide (DiaBeta, Micronase)
C. Poiglitazone (Actos)
D. Bedtime long-acting insulin (Lantus, Levamir)
E. Bedtime long-acting insulin and rapid-acting insulin (NovoLog, Humalog) with each meal
A. Metformin (Glucophage). Metformin is widely accepted as the first-line drug for type 2 diabetes mellitus. It is relatively effective, safe, and inexpensive, and has been used widely for many years. Unlike other oral hypoglycemics and insulin, it does not cause weight gain. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione, or insulin can be added, with the choice based on the severity of the hyperglycemia.
Which one of the following most increases insulin sensitivity in an overweight patient with diabetes mellitus? (check one)

A. Metformin (Glucophage)
B. Acarbose (Precose)
C. Glyburide (DiaBeta, Micronase)
D. NPH insulin
A. Metformin (Glucophage). Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. Acarbose is an α-glucosidase inhibitor that delays glucose absorption.
A 40-year-old female comes to your office for a routine examination. She has been in good health and has no complaints other than obesity. Her mother is diabetic and the patient has had a child that weighed 9 lb at birth. Her examination is negative except for her obesity. A fasting glucose level is 128 mg/dL, and when repeated 2 days later it is 135 mg/dL. Which one of the following would be most appropriate at this point? (check one)

A. Diagnose type 2 diabetes mellitus and begin diet and exercise therapy
B. Begin an oral hypoglycemic agent
C. Order a glucose tolerance test
D. Tell the patient that she has impaired glucose homeostasis but is not diabetic
A. Diagnose type 2 diabetes mellitus and begin diet and exercise therapy. The criteria for diagnosing diabetes mellitus include any one of the following: symptoms of diabetes (polyuria, polydipsia, weight loss) plus a casual glucose level ≥200 mg/dL; a fasting plasma glucose level ≥126 mg/dL; or a 2-hour postprandial glucose level ≥200 mg/dL after a 75 gram glucose load. In the absence of unequivocal hyperglycemia the test must be repeated on a different day. The criteria for impaired glucose homeostasis include either a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test. Normal values are now considered <100 mg/dL for fasting glucose and <140 mg/dL for the 2-hour glucose level on an oral glucose tolerance test.
A 35-year-old male with a previous history of kidney stones presents with symptoms consistent with a recurrence of this problem. The initial workup reveals elevated serum calcium. Which one of the following tests would be most appropriate at this point? (check one)

A. Serum calcitonin
B. 24-hour urine for calcium and phosphate
C. Serum phosphate and magnesium
D. Serum parathyroid hormone
E. Spot urine for microalbumin
D. Serum parathyroid hormone. A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be appropriate. Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis. In the past, tests based on renal responses to elevated PTH were used to make the diagnosis. These included blood phosphate, chloride, and magnesium, as well as urinary or nephrogenous cyclic adenosine monophosphate. These tests are not specific for this problem, however, and are therefore not cost-effective. Serum calcitonin levels have no practical clinical use.
Endocrine Board Review Questions 02
In a patient with a solitary thyroid nodule, which one of the following is associated with a higher incidence of malignancy? (check one)

A. Hoarseness
B. Hyperthyroidism
C. Female gender
D. A nodule size of 2 cm
E. A freely movable nodule
A. Hoarseness. When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include male gender; age <20 years or >65 years; rapid growth of the nodule; symptoms of local invasion such as dysphagia, neck pain, and hoarseness; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule >4 cm; and cervical lymphadenopathy.
Which one of the following can contribute to serum calcium elevation? (check one)

A. Furosemide (Lasix)
B. Verapamil (Calan, Isoptin)
C. Enalapril (Vasotec)
D. Hydrochlorothiazide
E. Allopurinol (Zyloprim)
D. Hydrochlorothiazide. While thiazide diuretics do not cause hypercalcemia by themselves, they can exacerbate the hypercalcemia associated with primary hyperparathyroidism. Thiazides decrease the renal clearance of calcium by increasing distal tubular calcium reabsorption. Furosemide tends to lower serum calcium levels and is used in the treatment of hypercalcemia. None of the other medications would be expected to significantly affect the serum calcium level in this patient.
A 60-year-old type 2 diabetic requires urgent appendectomy. Which one of the following should be withheld until normal kidney function is documented at 24 and 48 hours after the surgery? (check one)

A. Acarbose (Precose)
B. Glimepiride (Amaryl)
C. Metformin (Glucophage)
D. Nateglinide (Starlix)
C. Metformin (Glucophage). Administration of general anesthesia may cause hypotension, which leads to renal hypoperfusion and peripheral tissue hypoxia, with subsequent lactate accumulation. Therefore, if administration of radiocontrast material is required or urgent surgery is needed, metformin should be withheld and hydration maintained until preserved kidney function is documented at 24 and 48 hours after the intervention.
Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin (Glucophage)? (check one)

A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal distress
B. Hypoglycemia. Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is that it does not cause hypoglycemia. Lactic acidosis, while rare, can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or even a weight loss effect. Gastrointestinal distress is a common side-effect of metformin, particularly early in therapy.
U.S. Department of Transportation standards for commercial drivers would disqualify which one of the following? (check one)

A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8-6.4)
B. A 50-year-old female with uncorrected 20/40 vision in both eyes
C. A 57-year-old male who had an inferior myocardial infarction 3 years ago and had a recent negative treadmill test
D. A 64-year-old male who fails a whispered-voice test in one ear
A. A 38-year-old male type 1 diabetic, well-controlled on insulin, whose last HbA1c was 6.0% (N 3.8-6.4). Insulin-dependent diabetes, even if well controlled, disqualifies a driver for commercial interstate driving. Vision of 20/40 is the minimum allowed under Department of Transportation regulations. Adequate hearing in one ear and well-compensated controlled heart disease are both allowed. Blood pressure of 160/90 mm Hg or less merits an unrestricted 2-year certification. Drivers with a blood pressure of 160/90-181/105 mm Hg can receive a 3-month temporary certification during which treatment for hypertension should be undertaken.
A small child with failure to thrive is found to have a bone age that is markedly delayed relative to height age and chronologic age. The most likely etiology is: (check one)

A. Cystic fibrosis
B. Hypothyroidism
C. Down syndrome
D. Fetal alcohol syndrome
E. Gonadal dysgenesis
B. Hypothyroidism. Hypothyroidism is associated with markedly delayed bone age relative to height age and chronologic age. In cystic fibrosis, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a height age which is delayed relative to bone age. This pattern is also seen as a result of maternal substance abuse.
Chronic excess thyroid hormone replacement over a number of years in postmenopausal women can lead to: (check one)

A. Diffuse nontoxic goiter
B. Osteoarthritis
C. Osteoporosis
D. Hyperparathyroidism
C. Osteoporosis. Even mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone. Goiter is an indicator, not a cause, for hormone replacement. Osteoarthritis is not related to thyroid hormone replacement.
In evaluating an adult with anemia, which one of the following findings most reliably indicates a diagnosis of iron deficiency anemia? (check one)

A. Low total iron-binding capacity
B. Low serum iron
C. Low serum ferritin
D. Microcytosis
E. Hypochromia
C. Low serum ferritin. The total iron-binding capacity is elevated, not decreased, in iron deficiency anemia. As an acute-phase reactant, serum iron may be decreased in response to inflammation even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of iron deficiency anemia occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin, however, is diagnostic for iron deficiency even in its early stages.
Routine blood tests frequently reveal elevated calcium levels. When this elevation is associated with elevated parathyroid hormone levels, which one of the following is an indication for parathyroid surgery? (check one)

A. Age >50
B. Kidney stones
C. Serum calcium 0.5 mg/dL above the upper limit of normal
D. Concurrent hyperthyroidism
E. Increased bone density
B. Kidney stones. Indications for parathyroid surgery include kidney stones, age less than 50, a serum calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density. Hyperthyroidism is not a factor in deciding to perform parathyroid surgery.
At a routine visit, a 50-year-old white female with a 10-year history of type 2 diabetes mellitus has a blood pressure of 145/90 mm Hg and significant microalbuminuria. Which one of the following would be an absolute contraindication to use of an ACE inhibitor in this patient? (check one)

A. A previous history of angioneurotic edema
B. Renal insufficiency
C. Asthma
D. A history of recent myocardial infarction
E. A cardiac ejection fraction <25%
A. A previous history of angioneurotic edema. Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced cardiac ejection fraction are indications for ACE inhibitor therapy. ACE inhibitors do not affect asthma.
Gastrointestinal Board Review Questions 01
A 36-hour-old male is noted to have jaundice extending to the abdomen. He is breastfeeding well, 10 times a day, and is voiding and passing meconium-stained stool. He was born by normal spontaneous vaginal delivery at 38 weeks gestation after an uncomplicated pregnancy. The mother's blood type is A positive with a negative antibody screen. The infants total serum bilirubin is 13.0 mg/dL. Which one of the following would be the most appropriate management of this infants jaundice? (check one)

A. Continue breastfeeding and supplement with water or dextrose in water to prevent dehydration
B. Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk
C. Discontinue breastfeeding and supplement with formula until the jaundice resolves
D. Discontinue breastfeeding and supplement with formula until total serum bilirubin levels begin to decrease
B. Continue breastfeeding, evaluate for risk factors, and initiate phototherapy if at risk. In 2004 the American Academy of Pediatrics published updated clinical practice guidelines on the management of hyperbilirubinemia in the newborn infant at 35 or more weeks gestation. These guidelines focus on frequent clinical assessment of jaundice, and treatment based on the total serum bilirubin level, the infants age in hours, and risk factors. Phototherapy should not be started based solely on the total serum bilirubin level. The guidelines encourage breastfeeding 8-12 times daily in the first few days of life to prevent dehydration. There is no evidence to support supplementation with water or dextrose in water in a nondehydrated breastfeeding infant. This infant is not dehydrated and is getting an adequate number of feedings, and there is no reason to discontinue breastfeeding at this time.
A 3-week-old male is brought to your office because of a sudden onset of bilious vomiting of several hours duration. He is irritable and refuses to breastfeed, but stools have been normal. He was delivered at term after a normal pregnancy, and has had no health problems to date. A physical examination shows a fussy child with a distended abdomen. Radiography of the abdomen shows a double bubble sign. Which one of the following is the most likely diagnosis? (check one)

A. Infantile colic
B. Necrotizing enterocolitis
C. Hypertrophic pyloric stenosis
D. Intussusception
E. Midgut volvulus
E. Midgut volvulus. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus. Infantile colic usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature. It usually presents during the third to fifth weeks of life. Projectile vomiting after feeding, weight loss, and dehydration are common. The vomitus is always nonbilious, because the obstruction is proximal to the duodenum. If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly. An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.
A previously healthy 3-year-old male is brought to your office with a 4-hour history of abdominal pain followed by vomiting. Just after arriving at your office he passes bloody stool. A physical examination reveals normal vital signs, and guarding and tenderness in the right lower quadrant. A rectal examination shows blood on the examining finger. Which one of the following is the most likely diagnosis? (check one)

A. Appendicitis
B. Viral gastroenteritis
C. Midgut volvulus
D. Meckels diverticulum
E. Necrotizing enterocolitis
D. Meckels diverticulum. Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. Children with appendicitis have right lower quadrant pain, abdominal tenderness, guarding, and vomiting, but not rectal bleeding. With acute viral gastroenteritis, vomiting usually precedes diarrhea (usually without blood) by several hours, and abdominal pain is typically mild and nonfocal with no localized tenderness. The incidence of midgut volvulus peaks during the first month of life, but it can present anytime in childhood. Volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in the neonate; as a history of feeding problems with bilious vomiting that now appears to be due to bowel obstruction; or, less commonly, as a failure to thrive with severe feeding intolerance. Necrotizing enterocolitis is typically seen in the neonatal intensive-care unit, occurring in premature infants in their first few weeks of life. The infants are ill, and signs and symptoms include lethargy, irritability, decreased oral intake, abdominal distention, and bloody stools. A plain abdominal film showing pneumatosis intestinalis, caused by gas in the intestinal wall, is diagnostic of this disease.
The mother of an 4-week-old male asks about the viral gastroenteritis vaccine. You advise that it is (check one)

A. routinely given at the 12-month visit
B. associated with an increased risk for intussusception
C. initiated at 6-12 weeks of age
D. indicated only for immunocompromised children
E. indicated only for children attending day care
C. initiated at 6-12 weeks of age. Rotavirus vaccine (RotaTeq) was licensed in February 2006 to protect against viral gastroenteritis. The Advisory Committee on Immunization Practices recommends the routine vaccination of infants with three doses to be given at 2, 4, and 6 months of age. The first dose should be given between 6 and 12 weeks of age, and subsequent doses should be given at 4- to 10-week intervals, but all three doses should be administered by 32 weeks of age. Unlike the vaccine RotaShield, which was marketed in 1999, RotaTeq is not known to increase the risk for intussusception.
Which one of the following is a risk factor for acute pancreatitis? (check one)

A. Gastroesophageal reflux disease
B. Intravenous drug abuse
C. Angiotensin receptor blocker use
D. Pyelonephritis
E. Gallstones
E. Gallstones. Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive alcohol use. Gastroesophageal reflux disease, pyelonephritis, drug abuse (other than alcohol), and angiotensin receptor blocker use are not risk factors for the development of pancreatitis.
Treatment for Helicobacter pylori infection will reduce or improve which one of the following? (check one)

A. The risk of peptic ulcer bleeding from chronic NSAID therapy
B. The risk of developing gastric cancer in asymptomatic patients
C. Symptoms of nonulcer dyspepsia
D. Symptoms of gastroesophageal reflux disease
A. The risk of peptic ulcer bleeding from chronic NSAID therapy. Eradication of Helicobacter pylori significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy. Eradication has minimal or no effect on the symptoms of nonulcer dyspepsia and gastroesophageal reflux disease. Although H. pylori infection is associated with gastric cancer, no trials have shown that eradication of H. pylori purely to prevent gastric cancer is beneficial.
Which one of the following is associated with ulcerative colitis rather than Crohn's disease? (check one)

A. The absence of rectal involvement
B. Transmural involvement of the colon
C. Segmental noncontinuous distribution of inflammation
D. Fistula formation
E. An increased risk of carcinoma of the colon
E. An increased risk of carcinoma of the colon. Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission. All of the other options listed are features typically associated with Crohn's disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn's disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn's disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC.
A 54-year-old white female has been taking amoxicillin for 1 week for sinusitis. She has developed diarrhea and has had 6-8 stools per day for the past 2 days. Examination shows the patient to be well hydrated with normal vital signs and a normal physical examination. The stool is positive for occult blood, and a stool screen for Clostridium difficile toxin is positive. The most appropriate treatment at this time would be (check one)

A. vancomycin (Vancocin) intravenously
B. metronidazole (Flagyl) orally
C. trimethoprim/sulfamethoxazole (Bactrim, Septra) orally
D. ciprofloxacin (Cipro) orally
B. metronidazole (Flagyl) orally. Many antibiotics can induce pseudomembranous colitis. Although oral vancomycin was once the initial drug of choice for C. difficile, oral metronidazole is now the first-line agent because of cost considerations and because of concerns about the development of vancomycin-resistant organisms. If the patient has refractory symptoms despite treatment with oral metronidazole, then oral vancomycin would be appropriate. Vancomycin given orally is not absorbed, leading to high intraluminal levels of the drug.
Current thinking regarding infantile colic is that the cause is (check one)

A. malabsorption
B. overfeeding
C. excessive air swallowing
D. unknown
E. parental anxiety
D. unknown. Colic is a frustrating condition for parents and doctors alike. The parents would like an explanation and relief, and physicians would like to offer these things. At this time, however, in spite of numerous studies and theories, the cause of colic remains unknown.
An outbreak of pediatric diarrhea has swept your community. You evaluate a 30-month-old male who developed diarrhea yesterday. He is still breastfed. He is alert, his mucous membranes are moist, and his skin turgor is good. He passes a liquid stool in your office. Which one of the following would be the best advice with regard to his diet? (check one)

A. The mother should withhold breastfeeding
B. He should consume a normal age-appropriate diet, and continue breastfeeding
C. Fasting will promote intestinal mucosal recovery
D. Oral intake should be limited to clear fluids, bananas, rice, applesauce, and toast (BRAT diet)
B. He should consume a normal age-appropriate diet, and continue breastfeeding. Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be effective.
Gastrointestinal Board Review Questions 02
For 2 weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix) and spironolactone (Aldactone). On examination, his temperature is 38.0° C (100.4° F), blood pressure 100/60 mm Hg, heart rate 92 beats/min and regular. The heart and lung examination is normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal examination is normal, and the stool is negative for occult blood. You perform diagnostic paracentesis and send a sample of fluid for analysis. Which one of the following findings would best establish the suspected diagnosis of spontaneous bacterial peritonitis? (check one)

A. pH <7.2
B. Bloody appearance
C. Neutrophil count >300/mL
D. Positive cytology
E. Total protein >1 g/dL
C. Neutrophil count >300/mL. Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level >1 g/dL is actually evidence against spontaneous bacterial peritonitis.
A pregnant patient is positive for hepatitis B surface antigen (HBsAg). Which one of the following would be most appropriate for her infant? (check one)

A. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth
B. Hepatitis B vaccine only, at birth
C. HBIG only, at birth
D. Testing for HBsAg before any immunization
E. No immunization until 1 year of age
A. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine at birth. Infants born to hepatitis B-positive mothers should receive both immune globulin and hepatitis B vaccine. They should receive the entire series of the vaccine, with testing for seroconversion only after completion of the vaccination series; the recommended age for testing is 9-12 months of age.
Your community recently experienced an outbreak of infectious diarrheal illness due to the protozoan Cryptosporidium, a chlorine-resistant organism. A reporter from the local newspaper asks you if there are other chlorine-resistant fecal organisms that could contaminate public drinking water. You would tell the reporter that such organisms include: (check one)

A. Escherichia coli
B. Vibrio cholerae
C. Campylobacter jejuni
D. Giardia lamblia
E. Rotavirus
D. Giardia lamblia. Organisms that can persist in water environments and survive disinfection, especially chlorination, are most likely to cause disease outbreaks related to drinking water. Cryptosporidium oocysts and Giardia cysts are resistant to chlorine and are important causes of gastroenteritis from drinking water. Entamoeba histolytica and hepatitis A virus are also relatively chlorine resistant. The other organisms listed are chlorine sensitive.
Hepatitis C screening is routinely recommended in which one of the following? (check one)

A. Pregnant women
B. Nonsexual household contacts of hepatitis C-positive persons
C. Health care workers
D. Persons with a history of illicit intravenous drug use
D. Persons with a history of illicit intravenous drug use. Patients should be routinely screened for hepatitis C if they have a history of any of the following: intravenous drug abuse no matter how long or how often, receiving clotting factor produced before 1987, persistent alanine aminotransferase elevations, or recent needle stick with HCV-positive blood.
A nurse who completed a hepatitis B vaccine series a year ago is accidentally stuck by a needle that has just been used on a dialysis patient. The patient is known to be HBsAg-positive. Your first response should be to: (check one)

A. Provide reassurance only
B. Test the nurse for hepatitis B antibody
C. Repeat the hepatitis B vaccine series
D. Administer hepatitis B immune globulin (HBIG) only
E. Administer HBIG plus a booster of hepatitis B vaccine
B. Test the nurse for hepatitis B antibody. Postexposure prophylaxis after hepatitis B exposure via the percutaneous route depends upon the source of the exposure and the vaccination status of the exposed person. In the case described, a vaccinated person has been exposed to a known positive individual. The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme immunoassay) HBIG should be administered immediately, as well as a hepatitis B vaccine booster dose. An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months).
A 57-year-old African-American female has a partial resection of the colon for cancer. The surgical specimen has clean margins, and there is no lymph node involvement. There is no evidence of metastasis. You recommend periodic colonoscopy for surveillance, and also plan to monitor which one of the following tumor markers for recurrence? (check one)

A. Prostate-specific antigen (PSA)
B. Cancer antigen 27.29 (CA 27-29)
C. Cancer antigen 125 (CA-125)
D. Carcinoembryonic antigen (CEA)
E. Alpha-fetoprotein
D. Carcinoembryonic antigen (CEA). Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer. It is elevated in more than 70% of organ-confined prostate cancers. Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. CA-125 is a marker for ovarian cancer. Although it is elevated in 85% of ovarian cancers, it is elevated in only 50% of early-stage ovarian cancers. Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4-6 weeks after successful surgical resection. CEA elevation occurs in nearly half of patients with a normal preoperative CEA level that have cancer recurrence. Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. It is elevated in about 33% of early-stage breast cancers and about 67% of late-stage breast cancers. Some tumor markers, such as CEA, alpha-fetoprotein, and CA-125, may be more helpful in monitoring response to therapy than in detecting the primary tumor.
A 65-year-old white female comes to your office with evidence of a fecal impaction which you successfully treat. She relates a history of chronic laxative use for most of her adult years. After proper preparation, you perform sigmoidoscopy and note that the anal and rectal mucosa contain scattered areas of bluish-black discoloration. Which one of the following is the most likely explanation for the sigmoidoscopic findings? (check one)

A. Endometriosis
B. Collagenous colitis
C. Melanosis coli
D. Metastatic malignant melanoma
E. Arteriovenous malformations
C. Melanosis coli. This patient has typical findings of melanosis coli, the term used to describe black or brown discoloration of the mucosa of the colon. It results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa. The coloration is usually most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron. Ectopic endometrial tissue (endometriosis) most commonly involves the serosal layer of those parts of the bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon. Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are more common in the proximal bowel, and would not appear as described.
A 55-year-old white male smoker has had daily severe gastroesophageal reflux symptoms unrelieved by intensive medical therapy with proton pump inhibitors. A recent biopsy performed during upper endoscopy identified Barrett's esophagus. Which one of the following is true about this condition? (check one)

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

A. Listeria monocytogenes
B. Escherichia coli O157:H7
C. Shigella dysenteriae
D. Campylobacter jejuni
E. Salmonella enterica
D. Campylobacter jejuni. The treatment of acute and significant diarrhea often requires a specific diagnosis. Epidemiologic studies have shown that Campylobacter infections are the leading cause of bacterial diarrhea in the U.S.
A 25-year-old white male truck driver complains of 1 day of throbbing rectal pain. Your examination shows a large, thrombosed external hemorrhoid. Which one of the following is the preferred initial treatment for this patient? (check one)

A. Warm sitz baths, a high-residue diet, and NSAIDs
B. Rubber band ligation of the hemorrhoid
C. Elliptical excision of the thrombosed hemorrhoid
D. Stool softeners and a topical analgesic/hydrocortisone cream (e.g., Anusol-HC)
C. Elliptical excision of the thrombosed hemorrhoid. The appropriate management of a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate.
Gastrointestinal Board Review Questions 03
A 32-year-old meat cutter comes to your office with persistent symptoms of nausea, vomiting, and diarrhea which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His wife was sick during the first 2 days of the cruise with similar symptoms. On the ship, they both ate the "usual foods" in addition to oysters. Findings on examination are negative, and a stool specimen is negative for white cells. Which one of the following is the most likely cause of his illness? (check one)

A. Escherichia coli
B. Rotavirus
C. Norwalk virus
D. Hepatitis A
E. Giardia species
C. Norwalk virus. Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norwalk virus infections due to waterborne or foodborne spread. In the United States, these viruses are responsible for about 90% of all epidemics of nonbacterial gastroenteritis. The Norwalk-like viruses are common causes of waterborne epidemics of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships, at summer camps, and in schools. Symptomatic treatment is usually appropriate.
A 38-year-old male who is a new patient reports mild intermittent jaundice without other associated symptoms for the past several years. His liver function tests are normal except for a total bilirubin of 1.3 mg/dL (N 0.3-1.0) and an indirect or unconjugated bilirubin of 1.0 mg/dL (N 0.2-0.8). His CBC is normal. His past medical and surgical history is unremarkable. Findings are similar on repeat laboratory testing. The most likely cause of these findings is: (check one)

A. Hepatitis C
B. Wilson's disease
C. Sickle cell anemia
D. Gilbert's syndrome
E. Drug toxicity
D. Gilbert's syndrome. Gilbert's syndrome is the most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is Gilbert's syndrome. Fasting, heavy physical exertion, sickle cell anemia, and drug toxicity can also cause hyperbilirubinemia.
A 24-year-old white female presents to the office with a 6-month history of abdominal pain. A physical examination, including pelvic and rectal examinations, is normal. Which one of the following would indicate a need for further evaluation? (check one)

A. Relief of symptoms with defecation
B. Changes in stool consistency from loose and watery to constipation
C. Passage of mucus with bowel movements
D. Abdominal bloating
E. Worsening of symptoms at night
E. Worsening of symptoms at night. Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is the most common functional disorder of the gastrointestinal tract. The presence of nocturnal symptoms is a red flag which should alert the physician to an alternate diagnosis and may require further evaluation. The other symptoms listed are Rome I and II criteria for diagnosing irritable bowel syndrome.
A 36-year-old female makes an appointment because her husband of 12 years was just diagnosed with hepatitis C when he tried to become a blood donor for the first time. He recalls multiple blood transfusions following a motorcycle crash in 1988. His wife denies past liver disease, blood transfusions, and intravenous drug use. She has had no other sexual partners. The couple has three children. Which one of the following is the best advice about testing the wife and their three children? (check one)

A. No testing is required in the absence of jaundice or gastrointestinal symptoms
B. No testing is required if her husband has normal liver enzyme levels
C. No testing is required because tests have low sensitivity
D. She should be offered testing because sexual transmission is possible
E. All family members should be tested because of possible household fecal-oral spread
D. She should be offered testing because sexual transmission is possible. Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987. Sexual transmission is very low but possible, and the likelihood increases with multiple partners. The lifetime transmission risk of hepatitis C in a monogamous relationship is less than 1%, but the patient should be offered testing because she may choose to confirm that her test is negative. If the mother is seronegative, the children are at no risk. Maternal-fetal transmission is rare except in the setting of co-infection with HIV. Hepatitis C is insidious, and symptoms do not correlate with the extent of the disease. Normal liver enzyme levels do not indicate lack of infectivity. There is no risk to household contacts. Current HCV antibody tests are more than 99% sensitive and specific and are recommended for screening at-risk populations.
A moderately obese 50-year-old African-American female presents with colicky right upper quadrant pain that radiates to her right shoulder. Which one of the following is considered the best study to confirm the likely cause of the patient's symptoms? (check one)

A. Plain abdominal radiography
B. Oral cholecystography
C. Abdominal ultrasonography
D. A barium swallow
E. Esophagogastroscopy
C. Abdominal ultrasonography. The symptom complex presented is typical of cholelithiasis. Plain radiography of the abdomen may reveal radiopaque gallstones, but will not reveal radiolucent stones or biliary dilatation. Although rarely used, oral cholecystography is 98% accurate, but only when compliance is assured, the contrast agent is absorbed, and liver function is normal. Abdominal ultrasonography is considered the best study to confirm this diagnosis because of its high sensitivity and its accuracy in detecting gallstones. A barium swallow will identify some functional and structural esophageal abnormalities, but will not focus on the suspected organ in this case. The same is true of esophagogastroscopy.
A 32-year-old white female at 16 weeks' gestation presents to your office with right lower quadrant pain. Which one of the following imaging studies would be most appropriate for initial evaluation of this patient? (check one)

A. CT of the abdomen
B. MRI of the abdomen
C. Ultrasonography of the abdomen
D. A small bowel series
E. Intravenous pyelography
C. Ultrasonography of the abdomen. CT has demonstrated superiority over transabdominal ultrasonography for identifying appendicitis, associated abscess, and alternative diagnoses. However, ultrasonography is indicated for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion for gynecologic disease.
A positive spot urine test for homovanillic acid (HMA) and vanillylmandelic acid (VMA) is a marker for which one of the following? (check one)

A. Hepatoblastoma
B. Wilms' tumor
C. Lymphoma
D. Malignant teratoma
E. Neuroblastoma
E. Neuroblastoma. Tumor markers are useful in determining the diagnosis and sometimes the prognosis of certain tumors. They can aid in assessing response to therapy and detecting tumor recurrence. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors.
A slender 22-year-old female is concerned about a recent weight loss of 10 lb, frequent mild abdominal pain, and significant diarrhea of 2 months' duration. Her physical examination is unremarkable, and laboratory studies reveal only a moderate microcytic, hypochromic anemia. Based on this presentation, which one of the following is the most likely diagnosis? (check one)

A. Irritable bowel syndrome
B. Villous adenoma
C. Infectious colitis
D. Celiac disease
E. Ulcerative colitis
D. Celiac disease. This constellation of symptoms strongly suggests celiac disease, a surprisingly common disease with a prevalence of 1:13 in the U.S. Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.
A 62-year-old male presents for surgical clearance prior to transurethral resection of the prostate. His past history is significant for a pulmonary embolus after a cholecystectomy 15 years ago. His examination is unremarkable except that he is 23 kg (50 lb) overweight. The most appropriate recommendation to the urologist would be to: (check one)

A. Cancel the surgery indefinitely
B. Place the patient on 650 mg of aspirin daily prior to surgery
C. Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1-2 hr prior to surgery and once a day after surgery
D. Start warfarin (Coumadin) after surgery with a goal INR of 1.5
E. Start intravenous heparin according to a weight-based protocol 24 hours after surgery
C. Start the patient on subcutaneous enoxaparin (Lovenox), 40 mg 1-2 hr prior to surgery and once a day after surgery. A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. Aspirin is ineffective for prophylaxis of venous thromboembolism. Warfarin is effective at an INR of 2.0-3.0. Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a higher rate of postoperative hemorrhage.
A 60-year-old male indicates that he occasionally brings up what appears to be undigested food long after his meal. He also admits that he sometimes chokes on food, and that his wife says he has bad breath. The most likely diagnosis is: (check one)

A. Achalasia
B. Esophageal reflux
C. Cancer of the esophagus
D. Zenker's diverticulum
E. Large cervical bone spur
D. Zenker's diverticulum. The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker's diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.
Integumentary Board Review Questions 01
A 45-year-old white male consults you because of a painless, circular, 1-cm white spot inside his mouth, which he noticed 3 days ago. You are treating him with propranolol (Inderal) for hypertension, and you know him to be a heavy alcohol user. After a careful physical examination, your tentative diagnosis is leukoplakia of the buccal mucosa. You elect to observe the lesion for 2 weeks. On the patients return, the lesion is still present and unchanged in appearance. The best course of management at this time is to (check one)

A. reassure the patient and continue to observe
B. discontinue propranolol
C. treat with oral nystatin
D. order a fluorescent antinuclear antibody test
E. perform a biopsy of the lesion
E. perform a biopsy of the lesion. Leukoplakia is a white keratotic lesion seen on mucous membranes. Irritation from various mechanical and chemical stimuli, including alcohol, favors development of the lesion. Leukoplakia can occur in any area of the mouth and usually exhibits benign hyperkeratosis on biopsy. On long-term follow-up, 2%-6% of these lesions will have undergone malignant transformation into squamous cell carcinoma. Oral nystatin would not be appropriate treatment, as this lesion is not typical of oral candidiasis. Candidal lesions are usually multiple and spread quickly when left untreated. A fluorescent antinuclear antibody test is also not indicated, as the oral lesions of lupus erythematosus are typically irregular, erosive, and necrotic. An idiosyncratic reaction to propranolol is unlikely in this patient.
A 4-year-old white male is brought to your office in late August. His mother tells you that over the past few days he has developed a rash on his hands and sores in his mouth. On examination you note a vesicular exanthem on his hands, with lesions ranging from 3 to 6 mm in diameter. The oral lesions are shallow, whitish, 4- to 8-mm ulcerations distributed randomly over the hard palate, buccal mucosa, gingiva, tongue, lips, and pharynx. Except for a temperature of 37.4°C (99.3°F), the remainder of the examination is normal. The most likely diagnosis is (check one)

A. herpangina
B. hand, foot, and mouth disease
C. aphthous stomatitis
D. herpetic gingivostomatitis
E. streptococcal pharyngitis
B. hand, foot, and mouth disease. Hand, foot, and mouth disease is a mild infection occurring in young children, and is caused by coxsackievirus A16, or occasionally by other strains of coxsackie- or enterovirus. In addition to the oral lesions, vesicular lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and vesiculo-ulcerative lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial, and it may be due to a number of conditions. Systemic signs, such as fever, are generally absent. Lesions are randomly distributed. Herpetic gingivostomatitis also causes randomly distributed oral ulcers, but it is a more severe illness, regularly accompanied by a higher fever, and is extremely painful. Streptococcal pharyngitis is rarely accompanied by ulceration except in agranulocytic patients.
A 65-year-old white male comes to your office with a 0.5-cm nodule that has developed on his right forearm over the past 4 weeks. The lesion is dome shaped and has a central plug. You schedule a biopsy but he does not return to your office for 1 year. At that time the lesion appears to have healed spontaneously. The most likely diagnosis is (check one)

A. benign lentigo
B. lentigo maligna
C. basal cell carcinoma
D. squamous cell carcinoma
E. keratoacanthoma
E. keratoacanthoma. Keratoacanthoma grows rapidly and may heal within 6 months to a year. Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously. The other lesions do not resemble keratoacanthoma.
A 72-year-old white male in otherwise good health complains of generalized pruritus that worsens in the winter. The itching is most intense after he bathes. He recently noticed a rash on his abdomen and legs as well. On examination you note poorly defined red, scaly plaques with fine fissures on the abdomen. No eruption is present at other pruritic sites. Which one of the following is the most likely cause of this problem? (check one)

A. Stasis dermatitis
B. Lichen simplex chronicus
C. Xerosis
D. Rosacea
E. Candidiasis
C. Xerosis. Xerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth.
A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of. In such cases the best approach would be to (check one)

A. perform a punch biopsy and have the patient return if the biopsy indicates pathology
B. perform a shave biopsy and recheck in 2 months for signs of recurrence
C. use electrocautery to destroy the lesion and the surrounding tissue
D. perform an elliptical excision as soon as possible
E. freeze the site with liquid nitrogen
D. perform an elliptical excision as soon as possible. Despite this individual's busy schedule, he has a potentially life-threatening problem that needs proper diagnosis and treatment. Though an excisional biopsy takes longer, it is the procedure of choice when melanoma is suspected. After removal and diagnosis, prompt referral is essential for further evaluation and therapy. A shave biopsy should never be done for suspected melanoma, as this is likely to transect the lesion and destroy evidence concerning its depth, thus making it difficult to assess the prognosis. A punch biopsy should be used only with discretion when the lesion is too large for complete excision, or if substantial disfigurement would occur. Since this may not actually retrieve cancerous tissue from an unsampled area of a large lesion that might be malignant, it would be safest to refer such patients. Neither cryotherapy nor electrocautery should be used for a suspected melanoma.
Which one of the following decreases pain from infiltration of local anesthetics? (check one)

A. Cooling the anesthetic solution
B. Using a 22-gauge needle rather than a 30-gauge needle
C. Infiltrating quickly
D. Infiltrating through surrounding intact skin
E. Adding sodium bicarbonate to the mixture
E. Adding sodium bicarbonate to the mixture. The pain from infiltration of local anesthetics can be decreased by using a warm solution, using small needles, and performing the infiltration slowly.It is also helpful to add sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life. An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. It also helps to inject the agent through the edges of the wound (assuming the wound is not contaminated) and to pretreat the wound with topical anesthetics.
A newborn male has a skin eruption on his forehead, nose, and cheeks. The lesions are mostly closed comedones with a few open comedones, papules, and pustules. No significant erythema is seen. Which one of the following is the most likely diagnosis? (check one)

A. Erythema toxicum neonatorum
B. Localized superficial Candida infection
C. Herpes simplex
D. Milia
E. Acne neonatorum
E. Acne neonatorum. Acne neonatorum occurs in up to 20% of newborns. It typically consists of closed comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring. Findings in erythema toxicum neonatorum include papules, pustules, and erythema. Candida and herpes lesions usually present with vesiculopustular lesions in the neonatal period. Milia consists of 1- to 2-mm pearly keratin plugs without erythema, and may occur on the trunk and limbs.
A 5-year-old white male has an itchy lesion on his right foot. He often plays barefoot in a city park that is subject to frequent flooding. The lesion is located dorsally between the web of his right third and fourth toes, and extends toward the ankle. It measures approximately 3 cm in length, is erythematous, and has a serpiginous track. The remainder of his examination is within normal limits. Which one of the following is the most likely cause of these findings? (check one)

A. Dog or cat hookworm (Ancylostoma species)
B. Dog or other canid tapeworm (Echinococcus granulosus)
C. Cat protozoa (Toxoplasma gondii)
D. Dog or cat roundworm (Toxocara canis or T. mystax)
A. Dog or cat hookworm (Ancylostoma species). This patient has cutaneous larva migrans, a common condition caused by dog and cat hookworms. Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection. Echinococcosis (hydatid disease) is caused by the cestodes (tapeworms) Echinococcus granulosus and Echinococcus multilocularis, found in dogs and other canids. It infects humans who ingest eggs that are shed in the animals feces and results in slow-growing cysts in the liver or lungs, and occasionally in the brain, bones, or heart. Toxoplasmosis is caused by the protozoa Toxoplasma gondii, found in cat feces. Humans can contract it from litter boxes or feces-contaminated soil, or by consuming infected undercooked meat. It can be asymptomatic, or it may cause cervical lymphadenopathy, a mononucleosis-like illness; it can also lead to a serious congenital infection if the mother is infected during pregnancy, especially during the first trimester. Toxocariasis due to Toxocara canis and Toxocara cati causes visceral or ocular larva migrans in children who ingest soil contaminated with animal feces that contains parasite eggs, often found in areas such as playgrounds and sandboxes.
A middle-aged hairdresser presents with a complaint of soreness of the proximal nail folds of several fingers on either hand, which has slowly worsened over the last 6 months. The nails appear thickened and distorted. Otherwise she is healthy and has no evidence of systemic disease. Which one of the following would be the most effective initial treatment? (check one)

A. Soaking in a dilute iodine solution twice daily to cleanse and sterilize the nail beds
B. Oral amoxicillin/clavulanate (Augmentin) for up to 4-6 weeks
C. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks
D. Evaluation for HIV, hepatitis C, psoriasis, and rheumatoid arthritis
C. Topical betamethasone dipropionate (Diprolene) applied twice daily to the nail folds for 3-4 weeks. Chronic paronychia is a common condition in workers whose hands are exposed to chemical irritants or are wet for long periods of time. This patient is an otherwise healthy hairdresser, with frequent exposure to irritants. The patient should be advised to avoid exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection. Soaking in iodine solution would kill bacteria, but would also perpetuate the chronic irritation. Because the condition is related to chemical and water irritation, a prolonged course of antibiotics should not be the first treatment step, and could have serious side effects. There is no need to explore less likely autoimmune causes for nail changes at this time.
A 6-month-old Hispanic female has had itching and irritability for 4-5 weeks. There is a family history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally over the antecubital and popliteal fossae, as well as some involvement of the face. In addition to maintenance therapy with an emollient, which one of the following topical medications would be appropriate first-line treatment for flare-ups in this patient? (check one)

A. A calcineurin inhibitor such as pimecrolimus (Elidel)
B. An anesthetic
C. An antihistamine
D. An antibiotic
E. A corticosteroid
E. A corticosteroid. This child has atopic dermatitis (eczema). It is manifested by a pruritic rash on the face and/or extensor surfaces of the arms and/or legs, especially in children. There often is a family history of atopy or allergies. In addition to the regular use of emollients, the mainstay of maintenance therapy, topical corticosteroids have been shown to be the best first-line treatment for flare-ups of atopic dermatitis. Topical calcineurin inhibitors should be second-line treatment for flare-ups, but are not recommended for use in children under 2 years of age. Antibiotics should be reserved for the treatment of acutely infected lesions. There is no evidence to support the use of topical anesthetics or analgesics in the treatment of this disorder.
Integumentary Board Review Questions 02
Your hospital administrator asks you to develop a community screening program for melanoma. Which one of the following is true concerning screening for this disease? (check one)

A. Screening for melanoma is not indicated since the disease is rare
B. Screening for melanoma is not indicated since screening takes too much time
C. No definite clinical evidence has shown that screening for melanoma reduces mortality
D. Because of sunbathing, female patients are the most important population to screen
C. No definite clinical evidence has shown that screening for melanoma reduces mortality. There have been no randomized, controlled trials or other definitive data to indicate that screening for melanoma reduces mortality. There are, however, factors which indicate that screening would be beneficial, including the increasing prevalence of the disease and the fact that screening is time-effective and safe. If screening is performed, populations at greatest risk should be considered. Men, especially those over age 50, have the highest incidence of melanoma.
A 36-year-old member of the National Guard who has just returned from Iraq consults you because of several "boils" on the back of his neck that have failed to heal over the last 6 months, despite two week-long courses of cephalexin (Keflex). You observe three 1- to 2-cm raised minimally tender lesions with central ulceration and crust formation. He denies any fever or systemic symptoms. The most likely cause of these lesions is: (check one)

A. Pyogenic granuloma
B. Leishmaniasis
C. Atypical mycobacterial infection
D. Squamous cell carcinoma
E. Epidermal inclusion cysts
B. Leishmaniasis. The most likely diagnosis is cutaneous leishmaniasis, caused by an intracellular parasite transmitted by the bite of small sandflies. Lesions develop gradually, and are often misdiagnosed as folliculitis or as infected epidermal inclusion cysts, but they fail to respond to usual skin antibiotics. Hundreds of cases have been diagnosed in troops returning from Iraq, most due to Leishmania major. Treatment is not always required, as most lesions will resolve over several months; however, scarring is frequent. U.S. military medical facilities and the CDC are coordinating treatment when indicated with sodium stibogluconate. Family physicians can play a key role in correctly identifying these lesions.
A 23-year-old Hispanic female at 18 weeks' gestation presents with a 4-week history of a new facial rash. She has noticed worsening with sun exposure. Her past medical history and review of systems is normal. On examination, you note symmetric, hyperpigmented patches on her cheeks and upper lip. The remainder of her examination is normal. The most likely diagnosis is: (check one)

A. Lupus erythematosus
B. Pemphigoid gestationis (herpes gestationis)
C. Melasma (chloasma)
D. Prurigo gestationis
C. Melasma (chloasma). Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant women affected. It is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. Melasma often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist. The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient.
You see a 16-year-old white female for a preparticipation evaluation for sports, and she asks for advice about the treatment of acne. She has a few inflammatory papules on her face. No nodules are noted. She says she has not tried any over-the-counter acne treatments. Which one of the following would be considered first-line therapy for this condition? (check one)

A. Oral tetracycline
B. Oral isotretinoin (Accutane)
C. Topical sulfacetamide (Sulamyd)
D. Topical benzoyl peroxide
D. Topical benzoyl peroxide. The American Academy of Dermatology grades acne as mild, moderate, and severe. Mild acne is limited to a few to several papules and pustules without any nodules. Patients with moderate acne have several to many papules and pustules with a few to several nodules. Patients with severe acne have many or extensive papules, pustules, and nodules. The patient has mild acne according to the American Academy of Dermatology classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to topical agents and as first-line therapy in more severe acne. Caution must be used to avoid tetracycline in pregnant females. Oral isotretinoin is used in severe nodular acne, but also must be used with extreme caution in females who may become pregnant. Special registration is required by physicians who use isotretinoin, because of its teratogenicity.
The most appropriate initial treatment for scabies in an 8-year-old male is: (check one)

A. 0.5% malathion lotion (Ovide)
B. 5% permethrin cream (Elimite)
C. 5% precipitated sulfur in petroleum
D. trimethoprim/sulfamethoxazole (Bactrim, Septra) orally for 10 days
B. 5% permethrin cream (Elimite). In adults and children over 5 years of age, 5% permethrin cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and minimally toxic.
Painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy are best treated by: (check one)

A. Antibiotic therapy
B. Cotton-wick elevation of the affected nail corner
C. Removal of the entire nail
D. Excision of the lateral nail plate combined with lateral matricectomy
D. Excision of the lateral nail plate combined with lateral matricectomy. Excision of the lateral nail plate with lateral matricectomy yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy. Antibiotic therapy and cotton-wick elevation are acceptable for very mildly inflamed ingrown toenails. Partial nail avulsion often leaves a spicule of nail that will grow and become an ingrown nail. Phenol produces irregular tissue destruction and significant inflammation and discharge after the matricectomy procedure.
A 23-year-old male returns from a Florida beach vacation, where he sustained a cut to his foot while wading. The cut wasn't treated when it happened, and it is healing, but he says that it feels like something in the wound is "poking" him. Of the following, which one would most likely be easily visible on plain film radiography? (check one)

A. A wood splinter
B. A glass splinter
C. A plastic splinter
D. A sea urchin spine
B. A glass splinter. Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular belief, it doesn't have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. Alternative techniques such as ultrasonography or CT scanning may be effective and necessary in those cases. Sea urchin spines, like many animal parts, have not been found to be easily detected by plain radiography.
A 55-year-old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions. Which one of the following organisms would be the most likely cause of cellulitis in this patient? (check one)

A. Non-group A Streptococcus
B. Pneumococcus pneumoniae
C. Clostridium perfringens
D. Escherichia coli
E. Pasteurella multocida
A. Non-group A Streptococcus. Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non-group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery. Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in patients who have bacteremia with immunocompromised status. Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus, nephritic syndrome, and some hematologic cancers. Clostridium and Escherichia coli are more frequently associated with crepitant cellulitis and tissue necrosis. Pasteurella multocida cellulitis is most frequently associated with animal bites, especially cat bites.
A 12-year-old male middle-school wrestler comes to your office complaining of a recurrent painful rash on his arm. There appear to be several dry vesicles. The most likely diagnosis is which one of the following? (check one)

A. Molluscum contagiosum
B. Human papillomavirus
C. Herpes gladiatorum
D. Tinea corporis
E. Mat burn
C. Herpes gladiatorum. The most common infection transmitted person-to-person in wrestlers is herpes gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm, which is manifested by round to oval raised areas with central clearing. Mat burn is an abrasion.
You are evaluating a 45-year-old male construction worker with regard to his skin and sun exposure history. Which one of the following lesions should be considered premalignant? (check one)

A. Sebaceous hyperplasia
B. Actinic keratosis
C. Seborrheic keratosis
D. A de Morgan spot
E. A halo nevus
B. Actinic keratosis. Family physicians should advise patients of the dangers of sun exposure especially those with a fair complexion who work outdoors. Although malignant melanoma is the most serious condition of those listed, actinic keratosis may lead to squamous cell carcinoma with significant morbidity.
Random Board Review Questions 01
A 30-year-old previously healthy male comes to your office with a 1-year history of frequent abdominal pain, nonbloody diarrhea, and a 20-lb weight loss. He has no history of travel outside the United States, antibiotic use, or consumption of well water. His review of systems is notable for a chronic, intensely pruritic rash that is vesicular in nature. His review of systems is otherwise negative and he is on no medications.

The most likely cause of his symptoms is: (check one)

A. lactose intolerance
B. irritable bowel syndrome
C. collagenous colitis
D. celiac sprue
E. Crohn's disease
D. celiac sprue. Celiac sprue is an autoimmune disorder characterized by inflammation of the small bowel wall, blunting of the villi, and resultant malabsorption. Symptoms commonly include diarrhea, fatigue, weight loss, abdominal pain, and borborygmus; treatment consists of elimination of gluten proteins from the diet. Extraintestinal manifestations are less common but may include elevated transaminases, osteopenia, and iron deficiency anemia. Serum IgA tissue transglutaminase (TTG) antibodies are highly sensitive and specific for celiac sprue, and a small bowel biopsy showing villous atrophy is the gold standard for diagnosis. This patient's rash is consistent with dermatitis herpetiformis, which is pathognomonic for celiac sprue and responds well to a strict gluten-free diet.

Lactose intolerance, irritable bowel syndrome, collagenous colitis, and Crohn's disease are in the differential diagnosis for celiac sprue. However, significant weight loss is not characteristic of irritable bowel syndrome or lactose intolerance. The diarrhea associated with Crohn's disease is typically bloody. Collagenous colitis does cause symptoms similar to those experienced by this patient, but it is not associated with dermatitis herpetiformis.
Which one of the following is an absolute contraindication to electroconvulsive therapy (ECT)? (check one)

A. Age >80 years
B. A cardiac pacemaker
C. An implantable cardioverter-defibrillator
D. Pregnancy
E. There are no absolute contraindications to ECT
E. There are no absolute contraindications to ECT. There are no absolute contraindications to electroconvulsive therapy (ECT), but factors that have been associated with reduced efficacy include a prolonged episode, lack of response to medication, and coexisting psychiatric diagnoses such as a personality disorder. Persons who may be at increased risk for complications include those with unstable cardiac disease such as ischemia or arrhythmias, cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial pressure. ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with proper precautions and in consultation with an obstetrician.
A 55-year-old female presents to an urgent-care facility with a complaint of weakness of several weeks' duration. She has no other symptoms. She has been healthy except for a history of hypertension that has been difficult to control despite the use of hydrochlorothiazide, 25 mg daily; lisinopril (Prinivil, Zestril), 40 mg daily; amlodipine (Norvasc), 10 mg daily; and doxazosin (Cardura), 8 mg daily.

On examination her blood pressure is 164/102 mm Hg, with the optic fundi showing grade 2 changes. She has normal pulses, a normal cardiac examination, and no abdominal bruits. A CBC is normal and a blood chemistry panel is also normal except for a serum potassium level of 3.1 mmol/L (N 3.5-5.5).

Which one of the following would be best for confirming the most likely diagnosis in this patient? (check one)

A. Magnetic resonance angiography of the renal arteries
B. A renal biopsy
C. 24-hour urine for metanephrines
D. Early morning fasting cortisol
E. A plasma aldosterone/renin ratio
E. A plasma aldosterone/renin ratio. Difficult-to-control hypertension has many possible causes, including nonadherence or the use of alcohol, NSAIDs, certain antidepressants, or sympathomimetics. Secondary hypertension can be caused by relatively common problems such as chronic kidney disease, obstructive sleep apnea, or primary hyperaldosteronism, as in the case described here.

As many as 20% of patients referred to specialists for poorly controlled hypertension have primary hyperaldosteronism. It is more common in women and often is asymptomatic. A significant number of these individuals will not be hypokalemic. Screening can be done with a morning plasma aldosterone/renin ratio. If the ratio is 20 or more and the aldosterone level is >15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered.
A 15-month-old male is brought to your office 3 hours after the onset of an increased respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His immunizations are up to date and he attends day care regularly. His temperature is 38.2°C (100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min.

The child is sitting quietly on his mother's lap. His oxygen saturation is 94% on room air. On examination you note inspiratory crackles in the left lower lung field. The child appears to be well hydrated and the remainder of the examination, including an HEENT examination, is normal. Nebulized albuterol (AccuNeb) is administered and no improvement is noted.

Which one of the following would be most appropriate in the management of this patient? (check one)

A. Laboratory evaluation
B. Inpatient monitoring, with no antibiotics at this time
C. Hospitalization and intravenous ceftriaxone (Rocephin)
D. Close outpatient follow-up, with no antibiotics at this time
E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up
E. Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up. The diagnosis of community-acquired pneumonia is mostly based on the history and physical examination. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the history or physical examination. Children under 2 years of age who are in day care are at higher risk for developing community-acquired pneumonia. Laboratory tests are rarely helpful in differentiating viral versus bacterial etiologies and should not be routinely performed. Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration. Streptococcus pneumoniae is one of the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice.
For normal term infants, current practice is to introduce solid foods into the diet at what age? (check one)

A. 2-4 weeks
B. 2-3 months
C. 4-6 months
D. 7-9 months
E. 1 year
C. 4-6 months. In normal term infants, there is little evidence that solid foods contribute to well-being before the age of 4-6 months. In addition, the extrusion reflex (pushing foreign material out of the mouth with the tongue) makes feeding of solids difficult and often forced. This reflex disappears around the age of 4 months, making feeding easier. The introduction of solids at this age helps supply calories, iron, and vitamins, and may prepare the infant for later dietary diversity and healthy dietary habits.
A 28-year-old male recreational runner has a midshaft posteromedial tibial stress fracture. Although he can walk without pain, he cannot run without pain.

The most appropriate treatment at this point includes which one of the following? (check one)

A. A short leg walking cast
B. A non-weight-bearing short leg cast
C. A non-weight-bearing long leg cast
D. An air stirrup leg brace (Aircast)
E. Low-intensity ultrasonic pulse therapy
D. An air stirrup leg brace (Aircast). Midshaft posteromedial tibial stress fractures are common and are considered low risk. Management consists of relative rest from running and avoiding other activities that cause pain. Once usual daily activities are pain free, low-impact exercise can be initiated and followed by a gradual return to previous levels of running. A pneumatic stirrup leg brace has been found to be helpful during treatment (SOR C). Non-weight bearing is not necessary, as this patient can walk without pain. Casting is not recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has not been shown to be beneficial in stress fractures.
A 59-year-old male reports decreases in sexual desire and spontaneous erections, as well as reduced beard growth. The most appropriate test to screen for late-onset male hypogonadism is: (check one)

A. free testosterone
B. total testosterone
C. sex hormone-binding globulin
B. total testosterone. A serum total testosterone level is recommended as the initial screening test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is recommended only if the total testosterone level is borderline and abnormalities in sex hormone-binding globulin are suspected. Follow-up LH and FSH levels help to distinguish primary from secondary hypogonadism.
A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine (Synthroid), 125 μg/day. Her TSH level is 0.2μU/mL (N 0.5-5.0). She has no symptoms of either hypothyroidism or hyperthyroidism.

Which one of the following would be most appropriate at this point? (check one)

A. Continuing levothyroxine at the same dosage
B. Increasing the levothyroxine dosage
C. Decreasing the levothyroxine dosage
D. Discontinuing levothyroxine
E. Ordering a free T 4
C. Decreasing the levothyroxine dosage. Because of the precise relationship between circulating thyroid hormone and pituitary TSH secretion, measurement of serum TSH is essential in the management of patients receiving levothyroxine therapy. Immunoassays can reliably distinguish between normal and suppressed concentrations of TSH. In a patient receiving levothyroxine, a low TSH level usually indicates overreplacement. If this occurs, the dosage should be reduced slightly and the TSH level repeated in 2-3 months' time. There is no need to discontinue therapy in this situation, and repeating the TSH level in 2 weeks would not be helpful. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for detecting mild states of excess thyroid hormone.
A 40-year-old female comes to your office with a 1-month history of right heel pain that she describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot after prolonged sitting and when she gets out of bed in the morning. It gets better with continued walking, but worsens at the end of the day. She does not exercise except for being on her feet all day in the hospital where she works as a floor nurse. She denies any history of trauma. An examination reveals point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity.

Which one of the following should you recommend as first-line treatment? (check one)

A. Taping/strapping
B. Over-the-counter heel inserts
C. Extracorporeal shock wave therapy
D. A corticosteroid injection
E. A fiberglass walking cast
B. Over-the-counter heel inserts. Plantar fasciitis is a common cause of heel pain. It may be unilateral or bilateral, and the etiology is unknown, although it is thought to be due to cumulative overload stress. While it may be associated with obesity or overuse, it may also occur in active or inactive patients of all ages. Typically the pain is located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. The diagnosis is made by history and physical examination. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear.

The condition may last for months or years, and resolves in most patients over time with or without specific therapy. One long-term follow-up study showed that 80% of patients had complete resolution of their pain after 4 years. Treatments with limited (level 2) evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy). NSAIDs and ice, although not independently studied for plantar fasciitis, are included in most studies of other treatments, and are reasonable adjuncts to first-line therapy. Magnetic insoles and extracorporeal shockwave therapy are ineffective in treating plantar fasciitis.

Due to their expense, custom-made insoles, custom-made night splints, and corticosteroid iontophoresis should be reserved as second-line treatments for patients who fail first-line treatment. Surgery may be offered if more conservative therapies fail. Corticosteroid injection may have a short-term benefit at 1 month, but is no better than other treatments at 6 months and carries a risk of plantar fascia rupture.
A 3-year-old male presents with a 3-day history of fever and refusal to eat. Today his parents noted some sores just inside his lips. No one else in the family is ill, and he has no significant past medical history. He is up-to-date on his immunizations and has no known allergies.

On examination, positive findings include a temperature of 38.9°C (102.0°F) rectally, irritability, and ulcers on the oral buccal mucosa, soft palate, tongue, and lips. He also has cervical lymphadenopathy. The remainder of the physical examination is normal. The child is alert and has no skin lesions or meningeal signs.

Which one of the following would be the most appropriate treatment? (check one)

A. Ceftriaxone (Rocephin) intramuscularly
B. Nystatin oral suspension
C. Amoxicillin suspension
D. Acyclovir (Zovirax) suspension
E. Methotrexate (Trexall)
D. Acyclovir (Zovirax) suspension. The history and physical findings in this patient are consistent with gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 (HSV-1). There are no additional findings to suggest other diagnoses such as aphthous ulcers, Behçet's syndrome, or herpangina (coxsackievirus).

After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things. Although some clinicians might choose to use oral anesthetics for symptomatic care, it is not a specific therapy.

Antibiotics are not useful for the treatment of herpetic gingivostomatitis and could confuse the clinical picture should this child develop erythema multiforme, which occurs with HSV-1 infections. An orally applied corticosteroid is not specific treatment, but some might try it for symptomatic relief. An immunosuppressant is sometimes used for the treatment of Behçet's syndrome, but this patient's findings are not consistent with that diagnosis. Therefore, the only specific treatment listed is acyclovir suspension, which has been shown to lead to earlier resolution of fever, oral lesions, and difficulties with eating and drinking. It also reduces viral shedding from 5 days to 1 day (SOR B).
Random Board Review Questions 02
You see a 22-year-old female who sustained a right knee injury in a recent college soccer game.She is a defender and executed a sudden cutting maneuver. With her right foot planted and her ankle locked, she attempted to shift the position of her body to stop an oncoming ball and felt her knee pop. She has had a moderate amount of pain and swelling, which began within 2 hours of the injury, but she is most concerned about the loss of knee hyperextension.

Which one of the following tests is most likely to be abnormal in this patient? (check one)

A. Anterior drawer
B. Lachman
C. McMurray
D. Pivot shift
B. Lachman. Anterior cruciate ligament (ACL) tears occur more commonly in women than in men. The intensity of play is also a factor, with a much greater risk of ACL injuries occurring during games than during practices. The most accurate maneuver for detecting an ACL tear is the Lachman test (sensitivity 60%-100%, mean 84%), followed by the anterior drawer test (sensitivity 9%-93%, mean 62%) and the pivot shift test (sensitivity 27%-95%, mean 62%) (SOR C). McMurray's test is used to detect meniscal tears.
One of your patients has been diagnosed with monoclonal gammopathy of undetermined significance (MGUS). Which one of the following is used to determine whether his condition has progressed to multiple myeloma? (check one)

A. The length of time since the diagnosis of MGUS was made
B. The level of M protein
C. The percentage of plasma cells in bone marrow
D. Evidence of end-organ damage
D. Evidence of end-organ damage. The diagnosis of multiple myeloma is based on evidence of myeloma-related end-organ impairment in the presence of M protein, monoclonal plasma cells, or both. This evidence may include hypercalcemia, renal failure, anemia, or skeletal lesions. Monoclonal gammopathy of undetermined significance does not progress steadily to multiple myeloma. There is a stable 1% annual risk of progression.
A 60-year-old African-American male who has a 15-year history of diabetes mellitus reports a 1-week history of weakness of the lower left leg, giving way of the knee, and discomfort in the anterior thigh. He has no history of recent trauma. A physical examination reveals decreased sensation to pinprick and light touch over the left anterior thigh, and reduced motor strength on hip flexion and knee extension. The straight leg raising test is normal.

The most likely cause of this condition is: (check one)

A. femoral neuropathy
B. diabetic polyneuropathy
C. meralgia paresthetica
D. spinal stenosis
E. iliofemoral atherosclerosis
A. femoral neuropathy. These findings are typical of femoral neuropathy, a mononeuropathy commonly associated with diabetes mellitus, although it has been found to be secondary to a number of conditions that are common in diabetics and not to the diabetes itself. Diabetic polyneuropathy is characterized by symmetric and distal limb sensory and motor deficits. Meralgia paresthetica, or lateral femoral cutaneous neuropathy, may be secondary to diabetes mellitus, but is manifested by numbness and paresthesia over the anterolateral thigh with no motor dysfunction. Spinal stenosis causes pain in the legs, but is not associated with the neurologic signs seen in this patient, nor with knee problems. Iliofemoral atherosclerosis, a relatively common complication of diabetes mellitus, may produce intermittent claudication involving one or both calf muscles but would not produce the motor weakness noted in this patient.
Women who use low-dose estrogen oral contraceptives have a 50% lower risk of cancer of the: (check one)

A. breast
B. cervix
C. head and neck
D. lung
E. ovary
E. ovary. Women who use low-dose estrogen oral contraceptives have at least a 50% lower risk of subsequent epithelial ovarian cancer than women who have never used them. Epidemiologic data also suggests other potential long-term benefits of oral contraceptives, including a reduced risk of postmenopausal fractures, as well as reductions in the risk of endometrial and colorectal cancers. Oral contraceptives do not reduce the risk of carcinoma of the breast, cervix, lung, or head and neck.
Which one of the following is most typical of polymyalgia rheumatica? (check one)

A. Headache and neck pain
B. A normal erythrocyte sedimentation rate
C. A dramatic response to corticosteroids
D. A lack of systemic symptoms and signs
C. A dramatic response to corticosteroids. Polymyalgia rheumatica is an inflammatory disorder that occurs in persons over the age of 50. White women of European ancestry are most commonly affected. The clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder and pelvic girdle. One review found that 4%-13% of patients with clinical polymyalgia rheumatica have a normal erythrocyte sedimentation rate (ESR). As many as 5% of patients initially have a normal ESR that later rises.

Polymyalgia rheumatica can have a variety of systemic symptoms. Fever is common, with temperatures as high as 39°C (102°F) along with night sweats. Additional symptoms include depression, fatigue, malaise, anorexia, and weight loss.

Corticosteroids are the mainstay of therapy for polymyalgia rheumatica. Typically, a dramatic response is seen within 48-72 hours.
A 53-year-old male presents for a routine well-care visit. He has no health complaints. His wife has accompanied him, however, and is quite concerned about changes she has noticed over the last 1-2 years. She says that he has become quite apathetic and seems to have lost interest in his job and his hobbies. He has been accused of making sexually harassing comments and inappropriate touching at work, and he no longer helps with household chores at home. He often has difficulty expressing himself and his speech can lack meaning. The physical examination is normal.

Based on the history provided by the wife, you should suspect a diagnosis of : (check one)

A. Alzheimer's disease
B. major depressive disorder
C. frontotemporal dementia
D. dementia with Lewy bodies
E. schizophrenia
C. frontotemporal dementia. This patient meets the criteria for frontotemporal dementia (FTD), a common cause of dementia in patients younger than 65, with an insidious onset. Unlike with Alzheimer's disease, memory is often relatively preserved, even though insight is commonly impaired.

There are three subtypes of frontotemporal dementia: behavioral variant FTD, semantic dementia, and progressive nonfluent aphasia. This patient would be diagnosed with the behavioral variant due to his loss of executive functioning leading to personality change (apathy) and inappropriate behavior (SOR C). Speech output is often distorted in frontotemporal dementia, although the particular changes differ between the three variants.

Patients with FTD often are mistakenly thought to have major depressive disorder due to their apathy and diminished interest in activities. However, patients with depression do not usually exhibit inappropriate behavior and lack of restraint. Dementia with Lewy bodies and Alzheimer's dementia are both characterized predominantly by memory loss. Alzheimer's dementia is most common after age 65, whereas FTD occurs most often at a younger age. Lewy body dementia is associated with parkinsonian motor features. Patients diagnosed with schizophrenia exhibit apathy and personality changes such as those seen in FTD. However, the age of onset is much earlier, usually in the teens and twenties in men and the twenties and thirties in women.
An 88-year-old male has been hospitalized for the past 3 days after being found on the floor of his home by a neighbor and transported to the hospital by ambulance. He was cachectic and dehydrated at the time of admission, with a serum albumin level of 1.9 g/dL (N 3.5-4.7). He has received intravenous fluids and is now euvolemic. He began nasogastric tube feeding 2 days ago and has now developed nausea, vomiting, hypotension and delirium.

Which one of the following is the most classic electrolyte abnormality with this condition? (check one)

A. Hypocalcemia
B. Hypercalcemia
C. Hyperkalemia
D. Hypophosphatemia
E. Hyperphosphatemia
D. Hypophosphatemia. Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is hypophosphatemia. However, the syndrome is complex and may also include abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; hypokalemia; and hypomagnesemia.
When prescribing an inhaled corticosteroid for control of asthma, the risk of oral candidiasis can be decreased by: (check one)

A. using a valved holding chamber
B. limiting use of the inhaled corticosteroid to once daily
C. adding nasal fluticasone propionate (Flonase)
D. adding montelukast (Singulair)
E. adding salmeterol (Serevent)
A. using a valved holding chamber. Pharyngeal and laryngeal side effects of inhaled corticosteroids include sore throat, coughing on inhalation of the medication, a weak or hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the medication and using a valved holding chamber when it is delivered with a metered-dose inhaler can minimize the risk of oral candidiasis.
A 45-year-old female presents with a 3-month history of hoarseness that is not improving. She works as a high-school teacher. The most appropriate management at this time would be: (check one)

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

A. myocarditis
B. left heart failure
C. pulmonic stenosis
D. ventricular septal defect
B. left heart failure. Although myocarditis, pulmonic stenosis, and ventricular septal defects can be causes of right heart failure, left heart failure is the most common cause of right heart failure in adults.
Random Board Review Questions 03
As the medical review officer for a local business, you are required to interpret urine drug tests. Assuming the sample was properly collected and handled, which one of the following test results is consistent with the history provided and should be reported as a negative test? (check one)

A. Diazepam (Valium) identified in an employee taking oxazepam prescribed by a physician
B. Morphine identified in an employee undergoing a prescribed methadone pain management program
C. Morphine identified in an employee taking a prescribed cough medicine containing codeine
D. Tetrahydrocannabinol above the threshold value in an employee who reports secondary exposure to marijuana
E. Tetrahydrocannabinol identified in an employee taking prescribed tramadol (Ultram)
C. Morphine identified in an employee taking a prescribed cough medicine containing codeine. Results of urine drug test panels obtained in the workplace are reported by a Medical Review Officer (MRO) as positive, negative, dilute, refusal to test, or test canceled; the drug/metabolite for which the test is positive or the reason for refusal (e.g., the presence of an adulterant) or cancellation is also included in the final report. The MRO interpretation is based on consideration of many factors, including the confirmed patient medical history, specimen collection process, acceptability of the specimen submitted, and qualified laboratory measurement of drugs or metabolites in excess of the accepted thresholds. These thresholds are set to preclude the possibility that secondary contact with smoke, ingestion of poppy seeds, or similar exposures will result in an undeserved positive urine drug screen report. Other findings, such as the presence of behavioral or physical evidence of unauthorized use of opiates, may also factor into the final report.

When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. Morphine is a metabolite of codeine that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use.
An 18-year-old male presents with a sore throat, adenopathy, and fatigue. He has no evidence of airway compromise. A heterophil antibody test is positive for infectious mononucleosis.

Appropriate management includes which one of the following? (check one)

A. A corticosteroid
B. An antihistamine
C. An antiviral agent
D. Strict bed rest
E. Avoidance of contact sports
E. Avoidance of contact sports. Infectious mononucleosis presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age. Both an atypical lymphocytosis and a positive heterophil antibody test support the diagnosis, although false-negative heterophil testing is common early in the disease course. The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges.

In general, corticosteroids do not have a significant effect on the clinical course of infectious mononucleosis, and they should not be used routinely unless the patient has evidence of acute airway obstruction. Antihistamines are also not recommended as routine treatment for mononucleosis. The use of acyclovir has shown no consistent or significant benefit, and antiviral drugs are not recommended.

There is also no evidence to support bed rest as an effective management strategy for mononucleosis. Given the evidence from other disease states, bed rest may actually be harmful.

Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. This was demonstrated in a small study in which 100% of patients hospitalized for mononucleosis had an enlarged spleen by ultrasound examination, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3-4 weeks because of the increased risk of rupture.
A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of decreased appetite, lethargy, and confusion of 2 weeks' duration. Laboratory evaluation reveals the following:
Serum calcium......................... 15.8 mg/dL (N 8.4-10.0)
Serum phosphorus...................... 3.9 mg/dL (N 2.6-4.2)
Serum creatinine. ...................... 1.1 mg/dL (N 0.7-1.3)
Total serum protein..................... 5.0 g/dL (N 6.0-8.0)
Albumin.............................. 3.1 g/dL (N 3.7-4.8)

Which one of the following is the most appropriate INITIAL management? (check one)

A. Calcitonin-salmon (Miacalcin) subcutaneously
B. Pamidronate disodium (Aredia) by intravenous infusion
C. Normal saline intravenously
D. Furosemide intravenously
C. Normal saline intravenously. The initial management of hypercalcemia of malignancy includes fluid replacement with normal saline to correct the volume depletion that is invariably present and to enhance renal calcium excretion. The use of loop diuretics such as furosemide should be restricted to patients in danger of fluid overload, since these drugs can aggravate volume depletion and are not very effective alone in promoting renal calcium excretion. Although intravenous pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy, it is considered only after the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for the other calcium-lowering agents listed.
A 35-year-old African-American female with symptomatic uterine fibroids that are unresponsive to medical management prefers to avoid a hysterectomy. Which one of the following would be a reason for preferring myomectomy over fibroid embolization? (check one)

A. A desire for future pregnancy
B. Medical problems that increase general anesthesia risk
C. Religious objections to blood transfusion
D. The likelihood of a shorter hospital stay and recovery time
E. The minimal risk of fibroid recurrence
A. A desire for future pregnancy. In the symptomatic patient with uterine fibroids unresponsive to medical therapy, myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future. Uterine fibroid embolization requires a shorter hospitalization and less time off work. General anesthesia is not required, and a blood transfusion is unlikely to be needed. Uterine fibroids can recur or develop after either myomectomy or embolization.
A 70-year-old African-American male undergoes routine sigmoidoscopy. He has a long history of constipation, hypertension, and diet-controlled type 2 diabetes mellitus. The examination reveals brown to black leopard spotting of the colonic mucosa.

You would now: (check one)

A. perform a metastatic workup
B. review his medications
C. prescribe oral corticosteroids
D. prescribe antibiotics and a proton pump inhibitor
E. check his stool for Clostridium difficile
B. review his medications. This patient has melanosis coli, which is a benign condition resulting from abuse of anthraquinone laxatives such as cascara, senna, or aloe. The condition resolves with discontinuation of the medication.
The Valsalva maneuver will typically cause the intensity of a systolic murmur to increase in patients with which one of the following conditions? (check one)

A. Aortic stenosis
B. Rheumatic mitral insufficiency
C. Valvular pulmonic stenosis
D. Hypertrophic obstructive cardiomyopathy
D. Hypertrophic obstructive cardiomyopathy. The Valsalva maneuver decreases venous return to the heart, thereby decreasing cardiac output. This causes most murmurs to decrease in length and intensity. The murmur of hypertrophic obstructive cardiomyopathy, however, increases in loudness. The murmur of mitral valve prolapse becomes longer, and may also become louder.
A 12-year-old male presents with left hip pain. He is overweight and recently started playing tennis to lose weight. He says the pain started gradually after his last tennis game, but he does not recall any injury. He is walking with a limp. On examination he is afebrile and has limited internal rotation of the left hip.

What is the most likely cause of the hip pain? (check one)

A. Septic arthritis
B. Juvenile rheumatoid arthritis
C. Transient synovitis
D. Slipped capital femoral epiphysis
E. Legg-Calvé-Perthes disease
D. Slipped capital femoral epiphysis. Slipped capital femoral epiphysis is the most common hip disorder in this patient's age group. It usually occurs between the ages of 8 and 15 and is more common in boys and overweight or obese children. It presents with limping and pain, and limited internal rotation of the hip is noted on physical examination.

Septic arthritis would typically present with a fever. Juvenile rheumatoid arthritis, transient synovitis, and Legg-Calvé-Perthes disease are more common in younger children.
Which one of the following is associated with the use of percutaneous endoscopic gastrostomy (PEG) tubes? (check one)

A. A reduced risk of aspiration pneumonia in patients with dysphagia
B. Increased use of restraints
C. Improved nutritional status in nursing-home residents with dementia
D. Improved quality of life for patients with dementia
B. Increased use of restraints. When a patient or nursing-home resident is losing weight or has suffered an acute change in the ability to perform activities of daily living, a decision must be made as to whether or not to place a PEG tube to provide artificial nutrition. Studies have shown that PEG tubes do not improve nutritional status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia, although aspiration risk may possibly be decreased if the feeding tube is placed below the gastroduodenal junction (SOR B). Feeding tubes can also cause discomfort and agitation, leading to an increased use of restraints (SOR B).
A 58-year-old white male comes to your office for follow-up after a recent bout of acute bronchitis. He reports having a productive cough for several months. He gets breathless with exertion and notes that every time he gets a cold it "goes into my chest and lingers for months." He has been smoking for 30 years. A physical examination is negative except for scattered rhonchi. A chest radiograph done 4 months ago at an urgent care visit was negative except for hyperinflation and flattened diaphragms.

Which one of the following would be best for making the diagnosis? (check one)

A. A chest radiograph
B. CT of the chest
C. Peak flow measurement
D. Spirometry
E. A BNP level
D. Spirometry. It is important to distinguish between COPD and asthma because of the differences in treatment. Patients with COPD are usually in their sixties when the diagnosis is made. Symptoms of chronic cough (sometimes for months or years), dyspnea, or sputum production are often not reported because the patient may attribute them to smoking, aging, or poor physical condition.

Spirometry is the best test for the diagnosis of COPD. The pressure of outflow obstruction that is not fully reversible is demonstrated by postbronchodilator spirometry showing an FEV /FVC ratio of 70% or less.
A 50-year-old female presents with right eye pain. On examination, you find no redness, but when you test her extraocular muscles she reports marked pain with eye movement.

This finding suggests that her eye pain is caused by: (check one)

A. an intracranial process
B. an ocular condition
C. a retinal problem
D. an orbital problem
E. an optic nerve problem
D. an orbital problem. Pain with eye movement suggests an orbital condition. Orbital inflammation, infection, or tumor invasion can lead to such eye pain. Other findings suggestive of an orbital cause of eye pain include diplopia or proptosis. If an orbital lesion is suspected, imaging studies should be performed.
Random Board Review Questions 04
A 30-year-old female asks you whether she should have a colonoscopy, as her father was diagnosed with colon cancer at the age of 58. There are no other family members with a history of colon polyps or cancer.

You recommend that she have her first screening colonoscopy: (check one)

A. now and every 5 years if normal
B. now and every 10 years if normal
C. at age 40 and then every 5 years if normal
D. at age 40 and then every 10 years if normal
E. at age 50 and then every 5 years if normal
C. at age 40 and then every 5 years if normal. Patients should be risk-stratified according to their family history. Patients who have one first degree relative diagnosed with colorectal cancer or adenomatous polyps before age 60, or at least two second degree relatives with colorectal cancer, are in the highest risk group. They should start colon cancer screening at age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years. Colonoscopy is the preferred screening method for this highest-risk group, as high-risk patients are more likely to have right-sided colon lesions that would not be detected with sigmoidoscopy.
A 64-year-old African-American male presents with persistent pleuritic pain. The patient does not feel well in general and has had a low-grade fever of around 100°F (38°C). His medications include simvastatin (Zocor), lisinopril (Prinivil, Zestril), low-dose aspirin, spironolactone (Aldactone), furosemide (Lasix), isosorbide mononitrate (Imdur), hydralazine, carvedilol (Coreg), and nitroglycerin as needed.

A chest radiograph is normal and does not demonstrate a pneumothorax. Further evaluation rules out pulmonary embolus, pneumonia, and myocardial infarction. A diagnosis of pleurisy is made.

Which one of the patient's medications could be related to this condition? (check one)

A. Hydralazine
B. Simvastatin
C. Lisinopril
D. Spironolactone
E. Carvedilol
A. Hydralazine. Drug-induced pleuritis is one cause of pleurisy. Several drugs are associated with drug-induced pleural disease or drug-induced lupus pleuritis. Drugs that may cause lupus pleuritis include hydralazine, procainamide, and quinidine. Other drugs known to cause pleural disease include amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin.
A 30-year-old male presents to the emergency department with a sensation of a racing heart. His history is significant for known Wolff-Parkinson-White syndrome (WPW). On examination he is alert and in no severe distress. His blood pressure is 130/70 mm Hg, pulse rate 220 beats/min, and oxygen saturation 96%. An EKG reveals a regular, wide-complex tachycardia with a rate of 220 beats/min. You determine that he is stable, the EKG is consistent with WPW, and pharmacologic conversion is a safe initial therapy.

Which one of the following would be the treatment of choice? (check one)

A. Verapamil (Calan)
B. Adenosine (Adenocard)
C. Procainamide
D. Digoxin
C. Procainamide. Adenosine, digoxin, and calcium channel antagonists act by blocking conduction through the atrioventricular (AV) node, which may increase the ventricular rate paradoxically, initiating ventricular fibrillation. These agents should be avoided in Wolff-Parkinson-White syndrome. Procainamide is usually the treatment of choice in these situations, although amiodarone may also be used.
Which one of the following is contraindicated in the second and third trimesters of pregnancy? (check one)

A. Amoxicillin
B. Azithromycin (Zithromax)
C. Ceftriaxone (Rocephin)
D. Ciprofloxacin (Cipro)
E. Doxycycline
E. Doxycycline. Doxycycline is contraindicated in the second and third trimesters of pregnancy due to the risk of permanent discoloration of tooth enamel in the fetus. Cephalosporins such as ceftriaxone are usually considered safe to use during pregnancy. The use of ciprofloxacin during pregnancy does not appear to increase the risk of major congenital malformation, nor does the use of amoxicillin. Animal studies using rats and mice treated with daily doses of azithromycin up to maternally toxic levels revealed no impairment of fertility or harm to the fetus.
A 25-year-old medical student reads about the benefits of moderate alcohol consumption on lipid levels and begins to drink 5 ounces of red wine a day, adding 100 calories to his diet. Assuming that his diet and exercise levels stay the same, what effect will the additional 3000 calories a month have on his body weight over the next 10 years? (check one)

A. They will have essentially no effect
B. His weight will increase by about 25 kg
C. His weight will increase slightly then stabilize
D. His normal caloric expenditure will decrease
C. His weight will increase slightly then stabilize. There is not a direct relation between daily calorie consumption and weight. An adult male consuming an extra 100 calories a day above his caloric need will not continue to gain weight indefinitely; rather, his weight will increase to a certain point and then become constant. Fat must be fed, and maintaining the newly created tissue requires an increase in caloric expenditure. An extra 100 calories a day will result in a weight gain of approximately 5 kg, which will then be maintained.
You have just diagnosed mild persistent asthma in a 13-year-old African-American female. Along with patient education, your initial medical management should be: (check one)

A. a short-acting inhaled β-agonist to be used only as needed
B. a long-acting inhaled β-agonist daily
C. a low-dose inhaled corticosteroid daily, along with a short-acting inhaled β-agonist as needed
D. a low-dose inhaled corticosteroid daily, along with a long-acting inhaled β-agonist daily
E. montelukast (Singulair) daily
C. a low-dose inhaled corticosteroid daily, along with a short-acting inhaled β-agonist as needed. Inhaled corticosteroids improve asthma control in adults and children more effectively than any other single long-term controller medication, and all patients should also receive a prescription for a short-acting β-agonist (SOR A).
Patients with rheumatoid arthritis should be screened for tuberculosis before starting which one of the following medications? (check one)

A. Gold
B. Hydroxychloroquine (Plaquenil)
C. Infliximab (Remicade)
D. Methotrexate (Rheumatrex)
E. Sulfasalazine (Azulfidine)
C. Infliximab (Remicade). Tumor necrosis factor inhibitors have been associated with an increased risk of infections, including tuberculosis. This class of agents includes monoclonal antibodies such as infliximab, adalimumab, certolizumab pegol, and golimumab. Patients should be screened for tuberculosis and hepatitis B and C before starting these drugs.

The other drugs listed can have adverse effects, but do not increase the risk for tuberculosis.
A 42-year-old male with a history of intravenous drug use asks to be tested for hepatitis C. The hepatitis C virus (HCV) antibody enzyme immunoassay and recombinant immunoblot assay are both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative. These test results are most consistent with: (check one)

A. very early HCV infection
B. current active HCV infection
C. a false-positive antibody test
D. past infection with HCV that is now resolved
D. past infection with HCV that is now resolved. The most widely used initial assay for detecting hepatitis C virus (HCV) antibody is the enzyme immunoassay. A positive enzyme immunoassay should be followed by a confirmatory test such as the recombinant immunoblot assay. If negative, it indicates a false-positive antibody test. If positive, the quantitative HCV RNA polymerase chain reaction is used to measure the amount of virus in the blood to distinguish active from resolved HCV infection. In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved.
A nursing-home resident is hospitalized, and shortly before she is to be discharged she develops a skin ulcer, which proves to be infected with methicillin-resistant Staphylococcus aureus (MRSA). Which one of the following is most important in terms of infection control when she returns to the nursing home? (check one)

A. Surveillance cultures of nursing-home residents living near the patient
B. Aggressive housekeeping in the patient's room
C. Masks, gowns, and gloves for all those entering the patient's room
D. Strict handwashing practices by all staff, visitors, and residents
E. Isolation of the patient in a room by herself
D. Strict handwashing practices by all staff, visitors, and residents. All staff, visitors, and nursing-home residents should observe strict handwashing practices in this situation. Barrier precautions for wounds and medical devices should also be initiated. Surveillance cultures are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the spread of MRSA. Isolating the patient is not practical or cost-effective.
Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test? (check one)

A. An upper GI series
B. Abdominal ultrasonography
C. CT angiography
D. MRI of the brain
E. Colonoscopy
C. CT angiography. Since even a temporary reduction in renal function, such as occurs after pyelography or angiography, can cause lactic acidosis in patients taking metformin, the drug should be discontinued 48 hours before such procedures (SOR C) and restarted 48 hours after the procedure if renal function is normal. The other procedures listed are not indications for stopping metformin.
Random Board Review Questions 05
Which one of the following is most consistent with obsessive-compulsive disorder in adults? (check one)

A. Impulses related to excessive worry about real-life problems
B. A belief by the patient that obsessions are not produced by his or her own mind, but are "inserted" thoughts
C. Recognition by the patient that the obsessions or compulsions are excessive or unreasonable
D. Compulsions that bring relief to the patient rather than causing distress
E. Full remission with treatment
C. Recognition by the patient that the obsessions or compulsions are excessive or unreasonable. The DSM-IV criteria for obsessive-compulsive disorder (OCD) indicate that the patient at some point recognizes that the obsessions or compulsions are excessive or unreasonable. The impulses of OCD are not related to excessive worry about one's problems, and the patient recognizes that they are the product of his or her own mind. In addition, the patient experiences marked distress because of the impulses. Full remission is rare, but treatment can provide significant relief.
An 82-year-old resident of a local nursing home is brought to your clinic with fever, difficulty breathing, and a cough productive of purulent sputum. The patient is found to have an oxygen saturation of 86% on room air and a chest radiograph shows a new infiltrate. A decision is made to hospitalize the patient.

Which one of the following intravenous antibiotic regimens would be most appropriate for this patient? (check one)

A. Levofloxacin (Levaquin)
B. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
C. Ceftazidime (Fortaz, Tazicef) and levofloxacin
D. Ceftazidime and vancomycin
E. Ceftazidime, levofloxacin, and vancomycin
E. Ceftazidime, levofloxacin, and vancomycin. Nursing home-acquired pneumonia should be suspected in patients with a new infiltrate on a chest radiograph if it is associated with a fever, leukocytosis, purulent sputum, or hypoxia. Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. The 2005 American Thoracic Society/Infectious Diseases Society of America guideline recommends combination therapy consisting of an antipseudomonal cephalosporin such as cefepime or ceftazidime, an antipseudomonal carbapenem such as imipenem or meropenem, or an extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam, PLUS an antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin, or an aminoglycoside such as gentamicin, tobramycin, or amikacin, PLUS an anti-MRSA agent (vancomycin or linezolid). Ceftriaxone and azithromycin or levofloxacin alone would be reasonable treatment options for a patient with nursing home-acquired pneumonia who does not require hospitalization.
Which one of the following has the best evidence that it is safe for use in pregnancy? (check one)

A. Alprazolam (Xanax)
B. Lithium
C. Bupropion (Wellbutrin)
D. Fluoxetine (Prozac)
E. Paroxetine (Paxil)
D. Fluoxetine (Prozac). The use of psychiatric medications during pregnancy should always involve consideration of the potential risks to the fetus in comparison to the well-being of the mother. Lithium is known to be teratogenic. Benzodiazepines such as alprazolam are controversial due to a possible link to cleft lip/palate. Studies have shown no significant risk of congenital anomalies from SSRI use in pregnancy, except for paroxetine. Paroxetine is a category D medication and should be avoided in pregnant women (SOR B). There is concern about an increased risk of congenital cardiac malformations from first-trimester exposure. Bupropion has not been studied extensively for use in pregnancy, and in one published study of 136 patients it was linked to an increased risk of spontaneous abortion.
You examine an 11-month-old male who has had several paroxysms of abdominal pain in the last 2 hours. The episodes last 1-2 minutes; the infant screams, turns pale, and doubles up. Afterward, he seems normal. A physical examination is normal except for a possible fullness in the right upper quadrant of the abdomen.

The most likely diagnosis is: (check one)

A. pyloric stenosis
B. choledochal cyst
C. Meckel's diverticulum
D. intussusception
E. intestinal malrotation
D. intussusception. This is a classic presentation for intussusception, which usually occurs in children under the age of 2 years and is characterized by paroxysms of colicky abdominal pain. A mass is palpable in about two-thirds of patients.

Pyloric stenosis presents with a palpable mass, but usually develops between 4 and 6 weeks of age. A choledochal cyst presents with the classic triad of right upper quadrant pain, jaundice, and a palpable mass. Meckel's diverticulum usually presents in this age group with painless lower gastrointestinal bleeding. Intestinal malrotation usually presents within the first 4 weeks of life and is characterized by bilious vomiting.
A 62-year-old male with a history of prostate cancer and well-controlled hypertension presents with severe osteoporosis. At 55 years of age he received prostate brachytherapy and androgen deprivation for his prostate cancer and has been disease-free since. He presently takes lisinopril (Prinivil, Zestril), 5 mg daily; alendronate (Fosamax), 70 mg weekly; calcium, 1000 mg daily; and vitamin D, 1200 units daily. He has never smoked, exercises five times a week, and maintains a healthy lifestyle. In spite of his lifestyle and the medications he takes, he continues to have severe osteoporosis on his yearly bone density tests.

In addition to recommending fall precautions, which one of the following would you consider next to treat his osteoporosis? (check one)

A. Testosterone
B. Calcitonin
C. Teriparatide (Forteo)
D. Raloxifene (Evista)
E. Zoledronic acid (Reclast)
C. Teriparatide (Forteo). Teriparatide is indicated for the treatment of severe osteoporosis, for patients with multiple osteoporosis risk factors, or for patients with failure of bisphosphonate therapy (SOR B). Therapy with teriparatide is currently limited to 2 years and is contraindicated in patients with a history of bone malignancy, Paget disease, hypercalcemia, or previous treatment with skeletal radiation. Its route of administration (subcutaneous) and high cost should be considered when prescribing teriparatide therapy. Testosterone therapy is contraindicated in patients with a history of prostate cancer. Zoledronic acid is a parenterally administered bisphosphonate and would not be appropriate in a patient who has already failed bisphosphonate therapy. Likewise, raloxifene and calcitonin are not indicated in patients with severe osteoporosis who have failed bisphosphonate therapy.
A 20-year-old white female presents with painful and frequent urination that has had a gradual onset over the past week. She has never had a urinary tract infection. There is no associated hematuria, flank pain, suprapubic pain, or fever. She says she has not noted any itching or vaginal discharge. A midstream urine specimen taken earlier in the week showed significant pyuria but a culture was reported as no growth. She has taken an antibiotic for 2 days without relief. Her only other medication is an oral contraceptive agent. Which one of the following is the most likely infectious agent? (check one)

A. Escherichia coli
B. Chlamydia trachomatis
C. Candida albicans
D. Staphylococcus saprophyticus
B. Chlamydia trachomatis. Women who present with symptoms of acute dysuria, frequency, and pyuria do not always have bacterial cystitis. In fact, up to 30% will show either no growth or insignificant bacterial growth on a midstream urine culture. Most commonly these patients represent cases of sexually transmitted urethritis caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus.

In this case, the gradual onset, absence of hematuria, and week-long duration of symptoms suggest a sexually transmitted disease. A history of a new sexual partner or a finding of mucopurulent cervicitis would confirm the diagnosis. Empiric treatment with a tetracycline and a search for other sexually transmitted diseases would then be indicated.

Another possible diagnosis is urinary tract infection with Escherichia coli or Staphylococcus species; however, the onset of these infections is usually abrupt and accompanied by other signs, such as suprapubic pain or hematuria. Candida is unlikely because there is no accompanying discharge or itching, and the patient's symptoms predate the use of antibiotics.
A previously healthy 82-year-old male is brought to your office by his daughter after a recent fall while getting up to go to the bathroom in the middle of the night. The patient denies any history of dizziness, chest pain, palpitations, or current injury. He has a history of bilateral dense cataracts. On examination, he is found to have an increased stance width and walks carefully and cautiously with his arms and legs abducted. A timed up-and-go test is performed, wherein the patient is asked to rise from a chair without using his arms, walk 3 meters, turn, return to his chair, and sit down. It takes the patient 25 seconds and he is noted to have an "en bloc" turn.

Which one of the following is the most likely cause of this patient's gait and balance disorder? (check one)

A. Visual impairment
B. Cerebellar degeneration
C. Frontal lobe degeneration
D. Parkinson's disease
E. Motor neuropathy
A. Visual impairment. Gait and balance disorders are one of the most common causes of falls in older adults. Correctly identifying gait and balance disorders helps guide management and may prevent consequences such as injury, disability, loss of independence, or decreased quality of life. The "Timed Up and Go" test is a reliable diagnostic tool for gait and balance disorders and is quick to administer. A time of <10 seconds is considered normal, a time of >14 seconds is associated with an increased risk of falls, and a time of >20 seconds usually suggests severe gait impairment.

This patient has the cautious gait associated with visual impairment. It is characterized by abducted arms and legs; slow, careful, "walking on ice" movements; a wide-based stance; and "en bloc" turns. Patients with cerebellar degeneration have an ataxic gait that is wide-based and staggering. Frontal lobe degeneration is associated with gait apraxia that is described as "magnetic," with start and turn hesitation and freezing. Parkinson's disease patients have a typical gait that is short-stepped and shuffling, with hips, knees, and spine flexed, and may also exhibit festination and "en bloc" turns. Motor neuropathy causes a "steppage" gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.
A 17-year-old white female has a history of anorexia nervosa, and weight loss has recently been a problem. The patient is an academically successful high-school student who lives with her parents and a younger sibling. Her BMI is 17.4 kg/m2 . Her serum electrolyte levels and an EKG are normal.

Which one of the following interventions is most likely to be successful? (check one)

A. Family-based treatment
B. Adolescent-focused individual therapy
C. Fluoxetine (Prozac)
D. Phenelzine (Nardil)
E. Desipramine (Norpramin)
A. Family-based treatment. Family-based treatment for the adolescent with anorexia nervosa has been found to provide superior results when compared with individual adolescent-focused therapy (SOR B). Antidepressants have not been successful. They may be indicated for coexisting conditions, but this is more common with bulimia.
A 42-year-old male with well-controlled type 2 diabetes mellitus presents with a 24-hour history of influenza-like symptoms, including the sudden onset of headache, fever, myalgias, sore throat, and cough. It is December, and there have been a few documented cases of influenza recently in the community.

The CDC recommends initiating treatment in this situation: (check one)

A. on the basis of clinical symptoms alone
B. only if rapid influenza testing is positive
C. only if the diagnosis is confirmed by immunoassay testing
D. only if the diagnosis is confirmed by reverse transcriptase polymerase chain reaction (PCR) assay
A. on the basis of clinical symptoms alone. Influenza is a highly contagious viral illness spread by airborne droplets. This patient's symptoms are highly suggestive of typical influenza: a sudden onset of malaise, myalgia, headache, fever, rhinitis, sore throat, and cough. While influenza is typically uncomplicated and self-limited, it can result in severe complications, including encephalitis, pneumonia, respiratory failure, and death.

The effectiveness of treatment for influenza is dependent on how early in the course of the illness it is given. Because of the recent global H1N1 influenza outbreak that resulted in demand potentially outstripping the supply of antiviral medication, the Centers for Disease Control and Prevention has modified its recommendation as follows:
Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness or who require hospitalization.
Antiviral treatment is recommended as soon as possible for outpatients with confirmed or suspected influenza who are at higher risk for influenza complications based on their age or underlying medical conditions. Clinical judgment should be an important component of outpatient treatment decisions.
Antiviral treatment also may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza who does not have known risk factors for severe illness, if treatment can be initiated within 48 hours of illness onset.
Many rapid influenza tests produce false-negative results, and more accurate assays can take more than 24 hours. Thus, treatment of patients with a clinical picture suggesting influenza is recommended, even if a rapid test is negative. Delaying treatment until further test results are available is not recommended.
A 52-year-old male has had a chronic course of multiple vague and exaggerated symptoms for which no cause has been found despite extensive testing. Which one of the following is the most effective management approach for this patient? (check one)

A. Reassure the patient that his symptoms are not real
B. Schedule the patient for regular appointments every 2-4 weeks
C. Prescribe opioids for the pain
D. Order additional diagnostic tests
E. Advise the patient to go to the emergency department if the symptoms occur after office hours
B. Schedule the patient for regular appointments every 2-4 weeks. The management of somatizing patients can be difficult. One strategy that has been shown to be effective is to schedule regular office visits so that the patient does not need to develop new symptoms in order to receive medical attention. Regular visits have been shown to significantly reduce the cost and chaos of caring for patients with somatization disorder and to help progressively diminish emergency visits and telephone calls. In addition, it is important to describe the patient's diagnosis with compassion and avoid suggesting that it's "all in your head."

Continued diagnostic testing and referrals in the absence of new symptoms or findings is unwarranted. Visits to the emergency department often result in inconsistent care and mixed messages from physicians who are seeing the patient for the first time, and unnecessary and often repetitive tests may be ordered. Opiates have significant side effects such as constipation, sedation, impaired cognition, and risk of addiction.
Random Board Review Questions 06
Which one of the following patients should be advised to take aspirin, 81 mg daily, for the primary prevention of stroke? (check one)

A. A 42-year-old male with a history of hypertension
B. A 72-year-old female with no chronic medical conditions
C. An 80-year-old male with a history of depression
D. An 87-year-old female with a history of peptic ulcer disease
B. A 72-year-old female with no chronic medical conditions. The U.S. Preventive Services Task Force (USPSTF) has summarized the evidence for the use of aspirin in the primary prevention of cardiovascular disease as follows:
The USPSTF recommends the use of aspirin for men 45-79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation)
The USPSTF recommends the use of aspirin for women 55-79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement)
The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation)
In summary, consistent evidence from randomized clinical trials indicates that aspirin use reduces the risk for cardiovascular disease events in adults without a history of cardiovascular disease. It reduces the risk for myocardial infarction in men, and ischemic stroke in women. Consistent evidence shows that aspirin use increases the risk for gastrointestinal bleeding, and limited evidence shows that aspirin use increases the risk for hemorrhagic strokes. The overall benefit in the reduction of cardiovascular disease events with aspirin use depends on baseline risk and the risk for gastrointestinal bleeding.
A 12-month-old white female whom you have seen regularly for all of her scheduled well child care is found to have a hemoglobin level of 9.0 g/dL (N for age 10.5-13.5). She started whole milk at 9 months of age. She appears healthy otherwise and has no family history of anemia. A CBC reveals a mild microcytic, hypochromic anemia with RBC poikilocytosis, but is otherwise normal. The RBC distribution width is also elevated.

Of the following, the most appropriate next step would be to: (check one)

A. order tests for serum iron and total iron-binding capacity
B. order a serum ferritin level
C. order hemoglobin electrophoresis
D. prescribe oral iron
E. perform stool guaiac testing
D. prescribe oral iron. Iron deficiency is almost certainly the diagnosis in this child. The patient's response to a therapeutic trial of iron would be most helpful in establishing the diagnosis. Additional tests might be necessary if there is no response.
Because of safety concerns, which one of the following asthma medications should be used only as additive therapy and not as monotherapy? (check one)

A. Inhaled corticosteroids
B. Leukotriene-receptor antagonists
C. Short-acting β2-agonists
D. Long-acting β2-agonists
E. Mast cell stabilizers
D. Long-acting β2-agonists. Because of the risk of asthma exacerbation or asthma-related death, the FDA has added a warning against the use of long-acting β2-agonists as monotherapy. Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved and accepted for both monotherapy and combination therapy in the management of asthma (SOR A).
The mother of a 16-year-old male brings him to your office stating that she wants to find out if he has Crohn's disease. She says that both she and the child's aunt were diagnosed with this condition by another physician with "blood tests." The son tells you that for the past several years his stool is intermittently loose and he has up to three bowel movements in a day. He says he does not have fever, pain, hematochezia, weight loss, or any extraintestinal symptoms. A physical examination is normal.

Which one of the following would be the most appropriate preliminary testing? (check one)

A. A plain radiograph of the abdomen
B. CT of the abdomen and pelvis
C. An inflammatory bowel disease serologic panel
D. Colonoscopy with a biopsy
E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate
E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate. The diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available). Endoscopy is usually reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation. It is recommended that this preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate.

Patients who have minimal symptoms and normal preliminary testing likely do not have a significant case of IBD. Plain radiographs and CT of the abdomen may help rule out other etiologies but are not considered adequate to diagnose or exclude IBD. Panels of serologic blood tests have recently been developed and are being assessed as to their place in evaluating patients who may have IBD. However, this testing is expensive, lacks sufficient predictive value, and has yet to prove its utility compared to standard testing.
A 3-day-old female developed a rash 1 day ago that has continued to progress and spread. The infant was born at term after an uncomplicated pregnancy and delivery to a healthy mother following excellent prenatal care. The infant was discharged 2 days ago in good health. She does not appear to be irritable or in distress, and she is afebrile and feeding well. On examination, abnormal findings are confined to the skin, including her face, trunk, and proximal extremities, which have macules, papules, and pustules that are all 2-3 mm in diameter. Her palms and soles are spared. A stain of a pustular smear shows numerous eosinophils.

Which one of the following is the most likely diagnosis? (check one)

A. Staphylococcal pyoderma
B. Herpes simplex
C. Acne neonatorum
D. Erythema toxicum neonatorum
E. Rocky Mountain spotted fever
D. Erythema toxicum neonatorum. This infant has a typical presentation of erythema toxicum neonatorum. Staphylococcal pyoderma is vesicular and the stain of the vesicle content shows polymorphonuclear leukocytes and clusters of gram-positive bacteria. Because the mother is healthy and the infant shows no evidence of being otherwise ill, systemic infections such as herpes are unlikely. Acne neonatorum consists of closed comedones on the forehead, nose, and cheeks. Rocky Mountain spotted fever is a tickborne disease that does not need to be considered in a child who is not at risk.
A 52-year-old Hispanic female with diabetes mellitus and stage 3 chronic kidney disease sees you for follow-up after tests show an estimated glomerular filtration rate of 56 mL/min. Which one of the following medications should she avoid to prevent further deterioration in renal function? (check one)

A. Lisinopril (Prinivil, Zestril)
B. Folic acid
C. Low-dose aspirin
D. Candesartan (Atacand)
E. Ibuprofen
E. Ibuprofen. Patients with chronic kidney disease (CKD) and those at risk for CKD because of conditions such as hypertension and diabetes have an increased risk of deterioration in renal function from NSAID use. NSAIDs induce renal injury by acutely reducing renal blood flow and, in some patients, by causing interstitial nephritis. Because many of these drugs are available over the counter, patients often assume they are safe for anyone. Physicians should counsel all patients with CKD, as well as those at increased risk for CKD, to avoid NSAIDs.

ACE inhibitors and angiotensin II receptor blockers are renoprotective and their use is recommended in all diabetics. The use of low-dose aspirin and folic acid is recommended in all patients with diabetes, due to the vasculoprotective properties of these drugs. High-dose aspirin should be avoided because it acts as an NSAID.
The best drug treatment for symptomatic mitral valve prolapse is: (check one)

A. quinidine
B. propranolol (Inderal)
C. digoxin
D. procainamide
E. phenytoin (Dilantin)
B. propranolol (Inderal). The primary treatment for symptomatic mitral valve prolapse is β-blockers. Quinidine and digoxin were used to treat this problem in the past, especially if sinus bradycardia or cardiac arrest occurred with administration of propranolol. Procainamide and phenytoin have not been used to treat this syndrome. Asymptomatic patients require only routine monitoring, while those with significant mitral regurgitation may require surgery. Some patients with palpitations can be managed with lifestyle changes such as elimination of caffeine and alcohol. Orthostatic hypotension can often be managed with volume expansion, such as by increasing salt intake.
A 52-year-old male with stable coronary artery disease and controlled hypertension sees you for a routine visit and asks for advice regarding prevention of altitude illness for his upcoming trip to Bhutan to celebrate his anniversary. His medical chart indicates that he had a reaction to a sulfa drug in the past.

Which one of the following would be most appropriate? (check one)

A. Advise the patient to not make the trip
B. Recommend ginkgo biloba
C. Prescribe acetazolamide
D. Prescribe dexamethasone
D. Prescribe dexamethasone. Altitude illness is common, affecting 25%-85% of travelers to high altitudes. The most common manifestation is acute mountain sickness, heralded by malaise and headache. Risk factors include young age, residence at a low altitude, rapid ascent, strenuous physical exertion, and a previous history of altitude illness. However, activity restriction is not necessary for patients with coronary artery disease who are traveling to high altitudes (SOR C).

Ginkgo biloba has been evaluated for both prevention and treatment of acute mountain sickness and high-altitude cerebral edema, and it is not recommended. Acetazolamide is an effective prophylactic agent (SOR B), but is contraindicated in patients with a sulfa allergy. If used, it should be started a minimum of one day before ascent and continued until the patient acclimatizes at the highest planned elevation. Dexamethasone is an effective prophylactic and treatment agent (SOR B), and it is not contraindicated for those with a sulfa allergy. It would be the best option for this patient.
Which one of the following is most commonly implicated in interstitial nephritis? (check one)

B. ACE inhibitors
C. Diuretics
D. Corticosteroids
E. Antibiotics
E. Antibiotics. Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other drugs listed may cause renal injury, but not acute interstitial nephritis.
Which one of the following has been shown to be effective for improving symptoms of varicose veins? (check one)

A. Horse chestnut seed extract
B. Vitamin B12
C. Ephedra
D. Milk thistle
E. St. John's wort
A. Horse chestnut seed extract. Horse chestnut seed extract has been shown to have some effect when used orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins. It may also be useful for relieving pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances, including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability. Milk thistle may be effective for hepatic cirrhosis. Ephedra is considered unsafe, as it can cause severe life-threatening or disabling adverse effects in some people. St. John's wort may be effective for treating mild to moderate depression. Vitamin B12 is used to treat pernicious anemia.
Random Board Review Questions 07
Breastfeeding a full-term, healthy infant is contraindicated when which one of the following maternal conditions is present? (check one)

A. Chronic hepatitis B infection
B. Seropositive cytomegalovirus carrier state
C. Current tobacco smoking
D. Herpes simplex viral lesions on the breasts
E. Undifferentiated fever
D. Herpes simplex viral lesions on the breasts. Breastfeeding provides such optimal nutrition for an infant that the benefits still far outweigh the risks even when the mother smokes tobacco, tests positive for hepatitis B or C virus, or develops a simple undifferentiated fever. Maternal seropositivity to cytomegalovirus (CMV) is not considered a contraindication except when it has a recent onset or in mothers of low birthweight infants. When present, the CMV load can be substantially reduced by freezing and pasteurization of the milk. All patients who smoke should be strongly encouraged to discontinue use of tobacco, particularly in the presence of infants, but smoking is not a contraindication to breastfeeding.

Mothers with active herpes simplex lesions on a breast should not feed their infant from the infected breast, but may do so from the other breast if it is not infected. Breastfeeding is also contraindicated in the presence of active maternal tuberculosis, and following administration or use of radioactive isotopes, chemotherapeutic agents, "recreational" drugs, or certain prescription drugs.
What is the most common cause of erythema multiforme, accounting for more than 50% of cases? (check one)

A. Candida albicans
B. Herpes simplex virus
C. Mycoplasma pneumoniae
D. Penicillin therapy
E. Sulfonamide therapy
B. Herpes simplex virus. Erythema multiforme usually occurs in adults 20-40 years of age, although it can occur in patients of all ages. Herpes simplex virus (HSV) is the most commonly identified cause of this hypersensitivity reaction, accounting for more than 50% of cases.
A 25-year-old male presents to your office for evaluation of pain in the right index finger that has been present for the past 4 days. The pain has been getting progressively worse. On examination the finger is swollen and held in a flexed position. The pain increases with passive extension of the finger, and there is tenderness to palpation from the tip of the finger into the palm.

Which one of the following is the most appropriate management of this patient? (check one)

A. Surgical drainage and antibiotics
B. Antiviral medication
C. Oral antibiotics and splinting
D. Needle aspiration
E. Corticosteroid injection
A. Surgical drainage and antibiotics. This patient has pyogenic tenosynovitis. When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient's infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics. A delay in treatment of these infections can lead to ischemia of the tendons and damage to the flexor tendon and sheath. This can lead to impaired function of the finger. Needle aspiration would not adequately drain the infection. Antiviral medication would not be appropriate, as this is a bacterial infection. Corticosteroid injections are contraindicated in the presence of infection.
An 81-year-old male with type 2 diabetes mellitus has a hemoglobin A 1c of 10.9%. He is already on the maximum dosage of glipizide (Glucotrol). His other medical problems include mild renal insufficiency and moderate ischemic cardiomyopathy.

Which one of the following would be the most appropriate change in this patient's diabetes regimen? (check one)

A. Add metformin (Glucophage)
B. Add sitagliptin (Januvia)
C. Add pioglitazone (Actos)
D. Initiate insulin therapy
D. Initiate insulin therapy. This geriatric diabetic patient should be treated with insulin. Metformin is contraindicated in patients with renal insufficiency. Sitagliptin should not be added to a sulfonylurea drug initially, the dosage should be lowered in patients with renal insufficiency, and given alone it would probably not result in reasonable diabetic control. Pioglitazone can cause fluid retention and therefore would not be a good choice for a patient with cardiomyopathy.
Which one of the following seafood poisonings requires more than just supportive treatment? (check one)

A. Ciguatera
B. Neurotoxic shellfish
C. Paralytic shellfish
D. Scombroid fish
D. Scombroid fish. Only symptomatic treatment is indicated for ciguatera poisoning, as there is no specific treatment. The same is true for shellfish poisoning, although potential respiratory distress or failure must be kept in mind.

Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties such as mahi-mahi, amberjack, sardines, and herring can also cause this problem. The poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine. Symptoms occur within minutes to hours, and include flushing of the skin, oral paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia, tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually lead to resolution of symptoms within several hours.
A 22-year-old white female comes to your office complaining of dizziness. She was in her usual good health until about 2 weeks before this visit, when she developed a case of gastroenteritis that other members of her family have also had. Since that time she has been lightheaded when standing, feels her heart race, and gets headaches or blurred vision if she does not sit or lie down. She has not passed out but has been unable to work due to these symptoms. She is otherwise healthy and takes no regular medications.

A physical examination is normal except for her heart rate, which rises from 72 beats/min when she is lying or sitting to 112 beats/min when she stands. Her blood pressure remains unchanged with changes of position. Routine laboratory tests and an EKG are normal.

What is the most likely cause of this patient's condition? (check one)

A. Myocarditis
B. A seizure disorder
C. Postural orthostatic tachycardia syndrome (POTS)
D. Systemic lupus erythematosus
E. Somatization disorder
C. Postural orthostatic tachycardia syndrome (POTS). Postural orthostatic tachycardia syndrome (POTS) is manifested by a rise in heart rate >30 beats/min or by a heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enough. This condition is most prevalent in white females between the ages of 15 and 50 years old. Often these patients are hardworking, athletic, and otherwise in good health.

There is a high clinical correlation between POTS and chronic fatigue syndrome. Although no single etiology for POTS has been found, the condition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers.
Which one of the following is the greatest risk factor for abdominal aortic aneurysm (AAA)? (check one)

A. Cigarette smoking
B. Diabetes mellitus
C. Hypertension
D. African-American race
E. Female gender
A. Cigarette smoking. Cigarette smokers are five times more likely than nonsmokers to develop an abdominal aortic aneurysm (AAA). The risk is associated with the number of years the patient has smoked, and declines with cessation. Diabetes mellitus is protective, decreasing the risk of AAA by half. Women tend to develop AAA in their sixties, 10 years later than men. Whites are at greater risk than African-Americans. Hypertension is less of a risk factor than cigarette smoking (SOR A).
An asymptomatic 35-year-old female asks about having a thyroid test performed because hypothyroidism runs in her family. You order the tests, which show a TSH level of 7.6μU/mL (N 0.4-5.1) and a free T4 level within the normal range.

Which one of the following is most likely in this patient? (check one)

A. A euthyroid state
B. Primary hyperthyroidism
C. Secondary hyperthyroidism
D. Subclinical hypothyroidism
E. Overt hypothyroidism
D. Subclinical hypothyroidism. Subclinical hypothyroidism is defined as slightly elevated TSH (approximately 5-10 mIU/L) and normal levels of thyroid hormone (free T4 or free T3 ) in an asymptomatic patient. There is a low rate of progression to overt hypothyroidism manifested by symptoms, TSH levels >10 mIU/L, or reduced levels of thyroid hormone.

Recent studies have shown that there is an increased risk for cardiovascular morbidity and mortality in those with subclinical hypothyroidism. However, treatment with thyroid replacement hormone did not seem to affect this risk. The decision about whether to recommend thyroid replacement therapy to patients like the one described here should be individualized. An alternative to treating the patient with medication at this time would be to retest her TSH annually, or sooner if she becomes symptomatic.
Which one of the following tinea infections in children always requires systemic antifungal therapy? (check one)

A. Tinea cruris
B. Tinea corporis
C. Tinea capitis
D. Tinea pedis
E. Tinea versicolor
C. Tinea capitis. Dermatophyte infections caused by aerobic fungi produce infections in many areas. Tinea capitis requires systemic therapy to penetrate the affected hair shafts. Tinea cruris and tinea pedis rarely require systemic therapy. Extensive outbreaks of tinea corporis and tinea versicolor benefit from both oral and topical treatment (SOR A), but more localized infections require only topical treatment.
A 26-year-old female calls your office to inquire about the results of her recent Papanicolaou (Pap) test. The report indicates the presence of atypical squamous cells of undetermined significance (ASC-US), and her reflex HPV test is negative for high-risk HPV types. The patient has never had an abnormal Pap test and has had three normal tests over the past 6 years. She is a nonsmoker.

You advise the patient that the most appropriate next step would be to: (check one)

A. repeat the Pap test every 3 months for 1 year
B. repeat the Pap test in 6 months and 12 months
C. repeat the Pap test in 12 months
D. continue routine Pap tests, with the next test in 3 years
E. schedule colposcopy as soon as possible
C. repeat the Pap test in 12 months. The ASC-US/LSIL Triage Study (ALTS) demonstrated that there are three appropriate follow-up options for managing women with an ASC-US Papanicolaou (Pap) test result: (1) two repeat cytologic examinations performed at 6-month intervals; (2) reflex testing for HPV; or (3) a single colposcopic examination. This expert consensus recommendation has been confirmed in more recent clinical studies, additional analyses of the ALTS data, and meta-analyses of published studies (SOR A).

Reflex HPV testing refers to testing either the original liquid-based cytology residual specimen or a separate sample collected for HPV testing at the time of the initial screening visit. This approach eliminates the need for women to return to the office or clinic for repeat testing, rapidly reassures women who do not have a significant lesion, spares 40%-60% of women from undergoing colposcopy, and has been shown to have a favorable cost-effectiveness ratio. In this patient's case, the HPV testing was negative, and there is no need to repeat the Pap test at 6-month intervals or to perform colposcopy.

Although women in certain low-risk groups need routine cervical cancer screening only every 3 years, this patient should have a repeat Pap test in 12 months. Immediately repeating the test or testing at 3-month intervals is not recommended in any of the algorithms to manage ASC-US results for otherwise healthy women.
Random Board Review Questions 08
You are asked to perform a preoperative evaluation on a 55-year-old white female with type 2 diabetes mellitus prior to elective femoral-anterior tibial artery bypass surgery. She is unable to climb a flight of stairs or do heavy work around the house. She denies exertional chest pain, and is otherwise healthy.

Based on current guidelines, which one of the following diagnostic studies would be appropriate prior to surgery because the results could alter the management of this patient? (check one)

A. Pulmonary function studies
B. Coronary angiography
C. Carotid angiography
D. A dipyridamole-thallium scan
E. A hemoglobin A1c level
D. A dipyridamole-thallium scan. Family physicians are often asked to perform a preoperative evaluation prior to noncardiac surgery. This requires an assessment of the perioperative cardiovascular risk of the procedure involved, the functional status of the patient, and clinical factors that can increase the risk, such as diabetes mellitus, stroke, renal insufficiency, compensated or prior heart failure, mild angina, or previous myocardial infarction.

This patient is not undergoing emergency surgery, nor does she have an active cardiac condition; however, she is undergoing a high-risk procedure (>5% risk of perioperative myocardial infarction) with vascular surgery. As she cannot climb a flight of stairs or do heavy housework, her functional status is <4 METs, and she should be considered for further evaluation. The patient's diabetes is an additional clinical risk factor.

With vascular surgery being planned, appropriate recommendations include proceeding with the surgery with heart rate control, or performing noninvasive testing if it will change the management of the patient. Coronary angiography is indicated if the noninvasive testing is abnormal. Pulmonary function studies are most useful in patients with underlying lung disease or those undergoing pulmonary resection. Hemoglobin A1c is a measure of long-term diabetic control and is not particularly useful perioperatively. Carotid angiography is not indicated in asymptomatic patients being considered for lower-extremity vascular procedures.
A 62-year-old male has been taking omeprazole (Prilosec) for over a year for gastroesophageal reflux disease. He is asymptomatic and has had no problems tolerating the drug, but asks you about potential side effects, as well as the benefits of continuing therapy.

It would be most accurate to tell him that omeprazole therapy is associated with which one of the following? (check one)

A. A decreased rate of hip fracture
B. Decreased vitamin B12 absorption
C. A reduced likelihood of pneumonia
D. A reduced likelihood of Clostridium difficile colitis
E. An increased likelihood of iron deficiency anemia
B. Decreased vitamin B12 absorption. Although proton pump inhibitors are the most effective treatment for patients with asymptomatic gastroesophageal reflux disease, there are several potential problems with prolonged therapy. Omeprazole is associated with an increased risk of community-acquired pneumonia and Clostridium difficile colitis. Omeprazole has also been shown to acutely decrease the absorption of vitamin B 12 , and it decreases calcium absorption, leading to an increased risk of hip fracture. The risk for Clostridium difficile colitis is also increased.
A 48-year-old white female comes to see you because of abnormal vaginal bleeding. Her periods are lasting 3-5 days longer than usual, bleeding is heavier, and she has experienced some intermenstrual bleeding. Her physical examination is unremarkable, except for a parous cervix with dark blood at the os and in the vagina. She has no orthostatic hypotension, and her hemoglobin level is 11.5 g/dL. A pregnancy test is negative.

Which one of the following is the most important next step in management? (check one)

A. Laboratory tests to rule out thyroid dysfunction
B. An endometrial biopsy
C. Oral contraceptives, 4 times a day for 5-7 days
D. Cyclic combination therapy with conjugated estrogens (Premarin) and medroxy-progesterone (Provera) each month
E. Administration of a gonadotropin-releasing hormone analog such as leuprolide acetate (Eligard Lupron Depot)
B. An endometrial biopsy. A patient over the age of 35 who experiences abnormal vaginal bleeding must have an endometrial assessment to exclude endometrial hyperplasia or cancer. An endometrial biopsy is currently the preferred method for identifying endometrial disease. A laboratory evaluation for thyroid dysfunction or hemorrhagic diathesis is appropriate if no cancer is present on an endometrial biopsy and medical therapy fails to halt the bleeding. The other options listed can be used as medical therapy to control the bleeding once the histopathologic diagnosis has been made.
A 75-year-old African-American male with no previous history of cardiac problems complains of shortness of breath and a feeling of general weakness. His symptoms have developed over the past 24 hours. On physical examination you find a regular pulse with a rate of 160 beats/min. You note rales to the base of the scapula bilaterally, moderate jugular venous distention, and hepatojugular reflux. His blood pressure is 90/55 mm Hg; when he sits up he becomes weak and diaphoretic and complains of precordial pressure. An EKG reveals atrial flutter with 2:1 block.

Management at this time should include: (check one)

A. intravenous digoxin
B. intravenous verapamil (Calan, Isoptin)
C. amiodarone (Cordarone)
D. electrical cardioversion
E. insertion of a pacemaker
D. electrical cardioversion. Atrial flutter is not ordinarily a serious arrhythmia, but this patient has heart failure manifested by rales, jugular venous distention, hepatojugular reflux, hypotension, and angina. Electrical cardioversion should be performed immediately. This is generally a very easy rhythm to convert. Digoxin and verapamil are appropriate in hemodynamically stable patients. A pacemaker for rapid atrial pacing may be beneficial if digitalis intoxication is the cause of atrial flutter, but this is unlikely in a patient with no previous history of cardiac problems. Amiodarone is not indicated in this clinical situation.
A 60-year-old male is referred to you by his employer for management of his hypertension. He has been without primary care for several years due to a lapse in insurance coverage. During a recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm Hg. He has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago. He has no other health problems and does not smoke or drink alcohol. A review of systems is negative except for minor residual weakness in his right upper extremity resulting from his remote stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse, and you obtain a similar reading during your examination.

In addition to counseling him regarding lifestyle modifications, which one of the following is the most appropriate treatment for his hypertension? (check one)

A. An angiotensin receptor blocker
B. A β-blocker
C. A calcium channel blocker
D. A thiazide diuretic/ACE inhibitor combination
E. No medication
D. A thiazide diuretic/ACE inhibitor combination. This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. For patients with a history of previous stroke, JNC-7 recommends using combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke. Other classes of drugs have not been shown to be of benefit for secondary stroke prevention. Although blood pressure should not be lowered quickly in the setting of acute ischemic stroke, this patient is not having an acute stroke, so treatment of his hypertension is warranted.
With regard to the cardiovascular system, activation of the sympathetic branch of the autonomic nervous system will cause a decrease in which one of the following? (check one)

A. Heart rate
B. Coronary flow rate
C. Metabolic demand
D. Contractility of cardiac myocytes
E. The P-R interval
E. The P-R interval. The sympathetic nervous system acts as a positive chronotropic (increases heart rate) and inotropic (increases contractility) agent. This additional work by the heart will increase metabolic demand and coronary flow rate. The increased heart rate will decrease the time intervals between electrical events shown on an EKG.
A 40-year-old female with chronic plaque psoriasis requests topical treatment. Which one of the following topical therapies would be most effective and have the fewest adverse effects? (check one)

A. High-potency corticosteroids
B. Tazarotene (Tazorac)
C. Coal tar polytherapy
D. Anthralin
A. High-potency corticosteroids. Chronic plaque psoriasis is the most common type of psoriasis and is characterized by redness, thickness, and scaling. A variety of treatments were found to be more effective than placebo, but the best results were produced by topical vitamin D analogues and topical corticosteroids. Vitamin D and high-potency corticosteroids were equally effective when compared head to head, but the corticosteroids produced fewer local reactions (SOR A).
You have been treating a 43-year-old male for unipolar depression for 4 years. He has developed treatment-resistant depression, and despite having a good initial response to an SSRI, his symptoms are worsening. He has failed to improve despite escalated doses of multiple SSRIs and SNRIs. He is currently taking citalopram (Celexa), 60 mg daily.

Of the following, the most effective adjunctive therapy would be augmentation with: (check one)

A. lithium bicarbonate
B. high-dose triiodothyronine
C. an atypical antipsychotic, such as olanzapine (Zyprexa)
D. an anticonvulsant, such as gabapentin (Neurontin)
A. lithium bicarbonate. Up to one-third of patients with unipolar depression will fail to respond to treatment with a single antidepressant, despite adequate dosing and an appropriate treatment interval. Lithium, triiodothyronine (T3 ), and atypical antipsychotics can all provide clinical improvement when used in conjunction with the ineffective antidepressant. The American Psychiatric Association and the Institute for Clinical Systems Improvement both recommend a trial of lithium or low-dose T 3 for patients who have an incomplete response to antidepressant therapy. A meta-analysis showed that a serum lithium level ≥0.5 mEq/L and a treatment duration of 2 weeks or greater resulted in a good response (SOR A).

While thyroid supplementation as adjunctive therapy is effective, the recommended dosage is no higher than 50 μg/day (SOR B). Atypical antipsychotics can be used as add-on therapy, but are not as effective as lithium or T3 (SOR B). Anticonvulsant medications such as gabapentin have been shown to be effective in the management of bipolar affective disorder, but not as adjunctive therapy in the treatment of unipolar depression resistant to single-agent antidepressants.
A 4-year-old is brought to the emergency department with abdominal pain and is noted to have 3+ proteinuria on a dipstick. Three days later the pain has resolved spontaneously, and a repeat urinalysis in your office shows 2+ proteinuria with normal findings on microscopic examination. A metabolic panel, including creatinine and total protein, is also normal.

Which one of the following would be most appropriate at this point? (check one)

A. Renal ultrasonography
B. A spot first morning urine protein/creatinine ratio
C. An antinuclear antibody and complement panel
D. Referral to a nephrologist
B. A spot first morning urine protein/creatinine ratio. When proteinuria is noted on a dipstick and the history, examination, full urinalysis, and serum studies suggest no obvious underlying problem or renal insufficiency, a urine protein/creatinine ratio is recommended. This test correlates well with 24-hour urine protein, which is particularly difficult to collect in a younger patient. Renal ultrasonography is appropriate once renal insufficiency or nephritis is established. If pathogenic proteinuria is confirmed, an antinuclear antibody and/or complement panel may be indicated. A nephrology referral is not necessary until the presence of kidney disease or proteinuria from a cause other than benign postural proteinuria is confirmed.
A 25-year-old male presents to your office with a 1-week history of neck pain with radiation to the left hand, along with intermittent numbness and tingling in the left arm. His history is negative for injury, fever, or lower extremity symptoms. Extension and rotation of the neck to the left while pressing down on the head (Spurling's maneuver) exacerbates the symptoms. His examination is otherwise normal. Cervical radiographs are negative.

Which one of the following would be most appropriate at this point? (check one)

A. NSAIDs for pain relief
B. A trial of tricyclic antidepressants
C. Cervical corticosteroid injection
D. Cervical MRI
E. Referral to a spine subspecialist
A. NSAIDs for pain relief. Patients who present with acute cervical radiculopathy and normal radiographs can be treated conservatively. The vast majority of patients with cervical radiculopathy improve without surgery. Of the interventions listed, NSAIDs are the initial treatment of choice. Tricyclic antidepressants, as well as tramadol and venlafaxine, have been shown to help with chronic neuropathic pain. Cervical MRI is not indicated unless there are progressive neurologic defects or red flags such as fever or myelopathy. Likewise, referral to a subspecialist should be reserved for patients who have persistent pain after 6-8 weeks of conservative management and for those with signs of instability. Cervical corticosteroid injections have been found to be helpful in the management of cervical radiculopathy, but should not be administered before MRI is performed (SOR C).
Random Board Review Questions 09
A 21-year-old African-American female has been confused and delirious for 2 days. She has no significant past medical history, and she is taking no medications. She recently returned from a missionary trip to Southeast Asia. During your initial examination in the emergency department, she has several convulsions and rapidly becomes comatose. Her temperature is 37.9°C (100.3°F) and her blood pressure is 80/50 mm Hg. A neurologic examination shows no signs of meningeal irritation and a cranial nerve evaluation is normal. There is a mild, bilateral, symmetric increase in deep tendon reflexes. All other physical examination findings are normal.

Laboratory Findings

Hemoglobin........................... 7.0 g/dL (N 12.0-16.0)
Hematocrit............................ 20% (N 36-46)
WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6500/mm3 (N 4300-10,800)
Platelets. ............................. 450,000/mm3 (N 150,000-350,000)
Serum bilirubin
Total............................... 5.0 mg/dL (N 0.3-1.1)
Direct.............................. 1.0 mg/dL (N 0.1-0.4)

The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor infarction.

The most likely diagnosis is: (check one)

A. vitamin B12 deficiency
B. malaria
C. ehrlichiosis
D. sickle cell anemia
B. malaria. Clinical clues to the diagnosis of malaria in this case include an appropriately targeted recent travel history, a prodrome of delirium or erratic behavior, unarousable coma following a generalized convulsion, fever, and a lack of focal neurologic signs in the presence of a diffuse, symmetric encephalopathy. The peripheral blood smear shows normochromic, normocytic anemia with Plasmodium falciparum trophozoites and schizonts involving erythrocytes, diagnostic of cerebral malaria. Treatment of this true medical emergency is intravenous quinidine gluconate.

Vitamin B 12 deficiency is a predominantly peripheral neuropathy seen in older adults. Ehrlichiosis causes thrombocytopenia but not hemolytic anemia. Sickle cell disease presents with painful vaso-occlusive crises in multiple organs. Coma is rare.
While evaluating a stroke patient, you ask him to stick out his tongue. At first he is unable to do this, but a few moments later he performs this movement spontaneously.

This defect is known as: (check one)

A. apraxia
B. agnosia
C. expressive (Broca's) aphasia
D. astereognosis
A. apraxia. Apraxia is a transmission disturbance on the output side, which interferes with skilled movements. Even though the patient understands the request, he is unable to perform the task when asked, but may then perform it after a time delay. Agnosia is the inability to recognize previously familiar sensory input, and is a modality-bound deficit. For example, it results in a loss of ability to recognize objects. Aphasia is a language disorder, and expressive aphasia is a loss of the ability to express language. The ability to recognize objects by palpation in one hand but not the other is called astereognosis.
When an interpreter is needed for a patient with limited English proficiency, which one of the following should be AVOIDED when possible? (check one)

A. Using mostly short sentences, with frequent pauses
B. Using diagrams and pictures
C. Addressing the patient in the second person (i.e., "you")
D. Maintaining eye contact with the patient when speaking
E. Using an educated adult family member who is bilingual
E. Using an educated adult family member who is bilingual. Using trained, qualified interpreters for patients with limited English proficiency leads to fewer hospitalizations, less reliance on testing, a higher likelihood of making the correct diagnosis and providing appropriate treatment, and better patient understanding of conditions and therapies. Although the patient may request that a family member interpret, there are many pitfalls in using untrained interpreters: a lack of understanding of medical terminology, concerns about confidentiality, and unconscious editing by the interpreter of what the patient has said. Additionally, the patient may be reluctant to divulge sensitive or potentially embarrassing information to a friend or family member. The other principles listed are important practices when working with interpreters. Pictures and diagrams can help strengthen the patient's understanding of his or her health care.
A primigravida at 38 weeks gestation is concerned that her fetus is getting too large and wants to know what interventions could prevent complications from a large baby. On examination her uterine fundus measures 41 cm from the pubic symphysis. Ultrasonography is performed and an estimated fetal weight of 4000 g (8 lb 13 oz) is reported.

Which one of the following management options is supported by the best evidence? (check one)

A. Induction of labor
B. Cesarean section
C. Awaiting spontaneous labor
D. Weekly ultrasonography to follow fetal growth
C. Awaiting spontaneous labor. This estimated fetal weight is at the 90th percentile for a term fetus. Unfortunately, the accuracy of fetal weight estimates declines as pregnancy proceeds, and the actual size may be as much as 15% different from the estimate. Delivery of a large infant results in shoulder dystocia more often than delivery of a smaller infant, but most large infants are delivered without complications. Intuitively, it would seem logical to induce labor when the fetus seems to be getting large, but this intervention has been studied in controlled trials and the only difference in outcome was an increase in the cesarean rate for women who underwent elective induction for this indication.

Recently, there has been an increase in requests from patients to have an elective cesarean section near term to avoid the risks of labor, including pain, shoulder dystocia, and pelvic relaxation. The American Congress of Obstetricians and Gynecologists (ACOG) recommends consideration of cesarean delivery without a trial of labor if the estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the absence of diabetes. Even at that size, there is not adequate data to show that cesarean section is preferable to a trial of labor. Frequent ultrasonography is often performed to reduce anxiety for both patient and physician, but the problem of accuracy of weight estimates remains an issue even with repeated scans at term.
A 65-year-old female who is morbidly obese presents to your office with intertrigo in the axilla. On examination you detect small, reddish-brown macules that are coalescing into larger patches with sharp borders. You suspect cutaneous erythrasma complicating the intertrigo.

What would be the most appropriate topical treatment for this condition? (check one)

A. Cornstarch
B. A mild corticosteroid lotion
C. A high-potency corticosteroid lotion
D. Erythromycin
D. Erythromycin. Intertrigo is inflammation of skinfolds caused by skin-on-skin friction and is common on opposing cutaneous or mucocutaneous surfaces. Secondary cutaneous bacterial and fungal infections are common complications. Cutaneous erythrasma may complicate intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions. Erythrasma is caused by Corynebacterium minutissimum and presents as small reddish-brown macules that may coalesce into larger patches with sharp borders. Intertrigo complicated by erythrasma is treated with topical or oral erythromycin.
The CAGE-AID questionnaire is a tool for screening for: (check one)

A. depression
B. bipolar illness
C. substance abuse risk
D. psychosis
E. compatibility
C. substance abuse risk. The CAGE-AID (CAGE Adapted to Include Drugs) questionnaire is a tool for assessing potential substance abuse risk. In one study it had a sensitivity of 70% and a specificity of 85% for drug abuse when two or more affirmative responses were defined as a positive result. It consists of the following four questions:

Have you ever felt you ought to Cut down on your drinking or drug use?
Have people Annoyed you by criticizing your drinking or drug use?
Have you ever felt bad or Guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning as an Eye opener to steady your nerves or to get rid of a hangover?
You see a 6-year-old male for the third time in 3 months with a persistently painful hand condition. He has been treated with oral amoxicillin, followed by oral trimethoprim/ sulfamethoxazole (Bactrim, Septra), with no improvement. A physical examination reveals retraction of the proximal nail fold, absence of the cuticle, and erythema and tenderness around the nail fold area. The thumb and second and third fingers are affected on both hands. The patient is otherwise healthy.

First-line treatment for this condition includes: (check one)

A. warm soaks three times a day
B. avoidance of emollient lotions
C. a topical corticosteroid cream
D. an oral antifungal agent
C. a topical corticosteroid cream. This patient has symptoms and signs consistent with chronic paronychia. This condition is often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking.

Findings on examination are similar to those of acute paronychia, with tenderness, erythema, swelling, and retraction of the proximal nail fold. Often the adjacent cuticle is absent. Chronic paronychia has usually been persistent for at least 6 weeks by the time of diagnosis.

In addition to medication, basic treatment principles for the condition include avoidance of contact irritants, avoiding immersion of the hands in water, and use of an emollient. Topical corticosteroids have higher efficacy for treating chronic paronychia compared to oral antifungals (SOR B), particularly given the young age of the patient. A topical antifungal can also be tried in conjunction with the corticosteroid.
You see a 90-year-old male with a 5-year history of progressive hearing loss. The most common type of hearing loss at this age affects: (check one)

A. predominantly high frequencies
B. predominantly mid frequencies
C. predominantly low frequencies
D. all frequencies roughly the same
A. predominantly high frequencies. In the geriatric population, presbycusis is the most common cause of hearing loss. Patients typically have the most difficulty hearing higher-frequency sounds such as consonants. Lower-frequency sounds such as vowels are preserved.
A 44-year-old female who suffers from obstructive sleep apnea complains of gradual swelling in her legs over the last several weeks. Her vital signs include a BMI of 44.1 kg/m2 , a respiratory rate of 12/min, a blood pressure of 120/78 mm Hg, and an O 2 saturation of 86% on room air. An EKG and a chest radiograph are normal. Pulmonary function testing shows a restrictive pattern with no signs of abnormal diffusion. Abnormal blood tests include only a significantly elevated bicarbonate level.

Which one of the following treatments is most likely to reduce this patient's mortality rate? (check one)

A. ACE inhibitors
B. Routine use of nebulized albuterol (AccuNeb)
C. High-dose diuretic therapy
D. Continuous oxygen therapy
E. Continuous or bilevel positive airway pressure (CPAP or Bi-PAP)
E. Continuous or bilevel positive airway pressure (CPAP or Bi-PAP). This patient has obesity-hypoventilation syndrome, often referred to as Pickwickian syndrome. These patients are obese (BMI >30 kg/m 2 ), have sleep apnea, and suffer from chronic daytime hypoxia andcarbon dioxide retention. They are at increased risk for significant respiratory failure and death compared to patients with otherwise similar demographics. Treatment consists of nighttime positive airway pressure in the form of continuous (CPAP) or bi-level (BiPAP) devices, as indicated by sleep testing. The more hours per day that patients can use this therapy, the less carbon dioxide retention and less daytime hypoxia will ensue. Several small studies suggest that the increased mortality risk from obesity-hypoventilation syndrome can be decreased by adhering to this therapy. The use of daytime oxygen can improve oxygenation, but is not considered adequate to restore the chronic low respiratory drive that is characteristic of this condition.
A 38-year-old day-care worker consults you for "a cold that won't go away." It began with a runny nose, malaise, and a slight temperature elevation up to 100°F (37.8°C). She notes that after 2 weeks she is now experiencing "coughing fits," which are sometimes so severe that she vomits. She has had no immunizations since her freshman year in college and does not smoke. On examination you note excessive lacrimation and conjunctival injection. Her lungs are clear.

Which one of the following is the most likely diagnosis? (check one)

A. Pertussis
B. Rhinovirus infection
C. Nonasthmatic eosinophilic bronchitis
D. Cough-variant asthma
E. Gastroesophageal reflux
A. Pertussis. Pertussis, once a common disease in infants, declined to around 1000 cases in 1976 as a result of widespread vaccination. The incidence began to rise again in the 1980s, possibly because the immunity from vaccination rarely lasts more than 12 years.

The disease is characterized by a prodromal phase that lasts 1-2 weeks and is indistinguishable from a viral upper respiratory infection. It progresses to a more severe cough after the second week. The cough is paroxysmal and may be severe enough to cause vomiting or fracture ribs. Patients are rarely febrile, but may have increased lacrimation and conjunctival injection. The incubation period is long compared to a viral infection, usually 7-10 days.

Nonasthmatic eosinophilic bronchitis, cough-variant asthma, and gastroesophageal reflux disease cause a severe cough not associated with a catarrhal phase. A rhinovirus infection would probably be resolving within 2-3 weeks.
Random Board Review Questions 10
A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence is ideally treated by: (check one)

A. appropriate antibiotics
B. office banding
C. office cryotherapy
D. thrombectomy under local anesthesia
E. total hemorrhoidectomy
D. thrombectomy under local anesthesia. A thrombosed external hemorrhoid is manifested by the sudden development of a painful, tender, perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.
Which one of the following is most characteristic of patellofemoral pain syndrome in adolescent females? (check one)

A. Posterior knee pain
B. Pain exacerbated by walking on a flat surface
C. Inadequate hip abductor strength
D. A high rate of surgical intervention
C. Inadequate hip abductor strength. Patellofemoral pain syndrome is a common overuse injury observed in adolescent girls. The condition is characterized by anterior knee pain associated with activity. The pain is exacerbated by going up or down stairs or running in hilly terrain. It is associated with inadequate hip abductor and core strength; therefore, a prescription for a rehabilitation program is recommended. Surgical intervention is rarely required.
A 52-year-old patient is concerned about a biopsy result from a recent screening colonoscopy. Which one of the following types of colon polyp is most likely to become malignant? (check one)

A. Hyperplastic polyp
B. Hamartomatous polyp
C. Tubular adenoma
D. Villous adenoma
E. Tubulovillous adenoma
D. Villous adenoma. Hamartomatous (or juvenile) polyps and hyperplastic polyps are benign lesions and are not considered to be premalignant. Adenomas, on the other hand, have the potential to become malignant. Sessile adenomas and lesions >1.0 cm have a higher risk for becoming malignant. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are the most likely to develop into an adenocarcinoma.
Which one of the following treatments for diabetes mellitus reduces insulin resistance? (check one)

A. Acarbose (Precose)
B. Sitagliptin (Januvia)
C. Repaglinide (Prandin)
D. Exenatide (Byetta)
E. Pioglitazone (Actos)
E. Pioglitazone (Actos). Repaglinide and nateglinide are nonsulfonylureas that act on a portion of the sulfonylurea receptor to stimulate insulin secretion. Pioglitazone is a thiazolidinedione, which reduces insulin resistance. It is believed that the mechanism for this is activation of PPAR-Y, a receptor that affects several insulin-responsive genes. Acarbose is a competitive inhibitor of α-glucosidases, enzymes that break down complex carbohydrates into monosaccharides. This delays the absorption of carbohydrates such as starch, sucrose, and maltose, but does not affect the absorption of glucose. Sitagliptin is a DPP-IV inhibitor, and this class of drugs inhibits the enzyme responsible for the breakdown of the incretins GLP-1 and GIP. Exenatide is an incretin mimetic that stimulates insulin secretion in a glucose-dependent fashion, slows gastric emptying, and may promote satiety.
Which one of the following has been shown to be most effective for smokeless tobacco cessation? (check one)

A. Behavioral interventions
B. Mint snuff as a smokeless tobacco substitute
C. Bupropion (Wellbutrin)
D. The nicotine patch
E. Nicotine gum
A. Behavioral interventions. Behavioral interventions, especially those including telephone counseling and/or a dental examination, have been shown to be helpful for promoting smokeless tobacco cessation (SOR B). Studies examining mint snuff as a tobacco substitute, bupropion, and nicotine replacement in patch or gum form did not show any significant benefit.
An 81-year-old African-American female complains of increasing fatigue over the past several months. She has also noticed that her skin and hair feel dry and that she often feels cold. She also complains of intermittent swallowing difficulties. Her past medical history is significant for long-standing coronary artery disease, for which she takes metoprolol (Lopressor). Her physical examination is normal except for a resting pulse rate of 56 beats/min, dry skin, brittle hair, and a slow relaxation phase of the deep tendon reflexes. Her serum TSH level is 63.2 μU/mL (N 0.5-5.0).

Which one of the following should you do now? (check one)

A. Stop the metoprolol
B. Start levothyroxine (Synthroid)
C. Start liothyronine (Cytomel)
D. Start propylthiouracil
E. Refer for radioactive iodine ablation
B. Start levothyroxine (Synthroid). Autoimmune hypothyroidism is common in elderly women. Symptoms often include fatigue, bradycardia, dry skin, brittle hair, and a prolonged relaxation phase of the deep tendon reflexes. While replacement therapy with levothyroxine is indicated, care must be taken in the elderly, particularly in those with coronary artery disease, to replace the deficit slowly. Levothyroxine replacement should begin at 25μg daily for 6 weeks, with the dosage increased in 25-μg increments as needed, based on TSH levels.

Rapid replacement of thyroid hormone can increase the metabolic rate, and therefore myocardial oxygen demand, too quickly. This can precipitate complications of coronary artery disease such as atrial fibrillation, angina, and myocardial infarction. Stopping a β-blocker in this setting is likely to increase the risk. Radioactive iodine ablation is indicated for some cases of hyperthyroidism.
Which one of the following is associated with vacuum-assisted delivery? (check one)

A. Lower fetal risk than with forceps delivery
B. More maternal soft-tissue trauma than forceps delivery
C. A reduced likelihood of severe perineal laceration compared to spontaneous delivery
D. An increased incidence of shoulder dystocia
D. An increased incidence of shoulder dystocia. Vacuum-assisted delivery is associated with higher rates of neonatal cephalhematoma and retinal hemorrhage compared with forceps delivery. A systematic review of 10 trials found that vacuum-assisted deliveries are associated with less maternal soft-tissue trauma when compared to forceps delivery. Compared with spontaneous vaginal delivery, the likelihood of a severe perineal laceration is increased in women who have vacuum-assisted delivery without episiotomy, and the odds are even higher in vacuum-assisted delivery with episiotomy. Operative vaginal delivery is a risk factor for shoulder dystocia, which is more common with vacuum-assisted delivery than with forceps delivery.
A 21-year-old sexually active female presents with acute pelvic pain of several days' duration. A pelvic examination reveals right-sided tenderness and a general fullness in that area. In addition to laboratory testing, you decide to order an imaging study.

Which one of the following is the best choice at this time? (check one)

A. Transabdominal ultrasonography
B. Transvaginal ultrasonography
C. Contrast CT of the abdomen and pelvis
D. Hysteroscopy
E. Hysterosalpingography
B. Transvaginal ultrasonography. The best initial imaging study for acute pelvic pain in women is transvaginal ultrasonography (SOR C). This provides the greatest level of detail regarding the uterus and adnexae, superior to transcutaneous ultrasonography. CT of the abdomen/pelvis and hysterosalpingography may be indicated eventually in some patients with pelvic pain, but they are not the initial studies of choice. Hysteroscopy is not routinely used in the evaluation of pelvic pain.
A 27-year-old female presents to the emergency department with a complaint of bloody diarrhea and abdominal cramping. A few days ago she ate a rare hamburger at a birthday party for her 4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive for Escherichia coli O:157.

Which one of the following should you do next? (check one)

A. Provide levofloxacin (Levaquin) prophylaxis to her close contacts
B. Monitor her liver enzymes
C. Monitor her renal function
D. Reassure her that her son is not at risk of illness
C. Monitor her renal function. Escherichia coli O:157 is an increasingly common cause of serious gastrointestinal illness. The usual source is undercooked beef. The child is at risk, since at least 20% of cases result from secondary spread. Transmission is frequent in children's day-care facilities and nurseries. Some cases are asymptomatic, but the great majority are symptomatic, and patients present with bloody diarrhea. Levofloxacin is not useful for prophylaxis in contacts. This patient has a 10%-15% risk of developing hemolytic uremic syndrome secondary to her E. coli O:157 infection, making close monitoring of renal function essential.
A 21-year-old female complains of bulging veins in her right shoulder region, along with swelling and a "tingling" sensation in her right arm that has developed over the past 2 days. There were no unusual events other than her regular workouts with her swim team. Ultrasonography confirms an upper extremity deep-vein thrombosis of her right axillary vein.

Which one of the following would be the most appropriate treatment? (check one)

A. Intravenous heparin for 72 hours, followed by oral warfarin (Coumadin) for 3 months
B. Low molecular weight heparin (LMWH) subcutaneously for 5 days only
C. LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months
D. LMWH subcutaneously for at least 5 days, followed by oral warfarin indefinitely
E. Oral warfarin for 3 months
C. LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months. Upper extremity deep-vein thrombosis (UE-DVT) accounts for 4% of all cases of DVT. Catheter-related thromboses make up the majority of these cases. Occult cancer, use of oral contraceptives, and inheritable thrombophilia are other common explanations. Another proposed risk factor is the repetitive compression of the axillary-subclavian vein in athletes or laborers, which is the most likely cause of this patient's UE-DVT.

Taken as a whole, UE-DVT is generally associated with fewer venous complications, including less chance for thromboembolism, postphlebitic syndrome, and recurrence compared to lower-extremity deep-vein thrombosis (LE-DVT). However, the rates of these complications are still high enough that most experts recommend treatment identical to that of LE-DVT. Specifically, heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.
Random Board Review Questions 11
A 75-year-old male consults you after his family expresses concern about his loss of interest in his usual activities. They believe he has become increasingly withdrawn since the death of his wife 8 months earlier. You note he has lost 8 kg (18 lb) since his last office visit 6 months earlier. He does not drink alcohol. His physical examination is unremarkable for his age except for a blood pressure of 105/70 mm Hg. Detailed laboratory studies, including thyroid function tests, are all within normal limits. He tells you he would be fine if he could just get some sleep. His Mini-Mental State Examination is normal, but he is obviously clinically depressed.

The most appropriate medication for his depression would be: (check one)

A. trazodone (Oleptro)
B. mirtazapine (Remeron)
C. bupropion (Wellbutrin)
D. amitriptyline
E. nortriptyline (Pamelor)
B. mirtazapine (Remeron). Trazodone may be useful for insomnia, but is not recommended as a primary antidepressant because it causes sedation and orthostatic hypotension at therapeutic doses. Bupropion would aggravate this patient's insomnia. Tricyclic antidepressants may be effective, but are no longer considered first-line treatments because of side effects and because they can be cardiotoxic. Mirtazapine has serotonergic and noradrenergic properties and is associated with increased appetite and weight gain. It may be particularly useful for patients with insomnia and weight loss.
A 55-year-old female who has hypertension, hyperlipidemia, and osteoarthritis of the knees develops acute gout and is found to have hyperuricemia. Discontinuation of which one of the following medications may improve her hyperuricemia? (check one)

A. Hydrochlorothiazide
B. Losartan (Cozaar)
C. Metoprolol (Lopressor)
D. Simvastatin (Zocor)
E. Acetaminophen
A. Hydrochlorothiazide. Diuretics such as hydrochlorothiazide are known to increase serum uric acid levels, but losartan has been shown to decrease uric acid. Metoprolol, simvastatin, and acetaminophen have no specific effect on serum uric acid levels.
A patient with chronic kidney disease presents with chronic normocytic anemia with a hemoglobin level of 7.8 g/dL. The best outcome is predicted if you raise the hemoglobin level to: (check one)

A. 8-10 g/dL
B. 10-12 g/dL
C. 12-14 g/dL
D. >14 g/dL
B. 10-12 g/dL. The Cardiovascular risk Reduction by Early Anemia Treatment with Epoetin Beta (CREATE) trial, the Correction of Hemoglobin and Outcomes in Renal insufficiency (CHOIR) trial, and the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) have shown that patients who had hemoglobin levels targeted to normal ranges did worse than patients who had hemoglobin levels of 10-12 g/dL. The incidence of stroke, heart failure, and death increased in patients targeted to normal hemoglobin levels, and there was no demonstrable decrease in cardiovascular events (SOR A).
A 25-year-old female sees you in the office for follow-up after a visit to the emergency department for respiratory distress. She complains of several episodes of an acute onset of shortness of breath, wheezing, coughing, and a choking sensation, without any obvious precipitant. She has been on inhaled corticosteroids for 2 months without any improvement in her symptoms. Albuterol (Proventil, Ventolin) does not consistently relieve her symptoms. She is asymptomatic today. Spirometry shows a normal FEV1 , a normal FVC and FEV1 /FVC ratio, and a flattened inspiratory loop.

The most likely diagnosis is: (check one)

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

Pulmonary function tests (PFTs) are normal, with the exception of flattening of the inspiratory loop, which is diagnostic of extra-thoracic airway compression. Fiberoptic laryngoscopy shows paradoxical inspiratory and/or expiratory partial closure of the vocal cords. Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).

PFTs in patients with asthma are normal between exacerbations, but when symptoms are present the FEV1 /FVC ratio is reduced, as with COPD. With anaphylaxis, there will typically be itching or urticaria and signs of angioedema, such as lip or tongue swelling, in response to a trigger such as food or medication; PFTs are normal when anaphylaxis symptoms are absent. Globus hystericus is a type of conversion disorder in which emotional stress causes a subjective sensation of pain or tightness in the throat, and/or dysphagia; diagnostic tests such as spirometry and laryngoscopy are normal.
In a patient with a sudden onset of dyspnea, which one of the following makes a pulmonary embolus more likely? (check one)

A. Fever >38.0°C (100.4°F)
B. Chest pain
C. Orthopnea
D. Wheezes
E. Rhonchi
B. Chest pain. Chest pain is common in patients with pulmonary embolism (PE). When evaluating a patient for possible PE, the presence of orthopnea suggests heart failure, fever suggests an infectious process, wheezing suggests asthma or COPD, and rhonchi suggest heart failure, interstitial lung disease, or infection. These generalizations are supported by a 2008 study designed to improve the diagnosis of PE based on the history, physical examination, EKG, and chest radiograph.
A 2-year-old child stumbles, but his mother keeps him from falling by pulling up on his right hand. An hour later the child refuses to use his right arm and cries when his mother tries to move it. The most likely diagnosis is (check one)

A. dislocation of the ulna
B. dislocation of the olecranon epiphysis
C. subluxation of the head of the radius
D. subluxation of the head of the ulna
E. anterior dislocation of the humeral head
C. subluxation of the head of the radius. "Nursemaid's elbow" is one of the most common injuries in children under 5 years of age. It occurs when the child's hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.
You treat a 65-year-old white female for a clean minor laceration. Her chart reveals that she has received two previous doses of tetanus toxoid. The last dose was 12 years ago.

Which one of the following is the preferred treatment? (check one)

A. Reassurance that her tetanus immune status is adequate
B. Tetanus immune globulin (TIG) and tetanus toxoid (TT)
C. Tetanus toxoid only
D. Tdap
D. Tdap. Tetanus vaccine is indicated for adults with clean minor wounds who have received fewer than three previous doses of tetanus toxoid, or whose immune status is unknown. Tetanus immune globulin is not recommended if the wound is clean.

The CDC recommends that adults aged 65 years and older who have not received Tdap and are likely to have close contact with an infant less than 12 months of age (e.g., grandparents, child-care providers, and health-care practitioners) should receive a single dose to protect against pertussis and reduce the likelihood of transmission. For other adults aged 65 years and older, a single dose of Tdap vaccine should be given instead of a scheduled dose of Td vaccine if they have not previously received Tdap. Tdap can be administered regardless of the interval since the last vaccine containing tetanus or diphtheria toxoid, and either Tdap vaccine product may be used. After receiving Tdap, persons should continue to receive Td for routine booster immunizations against tetanus and diphtheria, according to previously published guidelines.
A 45-year-old male has diabetes mellitus and hypertension. He has no other medical problems.

Which one of the following classes of medications is the preferred first-line therapy for the treatment of hypertension in this patient? (check one)

A. Potassium-sparing diuretics
B. ACE inhibitors
C. α-Receptor blockers
D. Calcium channel blockers
E. β-Blockers
B. ACE inhibitors. The target blood pressure in patients with diabetes mellitus is <130/80 mm Hg (SOR A). ACE inhibitors and angiotensin receptor blockers (ARBs) are the preferred first-line agents for the management of patients with hypertension and diabetes mellitus (SOR A). If the target blood pressure is not achieved with an ACE inhibitor or ARB, the addition of a thiazide diuretic is the preferred second-line therapy for most patients; potassium-sparing and loop diuretics are not recommended (SOR B).

β-Blockers are recommended for patients with diabetes mellitus who also have a history of myocardial infarction, heart failure, coronary artery disease, or stable angina (SOR A). Calcium channel blockers should be reserved for patients with diabetes mellitus who cannot tolerate preferred antihypertensive agents, or for those who need additional agents to achieve their target blood pressure (SOR A).
A 73-year-old white female with a long history of rheumatoid arthritis has a normocytic normochromic anemia. Her hemoglobin level is 9.8 g/dL (N 12.0-16.0) with decreased serum iron, decreased total iron-binding capacity, and increased serum ferritin.

Which one of the following is the most appropriate treatment for this patient? (check one)

A. Oral iron
B. Intramuscular iron dextran (DexFerrum, InFeD)
C. Treatment of the rheumatoid arthritis
D. Transfusion
E. Folic acid
C. Treatment of the rheumatoid arthritis. This patient has anemia of chronic disease secondary to her rheumatoid arthritis. This anemia is usually mild, with hemoglobin levels of 9.0-11.0 g/dL, and is usually normocytic-normochromic, although it can be microcytic. Characteristically, serum iron and total iron-binding capacity are decreased and ferritin is increased. The best treatment of this anemia is to treat the underlying systemic disease. Neither iron nor folic acid is effective. Since the anemia is usually mild, transfusion is not necessary.
Which one of the following would suggest that the sudden and unexpected death of a healthy infant resulted from deliberate suffocation rather than sudden infant death syndrome? (check one)

A. No previous history of apneic episodes
B. An age of 9 months
C. Mottled skin
D. Clenched fists
E. Blood-tinged froth in the mouth
B. An age of 9 months. Sudden infant death syndrome (SIDS) is the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2-4 months of age and a quick dropoff by the age of 6 months. The cause of death is a retrospective diagnosis of exclusion, and is supported by a history of quiet death during sleep in a previously healthy infant younger than 6 months of age. Evidence of terminal activity may be present, such as clenched fists or a serosanguineous, blood-tinged, or mucoid discharge from the mouth or nose. Lividity and mottling are frequently present in dependent areas.

The reported history and autopsy findings of deliberate suffocation may mirror the findings of SIDS, but suffocation should be considered when there is documentation of any of the following: infant age older than 6 months, previous similar sibling deaths, simultaneous twin deaths, or evidence of pulmonary hemorrhage. A history of recurrent apnea or cyanosis has not been causally linked to SIDS; when such reported events have only been witnessed by one caretaker, deliberate suffocation should be suspected.
Random Board Review Questions 12
The most appropriate advice for a 50-year-old female who has passed six calcium oxalate stones over the past 4 years is to: (check one)

A. restrict her calcium intake
B. restrict her intake of yellow vegetables
C. increase her sodium intake
D. increase her dietary protein intake
E. take potassium citrate with meals
E. take potassium citrate with meals. Calcium oxalate stones are the most common of all renal calculi. A low-sodium, restricted-protein diet with increased fluid intake reduces stone formation. A low-calcium diet has been shown to be ineffective. Oxalate restriction also reduces stone formation. Oxalate-containing foods include spinach, chocolate, tea, and nuts, but not yellow vegetables. Potassium citrate should be taken at mealtime to increase urinary pH and urinary citrate (SOR B).
A 22-year-old female presents with lower right leg pain. She reports that it hurts when she presses her shin. She has been training for a marathon over the past 4 months and has increased her running frequency and distance. She now runs almost every day and is averaging approximately 40 miles per week. She has little pain while at rest, but the pain intensifies with weight bearing and ambulation. She initially thought the pain was from shin splints, but it has intensified this week and she has had to shorten her usual running distances due to worsening pain.

On examination you note tenderness to palpation over the anterior aspect of her mid-tibia. She also has trace edema localized to the area of tenderness.

Which one of the following imaging studies should be performed first? (check one)

A. Plain radiographs
D. Ultrasonography
E. Bone scintigraphy
A. Plain radiographs. The findings in this patient are consistent with a stress fracture. Plain radiographs should be the initial imaging modality because of availability and low cost (SOR C). These are usually negative initially, but are more likely to be positive over time. If the initial films are negative and the diagnosis is not urgently needed, a second plain radiograph can be performed in 2-3 weeks.

Although CT is useful for evaluation of bone pathology, it is not commonly used as even second-line imaging for stress fractures, due to lower sensitivity and higher radiation exposure than other modalities. Triple-phase bone scintigraphy has a high sensitivity and was previously used as a second-line modality; however, MRI has equal or better sensitivity than scintigraphy and higher specificity. MRI is now recommended as the second-line imaging modality when plain radiographs are negative and clinical suspicion of stress fracture persists (SOR C). Musculoskeletal ultrasonography has the advantage of low cost with no radiation exposure, but additional studies are needed before it can be recommended as a standard imaging modality.
A 23-year-old white male is brought to the emergency department with slurred speech, confusion, and ataxia. He works as an auto mechanic and has been known to consume alcohol heavily in the past, but denies recent alcohol intake. He appears intoxicated, but no odor of alcohol is noted on his breath. Abnormalities on the metabolic profile include a carbon dioxide content of 10 mmol/L (N 20-30). His blood alcohol level is <10 mg/dL (0.01%). A urinalysis shows calcium oxalate crystals and an RBC count of 10-20/hpf. Woods lamp examination of the urine shows fluorescence. His arterial pH is 7.25.

Which one of the following would be most appropriate at this point? (check one)

A. Immediate hemodialysis
B. Gastric lavage
C. Administration of activated charcoal
D. Fomepizole (Antizol)
D. Fomepizole (Antizol). Ethylene glycol poisoning should be suspected in patients with metabolic acidosis of unknown cause and subsequent renal failure, as rapid diagnosis and treatment will limit the toxicity and decrease both morbidity and mortality. This diagnosis should be considered in a patient who appears intoxicated but does not have an odor of alcohol, and has anion gap acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol levels. Ethylene glycol is found in products such as engine coolant, de-icing solution, and carpet and fabric cleaners. Ingestion of 100 mL of ethylene glycol by an adult can result in toxicity.

The American Academy of Clinical Toxicology criteria for treatment of ethylene glycol poisoning with an antidote include a plasma ethylene glycol concentration >20 mg/dL, a history of ingesting toxic amounts of ethylene glycol in the past few hours with an osmolal gap >10 mOsm/kg H O2 (N 5-10), and strong clinical suspicion of ethylene glycol poisoning, plus at least two of the following: arterial pH <7.3, serum bicarbonate <20 mmol/L, or urinary oxalate crystals.

Until recently, ethylene glycol poisoning was treated with sodium bicarbonate, ethanol, and hemodialysis. Treatment with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary. Ethylene glycol is rapidly absorbed, and use of ipecac or gastric lavage is therefore not effective. Large amounts of activated charcoal will only bind to relatively small amounts of ethylene glycol, and the therapeutic window for accomplishing this is less than 1 hour.
A 67-year-old white male with hypertension and chronic kidney disease presents with the recent onset of excessive thirst, frequent urination, and blurred vision. Laboratory testing reveals a fasting blood glucose level of 270 mg/dL, a hemoglobin A 1c of 8.5%, a BUN level of 32 mg/dL, and a serum creatinine level of 2.3 mg/dL. His calculated glomerular filtration rate is 28 mL/min.

Which one of the following medications should you start at this time? (check one)

A. Glipizide (Glucotrol)
B. Metformin (Glucophage)
C. Glyburide (DiaBeta)
D. Acarbose (Precose)
A. Glipizide (Glucotrol). It is recommended that metformin be avoided in patients with a creatinine level >1.5 mg/dL for men or >1.4 mg/dL for women. Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia. Acarbose should be avoided in patients with chronic kidney disease, as it has not been evaluated in these patients. Glipizide does not have an active metabolite, and is safe in patients with chronic renal disease.
A 60-year-old male has a drug-eluting stent placed in his right coronary artery. He will require treatment to prevent stent thrombosis, and once his initial treatment period is completed he will be placed on aspirin, 75-165 mg/day indefinitely.

Which one of the following is the preferred initial regimen for preventing stent thrombosis in this situation? (check one)

A. Aspirin/dipyridamole (Aggrenox) for 3 months
B. Aspirin, 162-325 mg/day for 3 months
C. Aspirin, 162-325 mg/day, plus clopidogrel (Plavix), both for 3 months
D. Aspirin, 162-325 mg/day, plus clopidogrel, both for 12 months
E. Warfarin (Coumadin) for 3 months
D. Aspirin, 162-325 mg/day, plus clopidogrel, both for 12 months. In patients with a drug-eluting stent, combined therapy with clopidrogel and aspirin is recommended for 12 months because of the increased risk of late stent thrombosis. After this time, aspirin at a dosage of 75-165 mg/day is recommended. The minimum duration of combined therapy is 1 month for a bare metal stent, 3 months for a sirolimus-eluting stent, and 6 months for other drug-eluting stents.
A 57-year-old male executive sees you because of "shaky hands." His tremor is most noticeable when he is holding something or writing, and is more prominent in his hand than in his shoulder. He has noticed that it seems better "after a beer or two" at social gatherings. He has no other health problems. On examination you note a very definite tremor when he unbuttons his shirt. His gait is normal and there is no resting tremor. He has a previous history of intolerance to A 57-year-old male executive sees you because of "shaky hands." His tremor is most noticeable when he is holding something or writing, and is more prominent in his hand than in his shoulder. He has noticed that it seems better "after a beer or two" at social gatherings. He has no other health problems. On examination you note a very definite tremor when he unbuttons his shirt. His gait is normal and there is no resting tremor. He has a previous history of intolerance to β-blockers.

Of the following, which medication would be the best choice for this patient? (check one)

A. Levodopa/carbidopa (Sinemet)
B. Amantadine (Symmetrel)
C. Primidone (Mysoline)
D. Lithium carbonate
C. Primidone (Mysoline). Parkinson's disease and essential tremor are the primary concerns in a person of this age who presents with a new tremor. A coarse, resting, pill-rolling tremor is characteristic of Parkinson's disease. Essential tremor is primarily an action tremor and is a common movement disorder, occurring in members of the same family with a high degree of frequency. Alcohol intake will temporarily cause marked reduction in the tremor. β-Adrenergic blockers have been the mainstay of treatment for these tremors, but this patient is intolerant to these drugs. Primidone has been effective in the treatment of essential tremor, and in head-to-head studies with propranolol has been shown to be superior after 1 year. Levodopa in combination with carbidopa is useful in the treatment of parkinsonian tremor but not essential tremor.
Which one of the following is true regarding medical errors? (check one)

A. Malpractice litigation is more common when physicians disclose errors to patients
B. The use of the word "error" should be avoided when disclosing mistakes to patients
C. Physicians in private practice are more likely to disclose errors to patients than physicians employed by institutions or health care organizations
D. Patients prefer to receive apologies and explanations when an error has been made
E. It is ethically defensible to only disclose an error if the patient is aware there is a problem
D. Patients prefer to receive apologies and explanations when an error has been made. When a medical error has been made, patients prefer that their physician disclose the error and offer an explanation of events. Withholding that information from a patient is not ethical and is counter to standards set forth by various organizations such as the Joint Commission on Accreditation of Health Care Organizations. Using the word "error" is acceptable and does not lead to an increase in litigation. In fact, there is no evidence that malpractice litigation rates increase when an error is admitted, and rates often decrease. Private-practice physicians are less likely to admit errors to patients. It is surmised that these physicians have less access to training in disclosure than those employed by hospitals or health care organizations.
A 60-year-old female presents with a 1-year history of episodes of urinary incontinence. She tells you that she will suddenly feel the need to urinate and can barely make it to the bathroom. She occasionally loses urine before reaching the toilet. Her only medication is hydrochlorothiazide, which she has been taking for many years for hypertension. On examination, her vaginal mucosa is pale and somewhat dry. Minimal prolapse of her vaginal and urethral areas is noted.

Which one of the following would be most appropriate at this point? (check one)

A. Urodynamic testing
B. Referral for surgical evaluation
C. Oral estrogen
D. Oral anticholinergic therapy
E. Stopping the hydrochlorothiazide
D. Oral anticholinergic therapy. First-line therapies for urge urinary incontinence include behavioral therapy, such as pelvic muscle contractions, and anticholinergic therapy. Oral estrogen is not indicated. Noninvasive treatments should be tried initially. Urodynamic testing is indicated preoperatively. Stopping the hydrochlorothiazide would not be helpful, as it would not address the issue of detrusor instability.
A 42-year-old female brings you the results of a comprehensive metabolic profile obtained through a health screening program offered by her employer. She fasted for 8 hours prior to the test, and her blood glucose level was reported as 110 mg/dL. Her lipid values and her blood pressure were normal, but her BMI is 30.5 kg/m 2 .

She currently views herself as relatively healthy and reports no symptoms consistent with diabetes mellitus during your review of systems. Additional testing reveals a hemoglobin A1c of 6.3%.

Based on this data, which one of the following is most appropriate at this time? (check one)

A. Order a C-peptide level
B. Order an islet cell antibody level
C. Recommend lifestyle modifications only
D. Start low-dose glyburide (DiaBeta) daily
E. Start low-dose insulin glargine (Lantus) daily
C. Recommend lifestyle modifications only. The ADA recommends testing to detect type 2 diabetes mellitus in asymptomatic adults with a BMI ≥25 kg/m 2 and one or more additional risk factors. Risk factors include physical inactivity, hypertension, an HDL-cholesterol level <35 mg/dL, a triglyceride level >250 mg/dL, a history of cardiovascular disease, a hemoglobin A 1c≥5.7%, a history of gestational diabetes or delivery of an infant weighing >4 kg (9 lb), and a history of polycystic ovary syndrome.

Diabetes mellitus can be diagnosed if the patient's fasting blood glucose level is ≥126 mg/dL on two separate occasions. It can also be diagnosed if a random blood glucose level is ≥200 mg/dL if classic symptoms of diabetes are present. A fasting blood glucose level of 100-125 mg/dL, a glucose level of 140-199 mg/dL 2 hours following a 75-g glucose load, or a hemoglobin A 1c of 5.7%-6.9% signifies impaired glucose tolerance. Patients meeting these criteria have a significantly higher risk of progression to diabetes and should be counseled about lifestyle modifications such as weight loss and exercise.
Which one of the following is consistent with spinal stenosis but not with a herniated vertebral disk? (check one)

A. Numbness
B. Muscle weakness
C. Pain relieved by sitting
D. Pain relieved by standing
C. Pain relieved by sitting. Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be present in both. Pain from spinal stenosis is relieved by sitting and aggravated by standing, whereas the opposite is true for pain from a herniated disk.
Random Board Review Questions 13
Which one of the following is a recommended treatment for presumptive methicillin-resistant Staphylococcus aureus (MRSA) infection? (check one)

A. Azithromycin (Zithromax)
B. Dicloxacillin
C. Levofloxacin (Levaquin)
D. Doxycycline
E. Cephalexin (Keflex)
D. Doxycycline. Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is resistant to β-lactam and macrolide antibiotics, and is showing increasing resistance to fluoroquinolones. FDA-approved treatments include clindamycin and doxycycline. Other commonly used treatments include minocycline and trimethoprim/sulfamethoxazole.
A mother brings in her 2-week-old infant for a well child check. She reports that she is primarily breastfeeding him, with occasional formula supplementation.

Which one of the following should you advise her regarding vitamin D intake for her baby? (check one)

A. Breastfed infants do not need supplemental vitamin D
B. As long as the baby is taking at least 16 oz of formula per day, he does not need supplemental vitamin D
C. The baby should be given 400 IU of supplemental vitamin D daily
D. Intake of vitamin D in excess of 200 IU/day is potentially toxic
E. Vitamin D supplementation should not be started until he is at least 6 months old
C. The baby should be given 400 IU of supplemental vitamin D daily. In 2008, the American Academy of Pediatrics increased its recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU/day (SOR C). Breastfeeding does not provide adequate levels of vitamin D. Exclusive formula feeding probably provides adequate levels of vitamin D, but infants who consume less than 1 liter of formula per day need supplementation with 400 IU of vitamin D daily. Vitamin D supplementation should be started within the first 2 months of birth.
A 60-year-old male is recovering from a non-Q-wave myocardial infarction. He has a 40-pack-year smoking history, currently smokes a pack of cigarettes per day, and has a strong family history of coronary artery disease. Studies ordered by the cardiologist showed no indication for any coronary artery procedures. His BMI is 27.5 kg/m 2 and his blood pressure is 130/70 mm Hg. Laboratory tests reveal a fasting blood glucose level of 85 mg/dL, a total cholesterol level of 195 mg/dL, and an LDL-cholesterol level of 95 mg/dL.

Which one of the following secondary prevention measures would be LEAST likely to improve this patient's cardiovascular outcome? (check one)

A. A weight reduction diet
B. A β-blocker
C. A statin
D. An antiplatelet agent
E. Smoking cessation
A. A weight reduction diet. Although dietary management may be appropriate, a weight reduction diet is not likely to improve this patient's cardiovascular outcome. In fact, even if this person were obese, there is insufficient evidence that weight reduction would decrease his cardiovascular mortality (SOR C). There is good evidence that the other options, even β-blockers in a patient with normal blood pressure, are indicated. All of these measures have evidence to support their usefulness for secondary prevention of coronary artery disease (SOR A).
You have just diagnosed post-traumatic stress disorder in a 32-year-old male. You immediately begin a program of patient education for him and his family, and connect them with a support group. Since his symptoms are quite severe you decide to begin pharmacotherapy before initiating trauma-focused psychotherapy.

Based on available evidence, which one of the following medications is the best INITIAL treatment choice? (check one)

A. Sertraline (Zoloft)
B. Amitriptyline
C. Phenelzine (Nardil)
D. Alprazolam (Xanax)
E. Haloperidol (Haldol)
A. Sertraline (Zoloft). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline have the broadest range of efficacy in treating posttraumatic stress disorder (PTSD) since they are able to reduce all three clusters of PTSD symptoms. Studies on the effectiveness of tricyclic antidepressants such as amitriptyline demonstrate modest lessening of the symptoms of reexperiencing, with minimal or no effect on avoidance or arousal symptoms. Patients treated with monoamine oxidase inhibitors such as phenelzine have shown moderate to good improvement in reexperiencing and avoidance symptoms, but little improvement in hyperarousal. Benzodiazepines such as alprazolam have been used to treat PTSD, but their efficacy against the major symptoms has not been proven in controlled studies.
You volunteer some of your time to provide services to athletes at a small liberal arts college that has several NCAA Division II teams. When screening these athletes for health problems, you would advise that students with uncontrolled stage 2 hypertension should not participate in: (check one)

A. rowing
B. soccer
C. tennis
D. fencing
E. baseball
A. rowing. Students with uncontrolled stage 2 hypertension should not participate in sports associated with static exercise, in which the blood pressure load is more significantly increased (SOR C). Rowing involves both a high static and a high dynamic load. Soccer, tennis, fencing, and baseball have relatively few static exercise components and blood pressure spikes are less likely.
A 36-year-old male presents to the emergency department with disorientation, tachycardia, diaphoresis, and hypertension. According to his family, he has been consuming up to a fifth of vodka daily but abruptly discontinued alcohol consumption 2 days ago. There is no history of additional substance abuse and a urine drug screen is negative.

Which one of the following is most indicated in the management of this patient? (check one)

A. An anticonvulsant
B. A typical antipsychotic
C. A benzodiazepine
D. A centrally-acting α2-agonist
E. Baclofen
C. A benzodiazepine. Psychomotor agitation is experienced by most patients during alcohol withdrawal. Benzodiazepines are clearly the drug class of choice. Providing medication on an as-needed basis rather than on a fixed schedule is generally preferred. Antipsychotics and butyrophenones (including haloperidol) lower the seizure threshold and should not be used. For short-term management of status epilepticus, anticonvulsants may be used in conjunction with benzodiazepines. The vast majority of seizures from withdrawal are self-limited and do not require anticonvulsant treatment. Clonidine and other α2-agonists do reduce minor symptoms of withdrawal, but have not been shown to prevent seizures. The effectiveness of baclofen in acute alcohol withdrawal is unknown.
A 54-year-old female has pain and swelling of the right knee. Examination of the synovial fluid reveals a leukocyte count of 5000/mm3 , and crystals that appear as short, blunt rods, rhomboids, and cuboids when viewed under polarized light.

The most likely diagnosis is: (check one)

A. gonococcal arthritis
B. tuberculous arthritis
C. rheumatoid arthritis
D. pseudogout
E. gout
D. pseudogout. Microscopic examination of synovial fluid in a patient suffering an acute attack of pseudogout shows large numbers of polymorphonuclear leukocytes. Calcium pyrophosphate dihydrate crystals are frequently found extracellularly and in polymorphonuclear leukocytes. When viewed with polarized light, the crystals appear as short, blunt rods, rhomboids, and cuboids. The diagnosis is made by finding typical crystals under compensated polarized light and is supported by radiographic evidence of chondrocalcinosis.
A 66-year-old male with type 2 diabetes mellitus is seen for a follow-up visit and has a hemoglobin A1c of 6.7%. He is currently taking metformin (Glucophage), 1000 mg twice daily. He has no history of coronary artery disease or heart failure.

Which one of the following would be most appropriate? (check one)

A. Continuing his current regimen
B. Increasing the metformin dosage
C. Adding a sulfonylurea
D. Adding a thiazolidinedione
E. Adding daily long-acting insulin
A. Continuing his current regimen. According to the American Diabetes Association, the goal for patients with type 2 diabetes mellitus is to achieve a hemoglobin A1c of <7.0% (SOR C). This patient has achieved this goal, and there is no indication for changes in his management.
Which one of the following would most likely be found in a patient with giardiasis? (check one)

A. Fecal leukocytosis
B. Mucus in the stool
C. Eosinophilia
D. Hematochezia
E. Foul-smelling flatus
E. Foul-smelling flatus. The diagnosis of giardiasis is suggested by its most characteristic symptoms: foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and the virtual absence of mucus or blood in the stool. Stools are usually mushy between exacerbations, though constipation may occur. If eosinophilia occurs, it is more likely to be related to some other concomitant cause rather than to giardiasis.
A 12-year-old male is brought to your office with an animal bite. After talking with the patient, you learn that he was bitten on his left hand as he attempted to pet a stray cat a little over 24 hours ago. He says that the bite was very painful, and that it bled for a few minutes. His parents cared for the bite by rinsing it and covering it with a bandage. His chart indicates that he received a tetanus shot last year.

On examination, the patient is afebrile with stable vital signs. The site is warm and tender to light palpation, with surrounding erythema measuring approximately 3 cm in diameter.

Which one of the following is the most likely infectious agent in this situation? (check one)

A. Candida albicans
B. Capnocytophaga canimorsus
C. Methicillin-resistant Staphylococcus aureus (MRSA)
D. Pasteurella multocida
E. Streptococcus pneumoniae
D. Pasteurella multocida. Pasteurella species are isolated from up to 50% of dog bite wounds and up to 75% of cat bite wounds, and the hand is considered a high-risk area for infection (SOR A). Although much more rare, Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease. Anaerobes isolated from dog and cat bite wounds include Bacteroides, Fusobacterium, Porphyromonas, Prevotella, Propionibacterium and Peptostreptococcus.

In addition to animal oral flora, human skin flora are also important pathogens, but are less commonly isolated. These can include streptococci and staphylococci, including methicillin-resistant Staphylococcus aureus (MRSA). Coverage for MRSA may be especially important if the patient has risk factors for colonization with community-acquired MRSA. Pets can also become colonized with MRSA and transmit it via bites and scratches.

Cat bites that become infected with Pasteurella multocida can be complicated by cellulitis, which may form around the wound within 24 hours and is often accompanied by redness, tenderness, and warmth. The use of prophylactic antibiotics is associated with a statistically significant reduction in the rate of infection in hand bites (SOR A). If infection develops and is left untreated, the most common complications are tenosynovitis and abscess formation; however, local complications can include septic arthritis and osteomyelitis. Fever, regional adenopathy, and lymphangitis are also seen.
Random Board Review Questions 14
A 3-year-old toilet-trained female is brought to your office by her mother, who has noted a red rash on the child's perineum for the last 5 days. The rash is pruritic and has been spreading. The mother has treated the area for 3 days with nystatin cream with no obvious improvement. The child has not used any other recent medications and has no significant past medical history. Your examination reveals a homogeneous, beefy red rash surrounding the vulva and anus.

The most likely etiologic agent is: (check one)

A. Malassezia furfur
B. Escherichia coli
C. Haemophilus influenzae
D. Staphylococcus aureus
E. group A Streptococcus pyogenes
E. group A Streptococcus pyogenes. The epidemiology of group A streptococcal disease of the perineum is similar to that of group A streptococcal pharyngitis, and the two often coexist. It is theorized that either auto-inoculation from mouth to hand to perineum occurs, or that the bacteria is transmitted through the gastrointestinal tract. In one study, the average age of patients with this disease varied from 1 to 11 years, with a mean of 5 years. Girls and boys were almost equally affected. The incidence is estimated to be about 1 in 200 pediatric visits and peaks in March, April, and May in North America. The condition usually presents with itching and a beefy redness around the anus and/or vulva and will not clear with medications used to treat candidal infections.
A 35-year-old male consults you about vague chest pain he developed while sitting at his desk earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right pneumothorax.

Which one of the following should you do next? (check one)

A. Admit the patient to the hospital for observation
B. Admit the patient to the hospital for chest tube placement
C. Obtain a repeat chest radiograph in 24-48 hours
D. Obtain an expiratory chest radiograph
C. Obtain a repeat chest radiograph in 24-48 hours. The majority of patients presenting with spontaneous pneumothorax are tall, thin individuals under 40 years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at the time of onset and may resolve within 24 hours even if untreated. Patients with small pneumothoraces involving <15% of the hemithorax may have a normal physical examination, although tachycardia is occasionally noted. The diagnosis is confirmed by chest radiographs. When a pneumothorax is suspected but not seen on a standard chest film, an expiratory film may be obtained to confirm the diagnosis.

Studies have found that an average of 30% of patients will have a recurrence within 6 months to 2 years. An initial pneumothorax of <20% may be monitored if the patient has few symptoms. Follow-up should include a chest radiograph to assess stability at 24-48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps almost all of them, will have subcutaneous bullae on a CT scan.
Which one of the following provides the best evidence for a given therapeutic intervention? (check one)

A. An individual randomized, controlled trial
B. A prospective case-control study
C. A systematic review of cohort studies
D. A systematic review of randomized, controlled trials
D. A systematic review of randomized, controlled trials. A systematic review is a literature review focused on a research question that tries to identify, appraise, select, and synthesize all high-quality research evidence relevant to that question. A randomized, controlled trial (RCT) involves a group of patients who are randomized into an experimental group and a control group. These groups are followed for the outcomes of interest. The process of randomization minimizes bias and is thus the individual study type that is most likely to provide accurate results about an intervention's effectiveness.

A cohort study is a nonexperimental study design that follows a group of people (a cohort), and then looks at how events differ among people within the group. A study that examines a cohort of persons who differ in respect to exposure to some suspected risk factor such as smoking is useful for trying to ascertain whether exposure is likely to cause specified events such as lung cancer. This study design is less reliable due to inherent biases that may not be accounted for and may exist in the groupings of patients.

Retrospective and prospective case-control studies compare people with a disease or specific diagnosis with people who do not have the disease. The groups are studied to find out if other characteristics are also different between the two groups. This type of study often overestimates the benefit of a trial and is of lower quality than a randomized, controlled trial.
A 46-year-old white female complains of a 3-month history of hoarseness and nocturnal wheezing. On further questioning, she tells you that she has to clear her throat repeatedly and feels like she has something stuck in her throat.

These symptoms are most likely related to: (check one)

A. thyroid disease
B. gastroesophageal reflux disease
C. sinusitis
D. tracheal stenosis
B. gastroesophageal reflux disease. Acid laryngitis is a group of respiratory symptoms related to gastroesophageal reflux disease. The symptoms of hoarseness (especially in the morning), a repeated need to clear the throat, and nocturnal or early morning wheezing may occur singly or in varying combinations, and are believed to be caused by gastric contents irritating the larynx and hypopharynx. Thyroid disease, sinusitis, and tracheal stenosis can produce one or more of the symptoms described, but not all of them.
A health-care worker repeatedly develops a rash on her hands after using latex gloves. The rash is papular and pruritic, with vesicles. Latex allergy is confirmed by skin patch testing.

Which one of the following foods is most likely to provoke an allergic response in this patient? (check one)

A. Avocados
B. Walnuts
C. Shellfish
D. Strawberries
E. Wheat
A. Avocados. Latex allergy management includes preventing exposure and treating reactions. Patients with latex allergy can reduce their risk of exposure by avoiding direct contact with common latex products. Additionally, they should be aware of foods with crossreactive proteins. Foods that have the highest association with latex allergy include avocados, bananas, chestnuts, and kiwi. Walnuts, shellfish, strawberries, and wheat have low or undetermined associations.
Which cardiac arrhythmia has been reported with high-dose methadone use? (check one)

A. Atrial fibrillation
B. Paroxysmal supraventricular tachycardia
C. Third degree heart block
D. Torsades de pointes
E. Multifocal atrial tachycardia
D. Torsades de pointes. The cardiac toxicity of methadone is primarily related to QT prolongation and torsades de pointes.
A 17-year-old white female at 20 weeks gestation presents with a 2-day history of painful vesicular lesions on her labia. This is the first time she has ever had this problem. Her last sexual contact was 10 days ago. She has also had a low-grade fever, malaise, headache, and mild, diffuse abdominal pain. On examination she has vesicles and erythematous papules on the labia bilaterally. A few firm, tender inguinal nodes are also noted.

Which one of the following tests is most sensitive for confirming the diagnosis? (check one)

A. A Papanicolaou smear of the lesions
B. Amniocentesis
C. Serologic studies
D. Viral polymerase chain reaction (PCR) testing
E. A Tzanck test
D. Viral polymerase chain reaction (PCR) testing. Diagnosis and appropriate treatment of genital herpes during pregnancy is particularly important because of the high mortality in neonates who contract herpes during delivery and then develop disseminated infection. In those who survive, there is a very high risk of serious neurologic sequelae.

HSV is acquired by deposition of the virus on a break in the skin or mucous membranes during close physical contact with an infected person. Neonatal infection most commonly results from transmission via the birth canal, although transplacental transmission can occur. The risk of HSV infection in the neonate is higher during an episode of primary genital herpes than during a recurrent episode.

DNA polymerase chain reaction testing is 95% sensitive as long as an ulcer is present, and has a specificity of 90%. The diagnosis is established by culturing the virus from an infected lesion. A Tzanck prep and Papanicolaou smear can detect cellular changes, but both have low sensitivity. Serologic diagnosis is mainly an epidemiologic tool and has limited clinical usefulness. Cultures of the virus by amniocentesis have shown both false-positive and false-negative results.
Outbreaks of dermatitis and folliculitis associated with swimming pools and hot tubs are often caused by which one of the following? (check one)

A. Listeria
B. Pseudomonas
C. Streptococcus
D. Shigella
E. Staphylococcus
B. Pseudomonas. Pseudomonas organisms have been associated with outbreaks of otitis externa, dermatitis, and folliculitis in persons using swimming pools and hot tubs.
A 40-year-old female presents with a complaint of fatigue. She says she is also concerned because she has gained about 10 lb over the last several months. Physical examination reveals no enlargement or other abnormalities of the thyroid gland. Laboratory testing reveals a TSH level of 0.03 μU/mL (N 0.4-4.0) and a free T4 level of 1.0 μg/dL (N 1.5-5.5).

Which one of the following is the most likely cause of her problem? (check one)

A. Malnutrition
B. Graves' disease
C. Goiter
D. Hashimoto's thyroiditis
E. Pituitary failure
E. Pituitary failure. This patient's symptoms and laboratory findings suggest a significant lack of TSH despite low levels of circulating thyroid hormone. This is diagnostic of secondary hypothyroidism. Such findings should prompt a workup for a pituitary or hypothalamic deficiency that is causing a lack of TSH production. Primary hypothyroidism, such as Hashimoto's thyroiditis, would be evidenced by an elevated TSH and low (or normal) T4 . Graves' disease is a cause of hyperthyroidism, which would be expected to increase T4 levels, although low TSH with a normal T4 level may be present. Some nonthyroid conditions such as malnutrition may suppress T4 . In such cases the TSH would be elevated or normal. This patient has gained weight, which does not coincide with malnutrition. The patient does not have the thyroid gland enlargement seen with goiter.
A 45-year-old male sees you for a routine annual visit and is found to have atrial fibrillation, with a ventricular rate of 70-75 beats/min. He is otherwise healthy, and a laboratory workup and echocardiogram are normal.

Which one of the following would be the most appropriate management? (check one)

A. Aspirin, 325 mg daily
B. Warfarin (Coumadin), with a target INR of 2.0-3.0
C. Clopidogrel (Plavix), 75 mg daily
D. Amiodarone (Cordarone), 200 mg daily
E. Observation only
A. Aspirin, 325 mg daily. Atrial fibrillation is the most common arrhythmia, and its prevalence increases with age. The major risk with atrial fibrillation is stroke, and a patient's risk can be determined by the CHADS 2 score. CHADS stands for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and previous Stroke or transient ischemic attack. Each of these is worth 1 point except for stroke, which is worth 2 points. A patient with 4 or more points is at high risk, and 2-3 points indicates moderate risk. Having ≤1 point indicates low risk, and this patient has 0 points.

Low-risk patients should be treated with aspirin, 81-325 mg daily (SOR B). Moderate-or high-risk patients should be treated with warfarin. Amiodarone is used for rate control, and clopidogrel is used for vascular events not related to atrial fibrillation.
Random Board Review Questions 15
You are helping a hospice program manage the symptoms of a 77-year-old male with end-stage colon cancer. He has required increasingly higher doses of his opioid medication to control symptoms of pain and dyspnea.

In this situation, it should be kept in mind that which one of the following adverse effects of opioids does NOT diminish over time? (check one)

A. Constipation
B. Nausea
C. Mental status changes
D. Pruritus
E. Sedation
A. Constipation. Constipation is one adverse effect of opioid treatment that does not diminish with time. Thus, this effect should be anticipated, and recommendations for prevention and treatment of constipation should be discussed when initiating opioids. Nausea and vomiting, mental status changes, sedation, and pruritus are also common with the initiation of opioid treatment, but these symptoms usually diminish with time, and can be managed expectantly.
Of the following, which one causes the most deaths in the United States? (check one)

A. Colorectal cancer
B. Breast cancer
C. Prostate cancer
D. Lung cancer
D. Lung cancer. Lung cancer is the leading cause of cancer-related deaths in the United States. In 2006, lung cancer caused more deaths than colorectal, breast, and prostate cancers combined.
A 28-year-old female consults you because of fatigue, arthralgias that are worse in the morning, and painful, swollen finger joints. She is a high-school teacher. Her erythrocyte sedimentation rate is 60 mm/hr and a test for rheumatoid factor is strongly positive.

The best choice for initial therapy would be: (check one)

A. prednisone
B. aspirin
C. naproxen (Naprosyn)
D. rituximab (Rituxan)
E. methotrexate (Rheumatrex)
E. methotrexate (Rheumatrex). Aspirin was once the best initial therapy for rheumatoid arthritis and then NSAIDs became the preferred treatment. Now, however, disease-modifying drugs such as methotrexate are the best choice for initial therapy. Aspirin and NSAIDs are no longer considered first-line treatment because of concerns about their limited effectiveness, inability to modify the long-term course of the disease, and gastrointestinal and cardiotoxic effects. Glucocorticoids such as prednisone are often useful, but have significant side effects. Biologic agents such as rituximab are expensive and have significantly more side effects than methotrexate.
Which one of the following treatments is most appropriate for a patient with uncomplicated acute bronchitis? (check one)

A. Amoxicillin
B. Amoxicillin/clavulanate (Augmentin)
C. Azithromycin (Zithromax)
D. Doxycycline
E. Supportive care only
E. Supportive care only. Respiratory viruses appear to be the most common cause of acute bronchitis; however, the organism responsible is rarely identified in clinical practice because viral cultures and serologic assays are not routinely performed. Fewer than 10% of patients will have a bacterial infection diagnosed as the cause of bronchitis. For this reason, for patients with a putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered. Antitussive agents are occasionally useful and can be offered as therapy for short-term symptomatic relief of coughing.
A 60-year-old male presents with profound weakness after 3 days of watery, frequent diarrhea. He has had no fever, bloody stool, or vomiting. His appetite has been poor. He has a history of hypertension treated with chlorthalidone, 25 mg daily, and potassium chloride, 20 mEq twice daily. Laboratory testing reveals a serum creatinine level of 2.0 mg/dL (N 0.6-1.5), a potassium level of 6.5 mmol/L (N 3.4-4.8), and a BUN of 50 mg/dL (N 8-25). Baseline values were normal.

Which one of the following is most likely to lower the serum potassium within 1 hour? (check one)

A. Regular insulin plus dextrose intravenously
B. Calcium chloride, 10% solution intravenously
C. Sodium polystyrene sulfonate (Kalexate) orally
D. Sodium polystyrene sulfonate rectally
A. Regular insulin plus dextrose intravenously. Insulin and glucose intravenously will provide the fastest and most consistent early lowering of serum potassium (SOR C). Calcium is important for arrhythmia prevention, but does not lower the potassium level. Sodium polystyrene sulfonate given orally or rectally will only lower potassium in a delayed fashion.
A 40-year-old male with HIV infection presents to the emergency department with a 5-day history of progressive cough and dyspnea on exertion. A chest radiograph shows bilateral diffuse interstitial infiltrates. Arterial blood gas levels show an increased alveolar-arterial gradient and a pO2 of 60 mm Hg. His CBC is normal but his CD4 count is 150/mm3 .

In addition to trimethoprim/sulfamethoxazole (Bactrim, Septra), which one of the following medications should be prescribed? (check one)

A. Pentamidine (Pentam)
B. Dapsone
C. Atovaquone (Mepron)
D. Clindamycin (Cleocin) and primaquine
E. Corticosteroids
E. Corticosteroids. Trimethoprim/sulfamethoxazole is the treatment of choice for acute Pneumocystis pneumonia. Adjunctive corticosteroids should also be started in any patient whose initial pO2 on room air is <70 mm Hg. Three prospective trials have shown that there is a decrease in mortality and frequency of respiratory failure when corticosteroids are used in addition to antibiotics. All of the other medications listed are effective therapy for Pneumocystis pneumonia, but they do not need to be given with trimethoprim/sulfamethoxazole.
You have been asked to see a 75-year-old female who has just had hip surgery to correct a fractured femoral neck. She has a 2-year history of diabetes mellitus treated with pioglitazone (Actos), 30 mg daily, and metformin (Glucophage), 1000 mg twice daily. She is now fully alert and has been able to eat her evening meal. A physical examination is normal except for her being mildly overweight and having a bandage on her left hip. A CBC and chemistry profile done earlier today were normal except for a serum glucose level of 200 mg/dL. Her hemoglobin A1c at an office visit 2 weeks ago was 6.8%.

Which one of the following would be the best management of this patient's diabetes at this time? (check one)

A. Stop her usual medications and begin a sliding-scale insulin regimen
B. Stop the metformin only
C. Initiate an insulin drip to maintain glucose levels of 80-120 mg/dL
D. Decrease the dosage of pioglitazone
E. Continue with her usual medication regimen
E. Continue with her usual medication regimen. Current evidence indicates that traditional sliding-scale insulin as the only means of controlling glucose in hospitalized patients is inadequate. For patients in a surgical intensive-care unit, using an insulin drip to maintain tight glucose control decreases the risk of sepsis but has no mortality benefit. Metformin should be stopped if the serum creatinine level is ≥1.5 mg/dL in men or ≥1.4 mg/dL in women, or if an imaging procedure requiring contrast is needed. In patients who have not had their hemoglobin A 1c measured in the past 30 days, this could be done to provide a better indication of glucose control. If adequate control has been demonstrated and no contraindications are noted, the patient's usual medication regimen should be continued (SOR B).
A 28-year-old white male comes to your office complaining of pain in the right wrist since falling 2 weeks ago. On examination, he is tender in the anatomic snuffbox. A radiograph reveals a nondisplaced fracture of the distal one-third of the carpal navicular bone (scaphoid).

Which one of the following is the most appropriate management at this time? (check one)

A. A bone scan
B. Physical therapy referral
C. A Velcro wrist splint
D. A short arm cast
E. A thumb spica cast
E. A thumb spica cast. Fracture of the scaphoid should be suspected in every "sprained wrist" presenting with tenderness in the anatomic snuffbox. Radiographs may be negative initially. The scaphoid circulation enters the bone for the most part through the distal half. Fractures through the proximal third tend to cause loss of circulation and are slower to heal, and should be referred to an orthopedist because of the risk of nonunion and avascular necrosis. Fractures through the middle or distal one-third can be handled by the family physician in consultation with an orthopedist. The fracture is treated with a thumb spica cast for 10-12 weeks. A wrist splint does not provide adequate immobilization. A bone scan is unnecessary, and physical therapy is inappropriate. If there is still no evidence of union after 10 weeks of immobilization, the patient should be referred to an orthopedist for further care.
You are caring for an 88-year-old female nursing-home resident with multiple comorbidities and advanced Alzheimer's disease. The patient has never completed advance directives and no longer has the ability to make decisions. The family inquires about hospice services for this patient.

Which one of the following is true regarding this patient and hospice? (check one)

A. Nursing-home residents are not eligible for hospice
B. The decision to enter hospice care is reversible
C. End-stage Alzheimer's disease is not a qualifying diagnosis for hospice
D. Failure to complete advance directives by this patient prevents participation in hospice
E. The patient must have a life expectancy of less than 4 months to qualify for hospice services
B. The decision to enter hospice care is reversible. The decision to utilize the Medicare hospice benefit is reversible, and patients may elect to return to Medicare Part A. Individuals who reside in nursing homes and assisted-living facilities are eligible for the Medicare hospice benefit. Patients with end-stage Alzheimer's disease are eligible for the Medicare hospice benefit if they meet criteria for hospice. If the patient lacks decision-making capacity, a family member or guardian may elect the Medicare hospice benefit for the patient. The patient must be certified by the hospice medical director and primary physician to have a life expectancy of less than 6 months to qualify for hospice services. This requirement is the same whether or not the patient resides in a nursing home.
A 28-year-old male presents with the recent onset of intermittent urethral discharge accompanied by dysuria. He is heterosexual, has no prior history of a sexually transmitted infection, and acquired a new sexual partner a month ago. He has no regional lymphadenopathy or ulcers, and gentle milking of the urethra produces no discharge. Evaluation of a first-void urine specimen, however, reveals 15 WBCs/hpf. You treat him with oral azithromycin (Zithromax), 1 g in a single dose, and ceftriaxone (Rocephin), 125 mg intramuscularly. Test results for gonorrhea, Chlamydia, syphilis, HIV, and hepatitis B are negative.

He returns 2 months later because his urethral discharge has persisted. He reports no relationships with a different sexual partner, and is confident that his current partner has only had sexual contact with him. You repeat the previous tests and again treat him with oral azithromycin.

According to CDC testing and treatment guidelines, which one of the following drugs should be added to his treatment regimen? (check one)

A. Metronidazole (Flagyl)
B. Amoxicillin/clavulanate (Augmentin)
C. Ciprofloxacin (Cipro)
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E. Cefixime (Suprax)
A. Metronidazole (Flagyl). According to CDC guidelines, the initial workup for urethritis in men includes gonorrhea and Chlamydia testing of the penile discharge or urine, urinalysis with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment for men with a purulent urethral discharge or a positive urine test (positive leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes azithromycin, 1 g orally as a single dose, OR doxycycline, 100 mg orally twice a day for 7 days, PLUS ceftriaxone, 125 mg intramuscularly, OR cefixime, 400 mg orally as a single dose.

If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and consideration should be given to obtaining cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine. Treatment should include azithromycin, 500 mg orally once daily for 5 days, or doxycycline, 100 mg orally twice daily for 7 days, plus metronidazole, 2 g orally as a single dose.
Random Board Review Questions 16
Two doses of varicella vaccine are recommended for: (check one)

A. adults under 60 years of age who develop shingles
B. all children with normal immune status
C. only immunocompromised individuals
D. only children between 12 months and 13 years of age
B. all children with normal immune status. Two doses of varicella vaccine are recommended for all children unless they are immunocompromised, in which case they should not be immunized against varicella, or with other live-virus vaccines.

Shingles is evidence of prior varicella infection and is a reason not to vaccinate with varicella vaccine.
The FDA has imposed a black box warning on all thiazolidinediones, such as pioglitazone (Actos). This warning addresses a contraindication to the prescription of these drugs in patients with: (check one)

A. renal insufficiency
B. dementia
C. exposure to radiocontrast media
D. heart failure
E. respiratory failure
D. heart failure. The black box warning for thiazolidinediones specifically addresses heart failure. These agents are also contraindicated in patients with type 1 diabetes mellitus or hepatic disease, and in premenopausal anovulatory women.
A 5-month-old female is brought in with a 1-day history of an axillary temperature of 100.6°F and mild irritability. Findings are normal on examination except for a runny nose and a moderately distorted, immobile, red right eardrum. There is no history of recent illness or otitis in the past.

The most appropriate management would be: (check one)

A. azithromycin (Zithromax) for 5 days
B. amoxicillin for 10 days
C. amoxicillin for 5 days
D. oral decongestants
E. observation and a repeat examination in 2 weeks
B. amoxicillin for 10 days. The treatment for otitis media is evolving. Recommendations by the American Academy of Family Physicians and the American Academy of Pediatrics advocate a 10-day course of antibiotics for children under the age of 2 years if the diagnosis is certain. If the diagnosis is not certain and the illness is not severe, there is an option of observation with follow-up. For children over the age of 2 years, the recommendation is still to treat if the diagnosis is certain, but there is an option of observation and follow-up if the illness is not severe and follow-up can be guaranteed.

Amoxicillin is the first-line therapy; the recommended dosage is 80-90 mg/kg/day in two divided doses, which increases the concentration of amoxicillin in the middle ear fluid to help with resistant Pneumococcus.

Azithromycin, because of a broader spectrum and potential for causing resistance, is not considered the treatment of first choice. Treatment regimens ranging from 5 to 7 days are appropriate for selected children over the age of 5 years.

Oral decongestants and antihistamines are not recommended for children with acute otitis media.
A previously healthy gravida 1 para 1 who is 3 weeks post partum complains of bilateral nipple pain with breastfeeding. When she first started breastfeeding she had some soreness that went away after repositioning with feeding. The current pain began gradually 3 days ago. It has been worsening, inhibiting feeding, and is present between feedings. Examination of the breast is notable for erythema and cracking of the areola.

The most likely cause is: (check one)

A. engorgement
B. mastitis
C. improper latch-on
D. eczema flare
E. Candida infection
E. Candida infection. In breastfeeding women, bilateral nipple pain with and between feedings after initial soreness has resolved is usually due to Candida. Pain from engorgement typically resolves after feeding. Mastitis is usually unilateral and is associated with systemic symptoms and wedge-shaped erythema of the breast tissue. Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a reasonable part of the differential, would be much more unusual.
An 8-year-old male presents with cervical lymphadenitis. He has a kitten at home and you are concerned about cat-scratch disease. Which one of the following antibiotics is most appropriate for treatment of Bartonella henselae infection? (check one)

A. Azithromycin (Zithromax)
B. Ceftriaxone (Rocephin)
C. Amoxicillin/clavulanate (Augmentin)
D. Doxycycline
E. Clindamycin (Cleocin)
A. Azithromycin (Zithromax). Azithromycin has been shown to reduce the duration of lymphadenopathy in cat-scratch disease (SOR B). Other antibiotics that have been used include rifampin, ciprofloxacin, trimethoprim/sulfamethoxazole, and gentamicin. Ceftriaxone, amoxicillin/clavulanate, doxycycline, and clindamycin are not effective in the treatment of Bartonella infection.
The parents of a young child ask your advice about the need for fluoride supplementation in order to prevent tooth decay. Which one of the following is true regarding current U.S. Preventive Services Task Force guidelines for fluoride supplementation? (check one)

A. It is not recommended due to potential fluoride toxicity
B. Dental fluoride varnish is too toxic for routine use
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride
D. Fluoridated toothpaste provides adequate protection if used as soon as the child has teeth
E. The need for fluoride supplementation is determined by serum fluoride levels
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride. The current (2004) recommendation of the U.S. Preventive Services Task Force (USPSTF) is that children over the age of 6 months receive oral fluoride supplementation if the primary drinking water source is deficient in fluoride. The USPSTF cites "fair" evidence (B recommendation) that such supplementation reduces the incidence of dental caries and concludes that the overall benefit outweighs the potential harm from dental fluorosis.

Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently recommended fluoride intake, and has no other functional or physiologic consequences. Fluoridated toothpaste can cause fluorosis in children younger than 2 years of age, and is therefore not recommended in this age group. Fluoridated toothpaste by itself does not reliably prevent tooth decay.

Fluoride varnish, applied by a dental or medical professional, is another treatment option to prevent caries. It provides longer-lasting protection than fluoride rinses, but since it is less concentrated, it may carry a lower risk of fluorosis than other forms of supplementation.

Oral fluoride supplementation for children over the age of 6 months is based not only on age but on the concentration of fluoride in the primary source of drinking water, whether it be tap water or bottled water. Most municipal water supplies in the United States are adequately fluoridated, but concentrations vary. Fluoride concentrations in bottled water vary widely. If the concentration is >0.6 ppm no supplementation is needed, and may result in fluorosis if given. Lower concentrations of fluoride may indicate the need for partial or full-dose supplementation.
An enlarged tongue is associated with which one of the following? (check one)

A. Pellagra
B. Amyloidosis
C. Pernicious anemia
D. Xerostomia
E. Syphilis
B. Amyloidosis. An enlarged tongue (macroglossia) may be part of a syndrome found in developmental conditions such as Down syndrome, or may be caused by a tumor (hemangioma or lymphangioma), metabolic diseases such as primary amyloidosis, or endocrine disturbances such as acromegaly or cretinism. A "bald" tongue may be associated with xerostomia, pernicious anemia, iron deficiency anemia, pellagra, or syphilis.
A 3-year-old male is brought to your office by his parents because they are concerned about three "spells" he has had in the past month. In each case, the child started crying when he was prevented by a parent from doing something he wished to do. While crying, he suddenly stopped breathing and his face and lips began to turn blue. After 30-45 seconds he resumed crying, his color returned to normal, and he showed no evidence of impairment. A physical examination today is normal and the child is developmentally appropriate for his age. A recent hemoglobin level was in the normal range.

Which one of the following should you do now? (check one)

A. Teach the parents age-appropriate disciplinary procedures to implement when the child behaves in this manner
B. Reassure the parents that this is a benign condition and will resolve as the child gets older
C. Order an EEG
D. Obtain appropriate laboratory studies to confirm the most likely diagnosis
E. Initiate treatment with valproic acid (Depakene)
B. Reassure the parents that this is a benign condition and will resolve as the child gets older. This child is experiencing simple breath-holding spells, a relatively common and benign condition that usually begins in children between the ages of 6 months and 6 years. The cause is uncertain but seems to be related to overactivity of the autonomic nervous system in association with emotions such as fear, anger, and frustration. The episodes are self-limited and may be associated with pallor, cyanosis, and loss of conciousness if prolonged. There may be an association with iron deficiency anemia, but this child had a recent normal hemoglobin level.

These events are not volitional, so disciplinary methods are neither effective nor warranted. While children may experience a loss of consciousness and even exhibit some twitching behavior, the episodes are not seizures so neither EEG evaluation nor anticonvulsant therapy is indicated. No additional laboratory studies are indicated. Parents should be reassured that the episodes are benign and will resolve without treatment.
A 36-year-old male complains of clear rhinorrhea, nasal congestion, and watery, itchy eyes for several months. Tests in the past have suggested that he has an allergy to dust mites.

Which one of the following is most likely to provide the most relief from his symptoms? (check one)

A. Oral antihistamines
B. An oral leukotriene-receptor antagonist
C. Intranasal antihistamines
D. Intranasal corticosteroids
E. Furnace filters and mite-proof bedding covers
D. Intranasal corticosteroids. This patient has classic symptoms of allergic rhinitis. Intranasal corticosteroids are considered the mainstay of treatment for mild to moderate cases. In multiple studies, intranasal corticosteroid sprays have proven to be more efficacious than the other options listed, even for ocular symptoms. Air filtration systems and bedding covers have not been shown to reduce symptoms.
A 57-year-old female is noted to have a serum calcium level of 11.1 mg/dL (N 8.9-10.5) on a chemistry profile obtained at the time of a routine annual visit. The remainder of the chemistry profile is unremarkable, including normal BUN and creatinine levels. She is otherwise healthy, and is on no medications. On follow-up testing her calcium level is unchanged, a vitamin D level is normal, and her parathyroid hormone level is elevated.

Which one of the following is the most likely cause of her hypercalcemia? (check one)

A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Cancer metastatic to bone
E. Humoral hypercalcemia of malignancy
A. Primary hyperparathyroidism. This woman most likely has primary hyperparathyroidism due to a parathyroid adenoma or hyperplasia. Secondary hyperparathyroidism is unlikely with normal renal function, a normal vitamin D level, and hypercalcemia. Likewise, tertiary hyperparathyroidism is unlikely with normal renal function. The parathyroid hormone level is suppressed with hypercalcemia associated with bone metastases. Parathyroid hormone-related protein, produced by cancer cells in humoral hypercalcemia of malignancy, is not detected by the assay for parathyroid hormone.
Random Board Review Questions 17
A 53-year-old female presents to the emergency department following a fall. She is found to have an ankle fracture and a blood pressure of 160/100 mm Hg. She tells the emergency department physician that she is not aware of any previous medical problems. A focused cardiovascular examination is otherwise normal. You are the patient's regular physician, and the emergency physician calls your office for further information about the blood pressure elevation. You confirm that this is a new problem.

Which one of the following would you ask the emergency physician to do? (check one)

A. Administer a dose of intravenous labetalol (Trandate) and ask the patient to follow up in your office within the week
B. Administer nifedipine (Adalat, Procardia), 10 mg; discharge the patient once the blood pressure falls to 140/90 mm Hg; and ask the patient to follow up with you tomorrow
C. Prescribe an appropriate antihypertensive agent and have the patient follow up with you in a month
D. Order an EKG and chest radiograph, and ask the patient to see you in a week if the results are normal
E. Perform no further evaluation of the hypertension, but ask the patient to follow up with you within a month
E. Perform no further evaluation of the hypertension, but ask the patient to follow up with you within a month. Uncomplicated hypertension is frequently detected in the emergency department. Many times this is a chronic condition, but it also may result from an acutely painful situation. Hypertensive emergencies, defined as severe blood pressure elevations to >180/120 mm Hg complicated by evidence of impending or worsening target organ dysfunction, warrant emergent treatment. There is no evidence, however, to suggest that treatment of an isolated blood pressure elevation in the emergency department is linked to a reduction in overall risk. In fact, the aggressive reduction of blood pressure with either intravenous or oral agents is not without potential risk.

The appropriate management for the patient in this scenario is simply to discharge her and ask her to follow up with you in the near future.
A 23-month-old child is brought to your office with a 2-day history of a fever to 102°F (39°C), cough, wheezing, and mildly labored breathing. He has no prior history of similar episodes and there is no improvement with administration of an aerosolized bronchodilator.

Which one of the following is now indicated? (check one)

A. Bronchodilator aerosol treatment every 6 hours
B. Corticosteroids
C. An antibiotic
D. A decongestant
E. Supportive care only
E. Supportive care only. This child has typical findings of bronchiolitis. The initial infection usually occurs by the age of 2 years. It is caused by respiratory syncytial virus (RSV). Bronchodilator treatment may be tried once and discontinued if there is no improvement. Treatment usually consists of supportive care only, including oxygen and intravenous fluids if indicated (SOR B). Corticosteroids, antibiotics, and decongestants are of no benefit. RSV infection may recur, since an infection does not provide immunity. Up to 10% of infected children will have wheezing past age 5, and bronchiolitis may predispose them to asthma.
Contraindications to use of the levonorgestrel intrauterine system (Mirena) include which one of the following? (check one)

A. Nulliparity
B. A previous history of deep vein thrombosis
C. A previous history of endometriosis
D. Current pelvic inflammatory disease
E. Current breastfeeding
D. Current pelvic inflammatory disease. Contraindications to insertion of the levonorgestrel intrauterine system (LNG-IUS) include uterine anomalies, postpartum endometritis, untreated cervicitis, and current pelvic inflammatory disease. Nulliparity may increase discomfort during insertion but is not a contraindication. Levonorgestrel is a synthetic progestin and is not associated with an increased risk of deep vein thrombosis. It also is not associated with any adverse effect on quantity or quality of milk in breastfeeding women, and has no adverse effects on the infant. The LNG-IUS is not contraindicated in patients with endometriosis, and there is some evidence that it may improve symptom scores in these women.
The best management of localized, well-differentiated prostate cancer in men older than 65 is: (check one)

A. radiation implants
B. external beam radiation therapy
C. watchful waiting
D. primary androgen deprivation therapy
E. robot-assisted prostatectomy
C. watchful waiting. For men older than 65 years of age with small-volume, low-grade disease and a 10- to 15-year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from prostate cancer. Radiation, androgen deprivation therapy, and surgical approaches have not been shown to improve disease-free survival (SOR A).
A 67-year-old Hispanic male comes to your office with severe periumbilical abdominal pain, vomiting, and diarrhea, which began suddenly several hours ago. His temperature is 37.0°C (98.6°F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left brachial pulse. Right arm and lower extremity pulses are normal. Testing reveals the presence of blood in both his stool and his urine. His hemoglobin level is 16.4 g/dL (N 13.0-18.0) and his WBC count is 25,300/mm3 (N 4300-10,800).

The diagnostic imaging procedure most likely to produce a specific diagnosis of the abdominal pain is: (check one)

A. intravenous pyelography (IVP)
B. sonography of the abdominal aorta
C. a barium enema
D. celiac and mesenteric arteriography
E. contrast venography
D. celiac and mesenteric arteriography. The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes superior mesenteric artery embolization likely. In this case, evidence of a brachial artery embolus and a cardiac rhythm indicating atrial fibrillation suggest the diagnosis. Some patients may have a surprisingly normal abdominal examination in spite of severe pain. Microscopic hematuria and blood in the stool may both occur with embolization, and severe leukocytosis is present in more than two-thirds of patients with this problem. Diagnostic confirmation by angiography is recommended. Immediate embolectomy with removal of the propagated clot can then be accomplished and a decision made regarding whether or not the intestine should be resected. A second procedure may be scheduled to reevaluate intestinal viability.
Which one of the following platelet counts is the threshold for prophylactic platelet transfusion in most patients? (check one)

A. 10,000/μL
B. 25,000/μL
C. 40,000/μL
D. 50,000/μL
E. 100,000/μL
A. 10,000/μL. The threshold for prophylactic platelet transfusion is 10,000/μL (SOR A). Platelet transfusion decreases the risk of spontaneous bleeding in such patients. A count below 50,000/μL is an indication for platelet transfusion in patients undergoing an invasive procedure.
Which one of the following medications has the best evidence for preventing hip fracture? (check one)

A. Ibandronate (Boniva)
B. Raloxifene (Evista)
C. Denosumab (Prolia)
D. Etidronate (Didronel)
E. Alendronate (Fosamax)
E. Alendronate (Fosamax). Ibandronate, raloxifene, denosumab, and etidronate have been shown to reduce new vertebral fractures, but are not proven to prevent hip fracture. Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture, and these are the anti-osteoporosis drugs of choice.
The sensitivity of a test is defined as: (check one)

A. the probability of disease before a test is performed
B. the probability of disease after a test is performed
C. the percentage of patients with a positive test result who are confirmed to have the disease
D. the percentage of patients with the disease who have a positive test result
E. the percentage of patients without the disease who have a negative test result
D. the percentage of patients with the disease who have a positive test result. Sensitivity is the percentage of patients with a disease who have a positive test result. Specificity is the percentage of patients without the disease who have a negative test result. Pretest probability is the probability of disease before a test is performed. Posttest probability is the probability of disease after a test is performed. Positive predictive value is the percentage of patients with a positive test result who are confirmed to have the disease.
A 28-year-old female sees you with a complaint of irregular menses. She has not had a menstrual period for 6 months. She is also concerned about weight gain, worsening acne, and dark hair on her upper lip, chin, and periareolar region. She is also interested in becoming pregnant soon. The patient tells you she has started an exercise program, which has helped with weight loss, but she continues to have amenorrhea. She has a negative urine β-hCG test, a mild elevation in free testosterone levels, and glucose intolerance.

Which one of the following would you consider initially for inducing ovulation? (check one)

A. Insulin
B. Metformin (Glucophage)
C. Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen)
D. Glipizide (Glucotrol)
E. Spironolactone (Aldactone)
B. Metformin (Glucophage). First-line agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS) include metformin and clomiphene, alone or in combination, as well as rosiglitazone (SOR A). In one study of nonobese women with PCOS, metformin was found to be more effective than clomiphene for improving the rate of conception (level of evidence 1b). However, the treatment of infertile women with PCOS remains controversial. One recent group of experts recommended that metformin use for ovulation induction in PCOS be restricted to women with glucose intolerance (SOR C).

Oral contraceptives are commonly used to treat menstrual irregularities in women with PCOS; however, there are few studies supporting their use, and they would not be appropriate for ovulation induction. Spironolactone is a first-line agent for treatment of hirsutism (SOR A) and has shown promise in treating menstrual irregularities, but is not commonly recommended for ovulation induction. There is a high prevalence of insulin resistance in women with PCOS, as measured by glucose intolerance; insulin-sensitizing agents are therefore indicated, but not insulin or sulfonylurea medications.
The FDA issued a boxed warning describing an increased risk of tendinopathy and tendon rupture associated with the use of which class of antibiotics? (check one)

A. Macrolides
B. Aminoglycosides
C. Fluoroquinolones
D. Tetracyclines
E. Polypeptides
C. Fluoroquinolones. Fluoroquinolones are associated with an increased risk of tendinopathy and tendon rupture. About 1/6000 prescriptions will cause an Achilles tendon rupture. The risk is higher in those also taking corticosteroids or over the age of 60.
Random Board Review Questions 18
When added to compression therapy, which one of the following has been shown to be an effective adjunctive treatment for venous ulcers? (check one)

A. Warfarin (Coumadin)
B. Enoxaparin (Lovenox)
C. Clopidogrel (Plavix)
D. Pentoxifylline (Trental)
E. Atorvastatin (Lipitor)
D. Pentoxifylline (Trental). Pentoxifylline is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy in patients unable to tolerate compression therapy. Aspirin has also been shown to be effective. Other treatments that have been studied but have not been found to be effective include oral zinc and antibiotics (SOR A).
A 75-year-old white male suffers an anteroseptal myocardial infarction. Four hours after admission to the hospital his blood pressure is 65/40 mm Hg. A Swan-Ganz catheter is inserted into the pulmonary artery, and the pulmonary capillary wedge pressure is found to be 8 mm Hg.

The best therapy in this instance is: (check one)

A. infusion of dopamine
B. infusion of 5% dextrose
C. infusion of normal saline
D. digoxin
E. furosemide (Lasix)
C. infusion of normal saline. A pulmonary capillary wedge pressure of 8 mm Hg suggests hypovolemia. Normal saline should be given because 5% dextrose is not a reliable volume expander.
A 72-year-old male with COPD presents to the emergency department with an acute exacerbation marked by increased sputum production and shortness of breath. His oxygen saturation is 88% on room air and he has diffuse inspiratory and expiratory wheezes bilaterally.

In addition to oxygen and bronchodilators, which one of the following is most appropriate for this patient? (check one)

A. No additional treatments
B. Systemic corticosteroids only
C. Inhaled corticosteroids only
D. Systemic corticosteroids and antibiotics
E. Inhaled corticosteroids and antibiotics
D. Systemic corticosteroids and antibiotics. Acute exacerbations of COPD are very common, with most caused by superimposed infections. Supplemental oxygen, antibiotics, and bronchodilators are used for management. Systemic corticosteroids, either oral or parenteral, have been shown to significantly reduce treatment failures and improve lung function and dyspnea over the first 72 hours, although there is an increased risk of adverse drug reactions.
A 42-year-old female with a history of alcoholism and binge drinking presents with a 3-hour history of severe epigastric pain associated with nausea and vomiting. Her pain radiates to her back and into her lower abdomen. The patient appears to be in moderate distress due to pain. She is afebrile with a pulse rate of 110 beats/min and a blood pressure of 98/66 mm Hg. Her abdominal examination is remarkable for epigastric tenderness, guarding, and mild abdominal distention. Laboratory evaluation reveals a serum lipase level of 562 U/L (N 22-51) and a serum amylase level of 317 U/L (N 36-128).

You admit the patient to the hospital. Your treatment plan includes volume repletion, pain control, and close monitoring of her hemodynamic status. After 48 hours of treatment, she is hemodynamically stable. Her serum lipase level is now 168 U/L. She is awake and alert and in no distress, but still requires parenteral pain medication.

Which one of the following is most appropriate for meeting her fluid and caloric needs at this time? (check one)

A. D5 normal saline intravenously at a maintenance rate
B. Enteral feedings via nasogastric feeding tube
C. A low-fat diet orally and oral fluids ad libitum
D. Intravenous total parenteral nutrition
D. Intravenous total parenteral nutrition. Although intravenous dextrose in normal saline can initially be used for aggressive rehydration, it does not meet the nutritional needs of patients with acute pancreatitis. Total enteral nutrition is superior to total parenteral nutrition in stable patients with acute pancreatitis, in both mild and severe cases (SOR A). When compared to total parenteral nutrition in these patients, enteral nutrition is associated with reduced rates of mortality, multiple organ failure, systemic infection, and operative interventions (SOR A). Enteral nutrition likely contributes to better outcomes by inhibiting bacterial translocation from the gut, thereby preventing the development of infected necrosis. This patient is awake and alert and presumably able to protect her airway, so nasogastric tube feeding is unnecessary to provide enteral nutrition.
Which one of the following is effective for single-dose prophylaxis against Lyme disease after an Ixodes scapularis tick bite? (check one)

A. Azithromycin (Zithromax)
B. Amoxicillin
C. Cefuroxime (Ceftin)
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
E. Doxycycline
E. Doxycycline. In controlled studies, it has been shown that a single 200-mg dose of doxycycline given within 72 hours after an Ixodes scapularis tick bite can prevent the development of Lyme disease.
A 63-year-old white male sees you for an initial visit and is accompanied by his daughter, who is a patient of yours and scheduled the visit. The father recently relocated to be near the daughter after his wife died. He has well-controlled type 2 diabetes mellitus, but is otherwise healthy. Referring to the copy of the medical records they brought with them, the daughter notes that her father has received influenza vaccine in 3 of the past 5 years, but she can find no documentation that he ever had "the pneumonia vaccine." She asks if he should receive it at this visit.

You advise them that he should receive pneumococcal vaccine: (check one)

A. annually, along with influenza vaccine
B. now and a repeat dose every 5 years
C. every 5 years starting at age 65
D. now and a repeat dose once at age 68
E. only once, at age 65
D. now and a repeat dose once at age 68. Both the CDC and the American Academy of Family Physicians recommend that all adults over the age of 65 receive a single dose of pneumococcal polysaccharide vaccine. Immunization before the age of 65 is recommended for certain subgroups of adults, including institutionalized individuals over the age of 50; those with chronic cardiac or pulmonary disease, diabetes mellitus, anatomic asplenia, chronic liver disease, or kidney failure; and health-care workers. It is recommended that those receiving the vaccine before the age of 65 receive an additional dose at age 65 or 5 years after the first dose, whichever is later.
A 50-year-old Hispanic male has a solitary 5-mm pulmonary nodule on a chest radiograph. His only medical problem is severe osteoarthritis. He quit smoking 10 years ago.

Which one of the following would be the most appropriate follow-up for the pulmonary nodule? (check one)

A. Positron emission tomography (PET)
B. Chest CT
C. A repeat chest radiograph in 6 weeks
D. A repeat chest radiograph in 6 months
E. Referral for a biopsy
B. Chest CT. Solitary pulmonary nodules are common radiologic findings, and the differential diagnosis includes both benign and malignant causes. The American College of Chest Physicians guidelines for evaluation of pulmonary nodules are based on size and patient risk factors for cancer. Lesions ≥8 mm in diameter with a "ground-glass" appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should also be evaluated, especially in a patient with a history of smoking.

CT is the imaging modality of choice to reevaluate pulmonary nodules seen on a radiograph (SOR C). PET is an appropriate next step when the cancer pretest probability and imaging results are discordant (SOR C). Patients with notable nodule growth during follow-up should undergo a biopsy (SOR C).
Early palliative care in patients with a terminal disease, including symptom management, psychosocial support, and assistance with decision making, has been shown to: (check one)

A. shorten the time to death
B. increase aggressive end-of-life care
C. increase health care costs
D. decrease depressive symptoms
E. reduce the need for hospice
D. decrease depressive symptoms. It has been shown that palliative care offered early in the course of a terminal disease has many benefits. Palliative care leads to improvement in a patient's quality of life and mood, and patients who receive palliative care often have fewer symptoms of depression than those who do not receive palliative care. In addition, palliative care reduces aggressive end-of-life care and thus reduces health care costs. Palliative care does not reduce the need for hospice, but in fact enables patients to enter hospice care earlier and perhaps for longer. Palliative care has been shown to extend survival times in terminal patients (SOR B).
Which one of the following community health programs best fits the definition of secondary prevention? (check one)

A. An antismoking education program at a local middle school
B. Blood pressure screening at a local church
C. A condom distribution program
D. Screening diabetic patients for microalbuminuria
B. Blood pressure screening at a local church. Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex). Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (e.g., routine Papanicolaou tests; screening for hypertension, diabetes, or hyperlipidemia). Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with β-blockers and aspirin).
A 4-month-old white male in respiratory distress is brought to the emergency department. On examination, heart sounds include a grade 4/6 pansystolic murmur, best heard at the lower left sternal border. He is acyanotic. A chest radiograph shows an enlarged heart and increased pulmonary vascular markings, and an EKG shows combined ventricular hypertrophy.

Of the following, the most likely diagnosis is: (check one)

A. hypoplastic left heart syndrome (aortic valve atresia)
B. transposition of the great vessels
C. ventricular septal defect
D. tetralogy of Fallot
E. patent ductus arteriosus
C. ventricular septal defect. Ventricular septal defect causes overload of both ventricles, since the blood is shunted left to right. The murmur is harsh and holosystolic, generally heard best at the lower left sternal border. As the volume of the shunting increases, cardiac enlargement and increased pulmonary vascular markings can be seen on a chest radiograph.

Hypoplastic left heart syndrome would be manifested by near-obliteration of the left ventricle on the EKG and chest radiograph, and the infant would be cyanotic. Transposition of the great vessels would cause AV conduction defects and single-sided hypertrophy on the EKG. The chest radiograph would show a straight shoulder on the left heart border where the aorta was directed to the right. Tetralogy of Fallot causes cyanosis and right ventricular enlargement. The murmur of patent ductus arteriosus is continuous, best heard below the left clavicle. The EKG shows left atrial and ventricular enlargement.
Random Board Review Questions 19
A 55-year-old male sees you for a follow-up visit for hypercholesterolemia and hypertension. He is in good health, does not smoke, and drinks alcohol infrequently. His medications include a multiple vitamin daily; aspirin, 81 mg daily; lisinopril (Prinivil, Zestril), 10 mg daily; and lovastatin (Mevacor), 20 mg daily. His vital signs are within normal limits except for a BMI of 33.4 kg/m2 .

At today's visit his ALT (SGPT) level is 55 IU/L (N 10-45) and his AST (SGOT) level is 44 IU/L (N 10-37). The remainder of the liver panel is normal.

Which one of the following is the most likely cause of the elevation in liver enzymes? (check one)

A. A side effect of lovastatin
B. Gallbladder disease
C. Hepatitis A
D. Alcoholic liver disease
E. Metabolic syndrome
E. Metabolic syndrome. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver tests in the developed world. Its prevalence increases with age, body mass index, and triglyceride concentrations, and in patients with diabetes mellitus, hypertension, or insulin resistance. There is a significant overlap between metabolic syndrome and diabetes mellitus, and NAFLD is regarded as the liver manifestation of insulin resistance.

Statin therapy is considered safe in such individuals and can improve liver enzyme levels and reduce cardiovascular morbidity in patients with mild to moderately abnormal liver tests that are potentially attributable to NAFLD.
A 67-year-old female is admitted to the hospital with severe community-acquired pneumonia. Her urine should be tested for which one of the following antigens? (check one)

A. Chlamydia
B. Mycoplasma
C. Legionella
D. Haemophilus influenzae
E. Pseudomonas
C. Legionella. In patients with severe pneumonia, the urine should be tested for antigens to Legionella and pneumococcus. Two blood cultures should also be drawn, but these are positive in only 10%-20% of all patients with community-acquired pneumonia.
A 22-year-old male presents to your office with a 2-hour history of a painful right scrotal mass. The physical examination raises concerns that the patient may have testicular torsion. The imaging study of choice would be (check one)

A. a plain film
B. color duplex Doppler ultrasonography
E. a nuclear scan
B. color duplex Doppler ultrasonography. The history and physical examination are critical for making a diagnosis in patients with scrotal pain. Transillumination may also be performed as part of the clinical assessment. If the diagnosis is uncertain, ultrasonography with color Doppler imaging has become the accepted standard for evaluation of the acutely swollen scrotum (SOR B). Ultrasonography alone can confirm the diagnosis in a number of conditions, such as hydrocele, spermatocele, and varicocele. For other conditions such as orchitis, carcinoma, or torsion, color Doppler ultrasonography is essential because it will show increased flow in orchitis, normal or increased flow in carcinoma, and decreased blood flow in testicular torsion.

For testicular torsion, color Doppler ultrasonography has a sensitivity of 86%-88% and a specificity of 90%-100%. When testicular torsion is strongly suspected, emergent surgical consultation should be obtained before ultrasonography is performed, because surgical exploration as soon as possible is critical to salvaging the testis and should not be delayed for imaging unless the diagnosis is in doubt.

While radionuclide imaging would be accurate for diagnosing testicular torsion, it is not used for this purpose because of time limits and lack of easy availability. CT or MRI may be appropriate if ultrasonography indicates a possibility of carcinoma. Plain films are not useful in assessing scrotal swelling or masses.
A 22-year-old male has acute low back pain without paresthesias or other neurologic signs. There is no lower extremity weakness.

Which treatment has been shown to be of most benefit initially? (check one)

A. Complete bed rest for 2 weeks
B. Bed rest plus local injection of corticosteroids
C. A low-back strengthening program
D. Resumption of physical activity as tolerated
D. Resumption of physical activity as tolerated. For patients who have acute back pain without sciatic involvement, a return to normal activities as tolerated has been shown to be more beneficial than either bed rest or a basic exercise program. Bed rest for more than 2 or 3 days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. Injections should be considered only if conservative therapy fails.
A 68-year-old female is being monitored in the hospital after elective surgery. On her third postoperative day she suddenly develops hypoxia, fever, tachycardia, and hypotension. You institute high-rate intravenous fluids and empiric antibiotics. However, approximately 2 hours into this therapy, her blood pressure remains at 80 mm Hg systolic with sluggish urine output.

Which one of the following hormones should be assessed at this time? (check one)

A. Aldosterone
B. Catecholamines
C. Cortisol
D. Renin
C. Cortisol. It has been recognized that patients suffering from a critical illness with an exaggerated inflammatory response often have a relative cortisol deficiency. Clinically, this can cause hypotension that is resistant to intravenous fluid resuscitation, and evidence is mounting that survival is increased if these patients are treated with intravenous corticosteroids during acute management. Cortisol levels can be assessed with a single serum reading, or by the change in the cortisol level after stimulation with cosyntropin (referred to as Δcortisol). The other hormones listed are not important for the acute management of a critically ill patient.
In order to be eligible for Medicare hospice benefits, a patient must be entitled to Medicare Part A and: (check one)

A. be essentially bedridden
B. have a life expectancy of 6 months or less
C. have a hematologic or a solid tumor malignancy
D. have a caregiver in the home who is present at least 50% of the time
E. have documentation of a do-not-resuscitate (DNR) order
B. have a life expectancy of 6 months or less. The Medicare Hospice Benefit reimburses hospice providers for the care of terminally ill patients. In order to be eligible for this benefit, patients must be entitled to Medicare Part A and be certified by both the personal physician and the hospice medical director as having a life expectancy of 6 months or less. Services covered include physician services; nursing services; social services; counseling services; physical, occupational, and speech therapy; diagnostic testing; home health aides; homemaker services; and medical supplies. These services may be provided in the patient's home or in the hospital setting. Malignancy, ambulatory status, caregiver availability, and do-not-resuscitate orders are not specifically related to eligibility requirements for this benefit.
A 7-year-old female with a history of asthma is brought to your office for a routine follow-up visit. She has a history of exercise-induced asthma, but also has had exacerbations in the past that were unrelated to exercise. In the past month, she has premedicated herself with albuterol (Proventil, Ventolin) with a spacer before recess 5 days/week as usual. She has also needed her albuterol to treat symptoms (wheezing and/or shortness of breath) once or twice per week and had one exacerbation requiring medical treatment in the past year. She has had no nighttime symptoms. Albuterol as needed is her only medication.

After reinforcing asthma education, which one of the following would be most appropriate? (check one)

A. Referral to an asthma specialist
B. Addition of a low-dose inhaled corticosteroid
C. Addition of a long-acting β-agonist
D. Elimination of premedication with albuterol, restricting use to an as-needed basis
E. No changes to her regimen
E. No changes to her regimen. This patient's asthma is well-controlled according to the 2007 NHLBI asthma guidelines. The "rule of twos" is useful in assessing asthma control: in children under the age of 12, asthma is NOT well-controlled if they have had symptoms or used a β-agonist for symptom relief more than twice per week, had two or more nocturnal awakenings due to asthma symptoms in the past month, or had two or more exacerbations requiring systemic corticosteroids in the past year. For individuals over 12 years of age, there must be more than two nocturnal awakenings per month to classify their asthma as not well controlled.

Exercise-induced asthma is considered separately. A β-agonist used as premedication before exercise is not a factor when assessing asthma control. Since this patient does not exceed the rule of twos, her asthma is categorized as well-controlled and no changes to her therapy are indicated. Asthma education should be reinforced at every visit.
A young woman in labor at term develops frank eclampsia. What is the best choice of anticonvulsant to treat her condition? (check one)

A. Phenytoin (Dilantin)
B. Diazepam (Valium)
C. Topiramate (Topamax)
D. Lamotrigine (Lamictal)
E. Magnesium sulfate
E. Magnesium sulfate. Intravenous magnesium sulfate reduces the risk of subsequent seizures in women with eclampsia compared with placebo, and with fewer adverse effects for the mother and baby compared with phenytoin or diazepam. The newer oral agents have no role in this emergency.
Which one of the following is associated with a history of sexual abuse in females? (check one)

A. Lifelong functional gastrointestinal disorders
B. Lifelong headache disorders
C. Obesity
D. Recurrent syncope
A. Lifelong functional gastrointestinal disorders. A comprehensive, systematic literature review found an association of sexual abuse with a lifelong history of functional gastrointestinal disorders, irrespective of the age of the victim at the time of abuse. There was no statistically significant association with obesity, headache, or syncope.
Of the following, the greatest risk for developing colon cancer is associated with a personal history of: (check one)

A. tobacco use
B. ulcerative colitis
C. villous adenoma
D. familial adenomatous polyposis
E. colon cancer in a first degree relative
D. familial adenomatous polyposis. People with familial adenomatous polyposis typically develop hundreds or thousands of polyps in their colon and rectum, usually in their teens or early adulthood. Cancer usually develops in one or more of these polyps as early as age 20. By age 40, almost all people with this disorder will have developed cancer if preventive colectomy is not performed.

The approximate lifetime risk of colon cancer in the general population of the United States is 6%. Most case-control studies of cigarette exposure and adenomas have found an elevated risk for smokers. Tobacco use raises the risk of colon cancer by approximately 50%.

Patients with ulcerative colitis are at increased risk for colon cancer. The anatomic extent and duration of the disease correlate with the degree of risk. In one meta-analysis, investigators found that the risk of colon cancer was 2% in the first 10 years after ulcerative colitis develops, 8% during the first 20 years, and 18% during the first 30 years.

The evidence is still evolving regarding the level of future risk of colon cancer associated with having had an adenomatous polyp removed in the past, but it may approach a doubling of the baseline risk of colon cancer. Studies suggest a clear association with a history of multiple polyps or a single large (>1 cm) polyp. The data is less clear for single small adenomas. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are most likely to develop into adenocarcinomas.

Having a family history of a first degree relative with colon cancer raises the risk approximately two-to threefold. If that relative was younger than age 50 at the time of diagnosis the risk is three-to fourfold higher.
Random Board Review Questions 20
An 82-year-old white male suffers from chronic low back pain. He is on warfarin (Coumadin) for chronic atrial fibrillation, tamsulosin (Flomax) for benign prostatic hyperplasia, and famotidine (Pepcid) for gastroesophageal reflux disease.

Which one of the following analgesic medications would have the least potential for adverse side effects? (check one)

A. The lidocaine patch (Lidoderm)
B. Hydrocodone/acetaminophen
C. Nortriptyline (Pamelor)
D. Duloxetine (Cymbalta)
E. Celecoxib (Celebrex)
A. The lidocaine patch (Lidoderm). Topical lidocaine produces very low serum levels of active drug, resulting in very few adverse effects (SOR C). Hydrocodone could produce any opiate-type effect. Nortriptyline and duloxetine could aggravate this patient's atrial arrhythmia and cause urinary retention. Celecoxib could aggravate his reflux problem.
Which one of the following is recommended for routine prenatal care? (check one)

A. Hepatitis C antibody testing
B. Parvovirus antibody testing
C. Cystic fibrosis carrier testing
D. HIV screening
E. Examination of a vaginal smear for clue cells
D. HIV screening. HIV screening is recommended as part of routine prenatal care, even in low-risk pregnancies. Counseling about cystic fibrosis carrier testing is recommended, but not routine testing. Hepatitis C and parvovirus antibodies are not part of routine prenatal screening. Routine screening for bacterial vaginosis with a vaginal smear for clue cells is not recommended.
At the 18-month visit, which one of the following is the most specific sign of autism? (check one)

A. Delayed or odd use of language
B. Repetitive behaviors
C. Stereotypic movements
D. Delayed attainment of social skill milestones
E. Self-injurious behaviors
D. Delayed attainment of social skill milestones. Delayed attainment of social skill milestones is the earliest and most specific sign of autism. Delayed or odd use of language is a common, but less specific, early sign of autism. Compared with social and language impairments, restricted interests and repetitive behaviors are less prominent and more variable in young children. Self-injurious behaviors are associated with autism, but not specific for it. For example, new-onset head banging may be the way an autistic child attempts to deal with pain from a dental abscess, headache, sinusitis, otitis media, or other source of pain.
A 55-year-old male presents with a 2-year history of persistent, worsening neck stiffness. Over the past month, the stiffness has been associated with left thumb tingling.

After completing a thorough history and physical examination, which one of the following studies would be the most appropriate next step in further evaluating the patient's complaints? (check one)

A. Lateral neck radiography
B. A cervical spine series
C. Neck MRI
D. CT myelography
E. Diskography
B. A cervical spine series. Based on the American College of Radiology's Appropriateness Criteria for chronic neck pain, a complete cervical spine series that includes five views is the correct study in a patient of any age with chronic neck pain and no history of trauma, malignancy, or surgery. If the radiographs are normal and the patient has neurologic signs or symptoms, the next step would be MRI. If MRI is contraindicated, CT myelography should be offered (SOR B). A single lateral radiograph is not sufficient. Diskography is not recommended in patients with chronic neck pain (SOR C).
You are initiating treatment for a patient being admitted to the hospital with a new diagnosis of pulmonary embolus. Low molecular weight heparin and warfarin (Coumadin) are started immediately.

When can the low molecular weight heparin be stopped? (check one)

A. When the INR is ≥2.0
B. When the INR is ≥2.0 for 24 hours
C. After 4 days, if the INR is ≥³2.0
D. After 4 days, if the INR has been ≥2.0 for 24 hours
E. After 5 days, if the INR has been ≥2.0 for 24 hours
E. After 5 days, if the INR has been ≥2.0 for 24 hours. For patients with a pulmonary embolus, American College of Chest Physicians guidelines recommend initial treatment with low molecular weight heparin (LMWH), unfractionated heparin, or fondaparinux for at least 5 days, and then can be stopped if the INR has been ≥2.0 for at least 24 hours (SOR C). Warfarin reduces the activity of coagulation factors II, VII, IX, and X produced in the liver. Coagulation factors produced prior to initiating warfarin remain active for their usual several-day lifespan, which is why LMWH and warfarin must be given concomitantly for at least 5 days. The INR may reach levels >2.0 before coagulation factors II and X have reached their new plateau levels, accounting for the need for an additional 24 hours of combined therapy before stopping LMWH.
A 70-year-old retired engineer who is an avid runner asks you about his slow, progressive decrease in exercise performance. He says he realizes he is getting older, but is in good health and is curious as to why this is happening.

You tell him that there are multiple physiologic changes associated with aging that lower exercise performance, including a decrease in: (check one)

A. cardiac output
B. systolic blood pressure
C. pulse pressure
D. residual lung volume
A. cardiac output. Cardiovascular changes associated with aging include decreased cardiac output, maximum heart rate, and stroke volume, as well as increased systolic and diastolic blood pressure. Respiratory changes include an increase in residual lung volume and a decrease in vital capacity. Other changes include decreases in nerve conduction, proprioception and balance, maximum O2 uptake, bone mass, muscle strength, and flexibility. Most of these changes, however, can be reduced in degree by a regular aerobic and resistance training program.
Which one of the following reduces the incidence of atopic dermatitis in children? (check one)

A. Exclusive breastfeeding until the infant is 4 months of age
B. Prenatal ingestion of probiotics by the mother
C. Delayed introduction of solid food until after 6 months of age
D. Application of emollients
E. Early exposure to dust mites
A. Exclusive breastfeeding until the infant is 4 months of age. Atopic dermatitis is a pruritic, inflammatory skin disorder affecting nearly 1 in 5 children residing in developed countries. The vast majority of those eventually afflicted experience the onset of symptoms by the age of 5 years, and more than half will present before the age of 1 year. The etiology is not fully understood, but it seems clear that environmental, immune, genetic, metabolic, infectious, and neuroendocrine factors all play a role. Environmental factors that may be involved include harsh detergents, abrasive clothing, Staphylococcus aureus skin infection, food allergens (cow's milk, eggs, peanuts, tree nuts, etc.), overheating, and psychological stress. Aeroallergens that are problematic for asthmatics, such as animal dander, dust mites, and pollen, have not been clearly linked to atopic dermatitis.

Large, well-designed studies have found no evidence that delaying the introduction of solid foods until after 6 months of age reduces the likelihood of atopic dermatitis. Ingestion of probiotic agents during pregnancy has also not been shown to have any effect, and studies of probiotic use in breastfeeding mothers and their infants have yielded conflicting results. Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so beyond 4 months does not appear to provide additional benefit. Maternal dietary restriction during pregnancy and lactation has not been associated with significant benefit. Limited studies have demonstrated that emollients and moisturizers can reduce associated xerosis and are thought to be helpful treatments, but the data is not convincing.
An 8-year-old male is brought to your office for evaluation of recurrent headaches. His mother explains that the headaches occur at least twice a week and often require him to miss school. The patient says he sometimes feels nauseated and that being in a dark room helps. His mother states that she had migraines as a child. The child's only other medical issue is constipation. A head CT ordered by another physician was negative.

Which one of the following would be best for preventing these episodes? (check one)

A. Sumatriptan (Imitrex)
B. Ibuprofen
C. Carbamazepine (Tegretol)
D. Propranolol (Inderal)
E. Amitriptyline
D. Propranolol (Inderal). This patient most likely is suffering from recurrent migraine headaches; at the described frequency and intensity, he meets the criteria for prophylactic medication. Ibuprofen or acetaminophen could still be used as rescue medications, but a daily agent is indicated and propranolol is the best choice for this patient (SOR B). Sumatriptan is not approved for children under the age of 12 years. Carbamazepine has significant side effects and requires monitoring. Amitriptyline is a commonly used agent, but it could worsen his constipation.
A 12-year-old Hispanic female develops fever, knee pain with swelling, diffuse abdominal pain, and a palpable purpuric rash. A CBC and platelet count are normal.

Her long-term prognosis depends on the severity of involvement of the: (check one)

A. gastrointestinal tract
B. heart
C. liver
D. kidneys
E. lungs
D. kidneys. This patient has Henoch-Schönlein purpura. This condition is associated with a palpable purpuric rash, without thrombocytopenia. Other diagnostic criteria include bowel angina (diffuse abdominal pain or bowel ischemia), age ≤20, renal involvement, and a biopsy showing predominant immunoglobulin A deposition. The long-term prognosis depends on the severity of renal involvement. Almost all children with Henoch-Schönlein purpura have a spontaneous resolution, but 5% may develop end-stage renal disease. Therefore, patients with renal involvement require careful monitoring (SOR A).
According to the Beers criteria, a list of drugs that should be avoided in geriatric patients, which one of the following NSAIDs should be avoided in older patients due to its higher rate of adverse central nervous system effects? (check one)

A. Indomethacin
B. Ibuprofen
C. Diclofenac sodium
D. Etodolac
E. Celecoxib (Celebrex)
A. Indomethacin. The Beers criteria, a list of drugs that should generally be avoided by older patients, was developed by expert consensus, and was last updated in 2002. Indomethacin is on the list due to its propensity to produce more central nervous system adverse effects than other NSAIDs.
Random Board Review Questions 21
Which one of the following treatments for type 2 diabetes mellitus often produces significant weight loss? (check one)

A. Exenatide (Byetta)
B. Glipizide (Glucotrol)
C. Pioglitazone (Actos)
D. Insulin detemir (Levemir)
E. Insulin lispro (Humalog)
A. Exenatide (Byetta). Of the many currently available medications to treat diabetes mellitus, only metformin and incretin mimetics such as exenatide have the additional benefit of helping the overweight or obese patient lose a significant amount of weight. Most of the other medications, including all the insulin formulations, unfortunately lead to weight gain or have no effect on weight.
A 7-year-old female is brought to your clinic by her mother, who has concerns about her behavior. For the last 2 months, the patient has resisted going to school. Each school morning she complains of not feeling well and asks to stay home. When forcibly taken to school she cries and begs to go home. Once at home she is playful and engages in normal activities. She also resists attending her usual swimming lessons in the evenings. She has frequent nightmares in which one of her parents dies.

After a thorough history and physical examination rule out an underlying medical condition, you diagnose the patient with: (check one)

A. separation anxiety disorder
B. generalized anxiety disorder
C. acute stress disorder
D. panic disorder with agoraphobia
E. social phobia
A. separation anxiety disorder. This patient suffers from separation anxiety disorder, which is unique to pediatric patients and is characterized by excessive anxiety regarding separation from the home or from people the child is attached to, such as family members or other caregivers. The anxiety is beyond what is developmentally appropriate for the child's age. Patients may even suffer distress from anticipation of the separation. Other characteristics include persistent worry about harm occurring to major attachment figures, worry about an event that may separate the patient from caregivers, reluctance to attend school due to the separation it implies, fear of being alone, recurring nightmares with themes of separation, and physical complaints when faced with separation. Children diagnosed with separation anxiety disorder must be under 18 years of age and have had symptoms for at least 4 weeks.

Social phobia is a persistent fear of a specific object or situation. Exposure to the object provokes an immediate anxiety response such as a panic attack. To meet the criteria for social phobia, patients must suffer symptoms for at least 6 months. Generalized anxiety disorder is characterized as excessive anxiety and worry regarding a number of events or activities. Physical symptoms include restlessness, irritability, or sleep disturbance. Symptoms must be present for at least 6 months.

Acute stress disorder occurs after a traumatic event that the individual considers life threatening. Patients experience dissociative symptoms, flashbacks, and increased arousal. Symptoms are present for at least 2 days, with a maximum of 4 weeks. Beyond 4 weeks, a diagnosis of posttraumatic stress disorder is made. Panic disorder with agoraphobia is characterized by recurrent panic attacks with a fear of being in situations in which the patient cannot escape or may be embarrassed by doing so. Symptoms must be present for 1 month for the diagnosis to be made (SOR C).
In patients with pes anserine bursitis, tenderness is most likely to be noted: (check one)

A. over the medial epicondyle
B. over the lateral pelvic/hip region
C. over the medial proximal tibia
D. just posterior to the medial malleolus
E. just distal to the lateral malleolus
C. over the medial proximal tibia. The pes anserine bursa is associated with the tendinous insertion of the sartorius, gracilis, and semitendinosus muscles into the medial aspect of the proximal tibia. Commonly associated with early osteoarthritis in the medial knee compartment, pes anserine bursitis can also result from overuse of the involved muscles or from direct trauma to the area. A patient with pes anserine bursitis will generally complain of pain in the area of insertion when flexing and extending the knee and tenderness of the area will be noted on examination. Slight swelling may be present but no effusion is generally evident. Treatment may include oral anti-inflammatory agents, physical therapy, and corticosteroid injection.
The results of a given study are reported as achieving significance at a p-value of <0.05 (the 5% level). True statements about this finding include which one of the following? (check one)

A. There is a 5% likelihood of the results having occurred by chance alone
B. If the study were replicated 100 times, 95 studies would repeat this finding and 5 would not
C. The confidence interval is 0%-10%
D. The null hypothesis has a 5% chance of being true
E. The β (type II) error is <5%
A. There is a 5% likelihood of the results having occurred by chance alone. The p-value is a level of statistical significance, and characterizes the likelihood of achieving the observed results of a study by chance alone; in this study that likelihood is 5%, although 5% or less of the results of the study can be achieved by chance alone and still be significant. The confidence interval is a measure of variance and is derived from the test data. The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%. The α or type I error is akin to the error of false-positive assignment; the β or type II error is analogous to the false-negative rate, or 1 - specificity, and cannot be calculated from the information given.
A 23-year-old female comes to your office 6 days after giving birth to her first child by cesarean section. Her pregnancy was complicated by preeclampsia. During the history she reports brief crying spells, irritability, poor sleep, and nervousness. Her husband notes that "even the littlest thing can set her off." She has a history of major depression 2 years ago that resolved with psychotherapy and SSRI treatment. She and her husband are concerned that she may be suffering from postpartum depression.

Which one of the following is the greatest risk factor for postpartum depression in this patient? (check one)

A. Operative delivery
B. First pregnancy and delivery
C. Preeclampsia
D. A previous history of depression
D. A previous history of depression. "Baby blues" are differentiated from postpartum depression by the severity and duration of symptoms. Baby blues occur in 80% of postpartum women and are associated with mild dysfunction. They begin during the first 2-3 days after delivery and resolve within 10 days. Symptoms include brief crying spells, irritability, poor sleep, nervousness, and emotional reactivity. An estimated 5%-7% of women develop a postpartum major depression associated with moderate to severe dysfunction during the first 3 months post partum. While women with baby blues are at risk for progression to major depression, no more than 8%-10% will progress to a major postpartum depression.

A previous history of major depressive disorder significantly increases the risk of developing postpartum depression (RR = 4.5), and a prior episode of postpartum depression is the strongest risk factor for postpartum depression in subsequent pregnancies. Prenatal and obstetric complications and socioeconomic status have not consistently been shown to be risk factors. First pregnancy is also not a significant risk factor.
A 40-year-old businessman has recently been diagnosed with irritable bowel syndrome after extensive testing by his gastroenterologist. His predominant symptoms are diarrhea and pain.

Which one of the following has been shown to be helpful in controlled trials? (check one)

A. Probiotics such as yogurt and buttermilk
B. Insoluble fiber such as wheat bran, corn bran, and defatted flaxseed
C. Soluble fiber such as psyllium (ispaghula)
D. Turmeric
E. Peppermint oil
E. Peppermint oil. Studies suggest that in 25% of patients, irritable bowel syndrome may be caused or aggravated by one or more dietary components. Restriction of fermentable, poorly absorbed carbohydrates is beneficial, including fructan (found in wheat and onions), sorbitol, and other such alcohols. Further studies are needed, however. Despite its popularity, fiber is marginally beneficial and insoluble fiber may worsen symptoms in patients with diarrhea. Probiotics in the form of foods such as buttermilk and live-culture yogurt have thus far not been established as useful. Daily use of peppermint oil has been shown to relieve symptoms.
A 32-year-old white female presents with a 6-week history of increasing headache, which she now describes as severe. The only abnormal finding on examination is a BMI of 32.4 kg/m2 . A neurologic examination is normal. CT of the head is normal and a lumbar puncture is remarkable only for increased cerebrospinal fluid pressure. There is no history of trauma or hypercoagulable disorder.

Management should be directed toward preventing which one of the following? (check one)

A. Visual loss
B. Hearing loss
C. Vertigo
D. A cerebrovascular accident
E. Cerebral herniation
A. Visual loss. Loss of vision is a devastating neurologic deficit that occurs with idiopathic intracranial hypertension (pseudotumor cerebri, benign intracranial hypertension), although it is uncommon. Sixth cranial nerve palsies may also occur as a false localizing sign. The typical presentation is a young, obese woman with a headache, palpable tinnitus, and nausea and vomiting. CT is usually normal or shows small ventricles. The lumbar puncture shows elevated pressure with normal fluid examination. CSF protein levels may be low.

Hearing loss and vertigo are not characteristic of this disorder. Long tract signs and facial nerve palsies have been attributed to idiopathic intracranial hypertension; they are atypical and should lead to consideration of other diagnoses.
The U.S. Preventive Services Task Force recommends which one of the following regarding general screening for COPD? (check one)

A. A routine chest radiograph for screening patients over 50 with a history of tobacco use
B. Spirometry for screening patients over 50 with a history of tobacco use
C. Arterial blood gas analysis for patients over 60 with a history of tobacco use
D. Peak flow measurement for office screening for COPD
E. No routine screening for COPD with spirometry
E. No routine screening for COPD with spirometry. The U.S. Preventive Services Task Force recommends against screening adults for COPD with spirometry. Spirometry is indicated for patients who have symptoms suggestive of COPD, but not for healthy adults. While tobacco use is a risk factor for COPD, routine spirometry, chest radiographs, or arterial blood gas analysis is not recommended to screen for COPD in patients with a history of tobacco use. Peak flow measurement is not recommended for screening for COPD.
A 27-year-old female presents with 2 weeks of generalized pruritus. She had previously been in good health except for a laparoscopic cholecystectomy 3 weeks earlier. She has had intermittent right upper quadrant abdominal pain since the surgery, and has occasionally taken acetaminophen with hydrocodone for pain relief. Her examination is remarkable only for questionable scleral icterus.

The most likely diagnosis is: (check one)

A. hydrocodone allergy
B. liver toxicity from acetaminophen
C. retained common duct stone
D. acute hepatitis
C. retained common duct stone. Postcholecystectomy pain associated with jaundice (which can cause itching) is a classic presentation for a retained common duct stone. Acetaminophen toxicity is usually painless, and is associated with ingestion of large amounts of the drug and/or alcohol, or other potentially hepatotoxic drugs. Viral hepatitis is usually painless and accompanied by other systemic symptoms. Hydrocodone can cause pruritus but not pain and jaundice.
Regular breast self-examinations to screen for breast cancer: (check one)

A. are performed by most American women
B. reduce mortality due to breast cancer
C. reduce all-cause mortality in women
D. are recommended by the U.S. Preventive Services Task Force
E. increase the number of breast biopsies performed
E. increase the number of breast biopsies performed. Most women do not regularly perform breast self-examinations (BSE). Evidence from large, well- designed, randomized trials of adequate duration has shown that the performance of regular BSE by trained women does not reduce breast cancer-specific mortality or all-cause mortality. The 2009 update to the U.S. Preventive Services Task Force breast cancer screening recommendations recommended against teaching BSE (D recommendation). The rationale for this recommendation is that there is moderate certainty that the harms outweigh the benefits. The two available trials indicated that more additional imaging procedures and biopsies were done for women who performed BSE than for control participants, with no gains in breast cancer detection or reduction in breast-cancer related mortality.
Random Board Review Questions 22
Actinic keratosis is a precursor lesion to: (check one)

A. keratoacanthoma
B. nodular melanoma
C. superficial spreading melanoma
D. basal cell carcinoma
E. cutaneous squamous cell carcinoma
E. cutaneous squamous cell carcinoma. Actinic keratoses are precursor lesions for cutaneous squamous cell carcinoma. The conversion rate of actinic keratoses into squamous cell carcinoma has been estimated to be 1 in 1000 per year. Thicker lesions, cutaneous horns, and lesions that show ulceration have a higher malignant potential. Although sun exposure is a risk factor for both melanoma and basal cell carcinoma, there are no recognized precursor lesions for either. Actinic keratosis is not a precursor lesion to keratoacanthoma.
In the elderly, the risk of heat wave-related death is highest in those who: (check one)

A. have COPD
B. have diabetes and are insulin dependent
C. have a functioning fan, but not air conditioning
D. are homebound
D. are homebound. Factors associated with a higher risk of heat-related death include being confined to bed, not leaving home daily, and being unable to care for oneself. Living alone during a heat wave is associated with an increased risk of death, but this increase is not statistically significant. Among medical conditions, the highest risk is associated with preexisting psychiatric illnesses, followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease.

A lower risk of heat-related death has been noted in those who have working air conditioning, visit air-conditioned sites, or participate in social activities. Those who take extra showers or baths and who use fans have a lower risk, but this difference is not statistically significant.
Which one of the following is a criterion for gastric bypass surgery, according to recommendations of the National Institutes of Health? (check one)

A. A Framingham risk score >25%
B. Severe insulin resistance
C. Failed pharmacotherapy
D. Clearance by a mental health professional
E. A BMI >30 kg/m2 with comorbidities
D. Clearance by a mental health professional. The National Institutes of Health Consensus Development Conference issued recommendations for gastric bypass surgery in 1991, and these are still considered to be basic criteria (SOR C). Indications for laparoscopic bariatric surgery for morbid obesity include a BMI >40 kg/m2 or a BMI of 35-40 kg/m2 withsignificant obesity-related comorbidities. Weight loss by nonoperative means should be attempted before surgery, and patients should be evaluated by a multidisciplinary team that includes a dietician and a mental health professional before surgery.
A 66-year-old male has hypertension that has become difficult to manage after several years of good control on a stable medical regimen. On evaluation, his BUN level is 40 mg/dL (N 8-25) and his serum creatinine level is 2.1 mg/dL (N 0.6-1.5).

Which one of the following tests would be best to evaluate this patient for renovascular hypertension? (check one)

A. Duplex Doppler ultrasonography
B. CT angiography
C. Aortography
D. Captopril (Capoten) renography
A. Duplex Doppler ultrasonography. Duplex Doppler ultrasonography is the preferred initial test for renovascular hypertension in patients with impaired renal function. Tests involving intravenous radiographic contrast material may cause deterioration in renal function. Captopril renography is not reliable in the setting of poor renal function. Magnetic resonance angiography also could be considered, but the association between the use of gadolinium contrast agents and nephrogenic systemic fibrosis in patients with renal dysfunction would be a concern.
A 24-year-old primigravida has nausea and vomiting associated with pregnancy. Which one of the following is recommended by the American Congress of Obstetricians and Gynecologists (ACOG) as first-line therapy? (check one)

A. Droperidol (Inapsine)
B. Ondansetron (Zofran)
C. Prochlorperazine
D. Metoclopramide (Reglan)
E. Doxylamine (Unisom) and vitamin B6
E. Doxylamine (Unisom) and vitamin B6. Approximately 10% of women with nausea and vomiting during pregnancy require medication. Pharmacologic therapies that have been used include vitamin B6 , antihistamines, and prokinetic agents, as well as other medications. Randomized, placebo-controlled trials have shown that vitamin B6 is effective for this problem. The combination of vitamin B 6 and doxylamine was studied in more than 6000 patients and was associated with a 70% reduction in nausea and vomiting, with no evidence of teratogenicity. It is recommended by the American Congress of Obstetricians and Gynecologists as first-line therapy for nausea and vomiting in pregnancy. A combination pill was removed from the U.S. market in 1983 because of unjustified concerns about teratogenicity, but the medications can be bought separately over the counter.

In rare cases, metoclopramide has been associated with tardive dyskinesia, and the FDA has issued a black-box warning concerning the use of this drug in general. The 5-HT3 -receptor antagonists, such as ondansetron, are being used for hyperemesis in pregnancy, but information is limited. Droperidol has been used for this problem in the past, but it is now used infrequently because of its risks, particularly heart arrhythmias.
A 45-year-old white male develops disabling tremulousness, loss of voice, and a marked sense of forceful and rapid heartbeat whenever he must speak to a large group.

Which one of the following drugs is likely to be of most value in enabling him to give presentations at sales and stockholders' meetings? (check one)

A. Desipramine (Norpramin)
B. Propranolol (Inderal)
C. Alprazolam (Xanax)
D. Amantadine (Symmetrel)
E. Buspirone (BuSpar)
B. Propranolol (Inderal). This patient has a specific situational anxiety disorder or social phobia called performance anxiety or speech phobia, characterized by marked and sometimes disabling symptoms of catecholamine excess during specific performance situations, such as public speaking. Rates of speech phobia may exceed 50% in the population, but it is unclear whether such fear and avoidance of public speaking warrants a psychiatric diagnosis.

Specific phobias such as speech phobia respond moderately well to β-blockers used prior to a performance. These drugs block peripheral anxiety symptoms such as tachycardia and tremulousness that can escalate subjective anxiety and impair performance. Drugs that are primarily psychotropics or antiparkinsonian agents are much less likely to be of value in this specific anxiety disorder, and may cause undesirable sedation and dry mouth.
A 2-year-old white male is seen for a well child visit. His mother is concerned because he is not yet able to walk. The routine physical examination, including an orthopedic evaluation, is unremarkable. Speech and other developmental landmarks seem normal for his age.

Which one of the following tests would be most appropriate? (check one)

A. A TSH level
B. Random urine for aminoaciduria
C. Phenylketonuria screening
D. A serum creatine kinase level
E. Chromosome analysis
D. A serum creatine kinase level. The diagnosis of Duchenne muscular dystrophy, the most common neuromuscular disorder of childhood, is usually not made until the affected individual presents with an established gait abnormality at the age of 4-5 years. By then, parents unaware of the X-linked inheritance may have had additional children who would also be at risk.

The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. The mean age for walking in affected boys is 17.2 months, whereas over 75% of developmentally normal children in the United States walk by 13.5 months. Massive elevation of creatine kinase (CK) from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies.

Hypothyroidism and phenylketonuria could present as delayed walking. However, these diseases cause significant mental retardation and would be associated with global developmental delay. Furthermore, these disorders are now diagnosed in the neonatal period by routine screening. Disorders of amino acid metabolism present in the newborn period with failure to thrive, poor feeding, and lethargy. Gross chromosomal abnormalities would usually be incompatible with a normal physical examination at 18 months of age.
An 80-year-old female is being started on warfarin (Coumadin) for atrial fibrillation. According to the American College of Chest Physicians guidelines, the initial dose in this patient should NOT exceed: (check one)

A. 2.5 mg
B. 5 mg
C. 7.5 mg
D. 10 mg
E. 12.5 mg
B. 5 mg. The American College of Chest Physicians recommends a starting warfarin dosage of ≤5 mg/day in elderly patients, or in patients who have conditions such as heart failure, liver disease, or a history of recent surgery. The INR should be used to guide adjustments in the dosage.
Over the past year, a 32-year-old white female has experienced increasing hair growth on her chin and chest, acne, and irregular menstrual periods. She takes no medications.

Which one of the following would be the most appropriate course of action at this point? (check one)

A. Empiric treatment with metformin (Glucophage)
B. CT of the adrenal glands
C. Laboratory testing
D. Brain MRI
E. Pelvic ultrasonography
C. Laboratory testing. Testing for androgen excess is indicated in the young woman with an acute onset of hirsutism or when it is associated with menstrual irregularity, infertility, central obesity, acanthosis nigricans, or clitoromegaly. It should be kept in mind that excess hair has a male pattern in women with hirsutism, whereas hypertrichosis is characterized by excessive hair growth all over the body.

Elevated early morning total testosterone is most often associated with polycystic ovary syndrome, but other causes of hyperandrogenism and other endocrinopathies should be eliminated. These studies should include pregnancy testing if the patient has amenorrhea, as well as a serum prolactin level to exclude hyperprolactinemia. DHEA-S and early morning 17-hydroxyprogesterone can detect adrenal hyperandrogenism and congenital adrenal hyperplasia. Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present. Pelvic ultrasonography can be performed to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and ultrasonography has a low sensitivity.
You have diagnosed type 2 diabetes mellitus in a 64-year-old male. He has no known coronary heart disease. You recommend lowering his LDL-cholesterol to below a threshold of: (check one)

A. 190 mg/dL
B. 160 mg/dL
C. 130 mg/dL
D. 100 mg/dL
E. 70 mg/dL
D. 100 mg/dL. High-risk patients should have a target LDL-cholesterol level of <100 mg/dL. High risk is defined as the presence of known coronary heart disease (CHD), diabetes mellitus, noncoronary atherosclerotic disease, or multiple risk factors for CHD (SOR C). Patients at very high risk (known CHD and multiple additional risk factors) have an optional target of <70 mg/dL.
Random Board Review Questions 23
A 56-year-old white male reports lower leg claudication that occurs when he walks approximately one block, and is relieved by standing still or sitting. He has a history of diabetes mellitus and hyperlipidemia. His most recent hemoglobin A 1c level was 5.9% and his LDL-cholesterol level at that time was 95 mg/dL. Current medications include glyburide (DiaBeta), metformin (Glucophage), simvastatin (Zocor), and daily aspirin. He stopped smoking 1 month ago and began a walking program. A physical examination is normal, except for barely palpable dorsalis pedis and posterior tibial pulses. Femoral and popliteal pulses are normal. Noninvasive vascular studies of his legs show an ankle-brachial index of 0.7 bilaterally, and decreased flow.

Which one of the following would be most appropriate for addressing this patient's symptoms? (check one)

A. Fish oil
B. Warfarin (Coumadin)
C. Cilostazol (Pletal)
D. Dipyridamole (Persantine)
E. Clopidogrel (Plavix)
C. Cilostazol (Pletal). The patient described has symptomatic arterial vascular disease manifested by intermittent claudication. He has already initiated the two most important changes: he has stopped smoking and started a walking program. His LDL-cholesterol is at target levels; further lowering is not likely to improve his symptoms. In the presence of diffuse disease, interventional treatments such as angioplasty or surgery may not be helpful; in addition, these interventions should be reserved as a last resort. Cilostazol has been shown to help with intermittent claudication, but additional antiplatelet agents are not likely to improve his symptoms. Fish oil and warfarin have not been found to be helpful in the management of this condition.
A mother calls for advice regarding her 2-year-old son. She found an open container of immediate-release diltiazem (Cardizem) on the floor, with some spilled and partially chewed tablets, and estimates that her son opened the container about 90 minutes ago. He does not appear to be in any distress.

Which one of the following would you advise her to do? (check one)

A. Administer syrup of ipecac at home and observe
B. Transport the child to the emergency department for gastric lavage
C. Transport the child to the emergency department for administration of activated charcoal
D. Transport the child to the emergency department for administration of activated charcoal and a cathartic
E. Transport the child to the hospital for admission to the pediatric intensive-care unit for observation
E. Transport the child to the hospital for admission to the pediatric intensive-care unit for observation. More than 9500 cases of calcium channel blocker intoxication were reported to U.S. poison control centers in 2005. Substantial toxicity can occur with one or two tablets, and all children suspected of ingesting a calcium channel blocker should be admitted to a pediatric intensive-care unit for monitoring and management.

The use of gastric emptying, cathartics, or adsorptive agents is unlikely to be helpful and should be considered only in patients presenting within 1 hour of ingestion, if then. The American Academy of Pediatrics has advised that syrup of ipecac not be kept in the home because of toxicity and dubious benefit.
A 55-year-old white male comes to your office with weakness and a headache. He also describes an annoying pruritus that occurs frequently after he takes a hot shower. The physical examination is remarkable for the presence of an enlarged spleen. He has a hemoglobin level of 21 g/dL (N 12-16) and a hematocrit of 63% (N 36-48). To confirm your clinical diagnosis, you obtain additional studies.

Which one of the following would be most consistent with the most likely diagnosis in this patient? (check one)

A. A low serum erythropoietin level
B. A low platelet count
C. A low arterial oxygen concentration
D. An elevated carboxyhemoglobin level
A. A low serum erythropoietin level. The patient described in this case has polycythemia vera. Pruritus after a hot shower (aquagenic pruritus) and the presence of splenomegaly helps to clinically distinguish polycythemia vera from other causes of erythrocytosis (hematocrit >55%). Specific criteria for the diagnosis of polycythemia vera include an elevated red cell mass, a normal arterial oxygen saturation (>92%), and the presence of splenomegaly. In addition, patients usually exhibit thrombocytosis (platelet count >400,000/mm3 ), leukocytosis (WBC>12,000/mm3 ), a low serum erythropoietin level, and an elevated leukocyte alkaline phosphatase score. High carboxyhemoglobin levels are associated with secondary polycythemia.
A previously healthy 73-year-old male is admitted to the intensive-care unit after an emergency appendectomy. He does well until the evening, when he suddenly appears confused. His speech is rambling and incoherent, and he is disoriented to person, place, and time. His wife says he was sleepy but otherwise acting normal 2 hours ago. On examination he has normal vital signs and no fever. Other than the cognitive changes and some mild peri-incisional tenderness the examination is normal. Serum electrolytes, a CBC, arterial blood gases, and a routine chemistry panel are normal.

The most likely cause for his altered sensorium is
(check one)

A. sepsis
B. acute psychosis
C. dementia with Lewy bodies
D. delirium
E. ischemic stroke
D. delirium. The syndrome of delirium is common in the postoperative setting. It is characterized by disorganized thinking; rambling, incoherent speech; and a reduced ability to maintain and shift attention. In addition, at least two of the following are typically present: a reduced level of consciousness with perceptual disturbances or hallucinations; sleep disturbances or changes in psychomotor activity; disorientation to time, place, or person; and memory impairment. This syndrome typically begins abruptly and may fluctuate hourly. There is usually a specific etiologic factor identified, such as surgery in this case.

A patient with normal vital signs, no fever, and normal laboratory studies is unlikely to be septic. Patients with psychosis typically maintain orientation to person and place, as well as attention. Dementia with Lewy bodies has a more chronic onset, and the absence of focal neurologic findings makes stroke unlikely. Alcohol withdrawal is also a consideration in the differential diagnosis.
A 75-year-old male develops a mild Clostridium difficile infection and is treated with 10 days of metronidazole (Flagyl), 500 mg orally 3 times daily. The diarrhea recurs 10 days after he completes the course of treatment.

Which one of the following would be most appropriate? (check one)

A. Repeat the course of metronidazole
B. Repeat the course of metronidazole and add vancomycin
C. Administer vancomycin intravenously
D. Prescribe loperamide (Imodium), 4 mg twice daily as needed
E. Prescribe a probiotic
A. Repeat the course of metronidazole. Clostridium difficile infection is more common with aging and can be treated with either metronidazole or vancomycin daily. For mild recurrent disease, repeating the course of the original agent is appropriate (SOR B). Multiple recurrences or severe disease warrants the use of both agents. The effectiveness of probiotics such as Lactobacillus remains uncertain. Intravenous vancomycin has not been effective. Antiperistaltic drugs should be avoided.
Which one of the following, when confirmed with a repeat test, meets the diagnostic criteria for diabetes mellitus? (check one)

A. A fasting blood glucose level of 120 mg/dL
B. A 2-hour value of 180 mg/dL on an oral glucose tolerance test
C. A random glucose level of 180 mg/dL in a patient with symptoms of diabetes mellitus
D. A positive urine dipstick for glucose
E. A hemoglobin A1c of 7.0%
E. A hemoglobin A1c of 7.0%. An international expert committee issued a report in 2009 recommending that a hemoglobin A1c level ≥6.5% be used to diagnose diabetes mellitus. Other criteria include a fasting plasma glucose level ≥126 mg/dL, a random glucose leve l≥200 mg/dL in a patient with symptoms of diabetes, or a 2-hour oral glucose tolerance test value ≥200 mg/dL. While a urine dipstick may be used to screen for diabetes, it is not a diagnostic test.
Screening for osteoporosis should be done in which one of the following groups? (check one)

A. Postmenopausal women
B. Women over age 50 with a BMI ≥30 kg/m2
C. Men over age 50 with type 2 diabetes mellitus
D. Men over age 70
D. Men over age 70. All women ≥65 (SOR A) and all men ≥70 (SOR C) should be screened for osteoporosis. For men and women age 50-69, the presence of factors associated with low bone density would merit screening. Risk factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions.

Chronic systemic diseases that increase risk include COPD, HIV, severe liver disease, renal failure, systemic lupus erythematosus, and rheumatoid arthritis. Endocrine disorders that increase risk include type 1 diabetes mellitus, hyperparathyroidism, hyperthyroidism, Cushing's syndrome, and others. Medications that increase risk include anticonvulsants, corticosteroids, and immunosuppressants. Nutritional risks include celiac disease, vitamin D deficiency, anorexia nervosa, gastric bypass, and increased alcohol or caffeine intake.
In patients with chronic renal insufficiency and hypertension, the target blood pressure should be: (check one)

A. <110/70 mm Hg
B. <120/80 mm Hg
C. <130/80 mm Hg
D. <140/90 mm Hg
C. <130/80 mm Hg. Treatment of hypertension reduces the risk of stroke, myocardial infarction, and heart failure. For most patients, JNC-7 recommends a goal blood pressure of <140/90 mm Hg. However, the goal for patients with chronic kidney disease (CKD) or diabetes mellitus is <130/80 mm Hg. Both conditions are independent risk factors for cardiovascular disease. The National Kidney Foundation and the American Society of Nephrology recommend treating most patients with CKD with an ACE inhibitor or angiotensin receptor blocker (ARB), plus a diuretic, with a goal blood pressure of <130/80 mm Hg. Most patients with CKD will require two drugs to reach this goal.
A 59-year-old male with known cirrhosis is beginning to show some lower abdominal distention. Ultrasonography confirms your suspicion that he has developed moderate ascites for the first time.

Which one of the following is recommended as the initial treatment of choice for this condition? (check one)

A. Chlorthalidone
B. Spironolactone (Aldactone)
C. Furosemide (Lasix)
D. Ramipril (Altace)
E. Large-volume paracentesis
B. Spironolactone (Aldactone). In patients with grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction. Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide (SOR A). Chlorthalidone, a thiazide diuretic, is not recommended. Large-volume paracentesis is the recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is followed by salt restriction and diuretics.
About a month after returning from the Middle East, an American soldier develops a papule on his forearm that subsequently ulcerates to form a shallow annular lesion with a raised margin. The lesion shows no signs of healing 3 months after it first appeared. He has no systemic symptoms.

The most likely diagnosis is: (check one)

A. leishmaniasis
B. schistosomiasis
C. malaria
D. trypanosomiasis
E. syphilis
A. leishmaniasis. The indolent course of the sore described favors the diagnosis of cutaneous leishmaniasis. Neither malaria nor schistosomiasis produces these sores. The chancres of syphilis and trypanosomiasis are more fleeting in duration.
Random Board Review Questions 24
Which one of the following organisms is NOT killed by alcohol-based hand disinfectants? (check one)

A. Methicillin-resistant Staphylococcus aureus (MRSA)
B. Methicillin-sensitive Staphylococcus aureus
C. Pseudomonas aeruginosa
D. Klebsiella pneumoniae
E. Clostridium difficile
E. Clostridium difficile. Sporulating organisms such as Clostridium difficile are not killed by alcohol products. Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae are killed by alcohol products (SOR A).
A 53-year-old male presents with a 1-day history of swelling in his upper arm, shown in Figure 1.

The swelling appeared after a sudden painful "pop" as he was lifting a heavy box. A physical examination reveals a soft to firm, nontender mass in the anterior aspect of the arm, and weakness of forearm supination. Shoulder radiographs are normal.

Which one of the following is the most likely diagnosis? (check one)

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

Acute anterior shoulder dislocation is typically very painful, with restricted shoulder movements. Lateral epicondylitis results in pain and tenderness over a localized area of the proximal lateral forearm. Biceps tendinitis results in a deep throbbing pain over the anterior shoulder, accompanied by bicipital groove tenderness.
One week after returning from a Caribbean vacation, a 43-year-old female presents to a walk-in clinic with a complaint of redness and itching on the sole of her foot, shown in Figure 2.

She recalls experiencing a stinging sensation in the same area while she was wading in the surf on the day before she was to return home, but was unable to see any sign of injury immediately following the incident. Since her return the itching has intensified and the red area has enlarged.

The most likely cause of this condition is a: (check one)

A. filarial nematode
B. jellyfish
C. hookworm
D. roundworm
E. tapeworm
C. hookworm. When third-stage hookworm larvae, most commonly of the species infecting dogs and cats, penetrate the skin and migrate through the dermis, they create the serpiginous, erythematous tracks characteristic of cutaneous larva migrans. Although this dermatosis can occur in northern areas when conditions are ideal, it is most often encountered in tropical and semitropical regions such as the Caribbean, Africa, Asia, and South America.

Travelers to beach environments where pet feces have been previously deposited are most at risk because of the direct contact of bare skin with the sand. As in this case, a stinging or itching sensation may be noted upon penetration; this is followed by the development of the creeping eruption, which usually appears 1-5 days later, although the onset may be delayed for up to a month. The larvae will not develop in the human host, so the infection is self-limited, usually resolving within weeks to months. Treatment with antihelminthic drugs can greatly reduce the clinical course. Preventive measures include treatment of infected dogs and cats and limiting exposure to contaminated soil by wearing shoes and protective clothing.
An 80-year-old white male is admitted to the hospital with an acute myocardial infarction. He is given an antiarrhythmic for ventricular ectopic beats. During monitoring in the coronary care unit, he develops the rhythm shown on the EKG in Figure 3.
This rhythm is best described as: (check one)

A. ventricular flutter
B. ventricular fibrillation
C. ventricular tachycardia
D. torsades de pointes
D. torsades de pointes. The EKG shown represents torsades de pointes. This special form of ventricular tachyarrhythmia is often regarded as an intermediary between ventricular tachycardia and ventricular fibrillation. Morphologically it is characterized by wide QRS complexes with apices that are sometimes positive and sometimes negative. It is generally restricted to polymorphous tachycardias associated with QT prolongation.

Anything that produces or is associated with a prolonged QT interval can cause torsades de pointes, including drugs (quinidine, procainamide, disopyramide, phenothiazines), electrolyte disturbances, insecticide poisoning, subarachnoid hemorrhage, and congenital QT prolongation. Its great clinical importance lies in the fact that the usual anti-arrhythmic drugs are not only useless but contraindicated, because they can make matters worse.

Ventricular flutter is the term used by some authorities to describe a rapid ventricular tachycardia producing a regular zigzag on EKG, without clearly formed QRS complexes. Ventricular tachycardia consists of at least three consecutive ectopic QRS complexes recurring at a rapid rate. They are usually regular. Ventricular fibrillation is characterized by the complete absence of properly formed ventricular complexes; the baseline wavers unevenly, with no clear-cut QRS deflections.
A 7-year-old male complains of left shoulder pain after a bicycle accident. The neurovascular evaluation is normal. A radiograph is shown in Figure 4.
The best management for his condition is: (check one)

A. chest radiography and frequent vital sign observation
B. internal fixation under general anesthesia
C. Steinmann's pin fixation under local anesthesia
D. sending the patient home in a sling and swathe
E. a modified shoulder spica cast
D. sending the patient home in a sling and swathe. Fractures of the medial third of the clavicle in pediatric patients are common and are best treated by a figure-of-8 apparatus. Open surgical reduction with intramedullary fixation will minimize angular deformity at the fracture site but leaves a scar and may result in nonunion. With the rare exception of neurovascular injury accompanying the fracture, there are no indications for open reduction of a clavicular fracture in a child.
A 68-year-old white female with a several-year history of well-controlled essential hypertension and a history of acute myocardial infarction 2 years ago is brought to the emergency department complaining of sudden, painless, complete loss of vision in her left eye that began 1 hour ago. Her vital signs are stable, and her blood pressure is 148/90 mm Hg. Her corrected visual acuity is: left—absent, with no light perception; right—20/30. The external eye examination is entirely unremarkable. A retinal examination reveals the findings shown in Figure 5.
The most likely diagnosis is: (check one)

A. acute narrow-angle glaucoma
B. optic neuritis
C. retinal hemorrhage
D. central retinal artery occlusion
E. central retinal vein occlusion
D. central retinal artery occlusion. The retinal findings shown are consistent with central retinal artery occlusion. The painless, unilateral, sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis. Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red eye, which will lead to blindness if not treated. In persons with optic neuritis, funduscopy reveals a blurred disc and no cherry-red spot. Occlusion of the central retinal vein causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages.
The pruritic lesions on the arm shown in Figure 6 are typical of: (check one)

A. poison ivy dermatitis
B. brown recluse spider bites
C. bedbug bites
D. Hymenoptera stings
E. molluscum contagiosum
C. bedbug bites. Bedbug bites are difficult to diagnose due to the variability in bite response between people and the changes in a given individual's skin reaction over time. It is best to collect and identify bedbugs to confirm bites. Cimex lectularius injects saliva into the bloodstream of the host to prevent coagulation. It is this saliva that causes the intense itching and welts.
A 23-year-old female with a history of systemic lupus erythematosus presents with a 48-hour history of vague left precordial pain. Serum markers for acute cardiac injury are normal. An EKG performed in the emergency department is shown in Figure 7.
Which one of the following would be best at this point for determining the cause of the patient's chest pain? (check one)

A. Cardiac angiography
B. Echocardiography
C. An erythrocyte sedimentation rate
E. An antinuclear antibody titer
B. Echocardiography. Echocardiography is the most effective imaging study for the diagnosis of pericardial effusion. It is a simple, sensitive, specific, noninvasive test that can be used at the patient's beside (SOR A). The test also helps to quantify the amount of pericardial fluid and to detect the presence of any accompanying cardiac tamponade. The erythrocyte sedimentation rate, WBC count, and antinuclear antibody titer are helpful for guiding the follow-up care of patients with systemic lupus erythematosus, but not for diagnosing precordial pain. Cardiac angiography has no role in the diagnosis of pericardial effusion.
A 26-year-old male presents with hand pain. He tells you he was out drinking with friends last night and does not remember sustaining any injuries. On examination, there is diffuse swelling and tenderness across the dorsal and lateral aspects of the hand. Radiographs are shown in Figures 8 and 9.

Which one of the following would be the most appropriate treatment? (check one)

A. A wrist extension splint
B. A molded finger splint
C. A ular gutter splint
D. A short arm cast
E. Surgical pin fixation
C. A ular gutter splint. In the radiograph shown, there is a fracture of the fifth metacarpal head, commonly known as a boxer's fracture. There is only slight volar angulation and no displacement. The proper treatment for this fracture is an ulnar gutter splint, which immobilizes the wrist, hand, and fourth and fifth digits in the neutral position. Generally, 3 or 4 weeks of continuous splinting is adequate for healing.

Surgical pinning is indicated in cases of significant angulation (35°-40° or more of volar angulation) or in fractures with significant rotational deformity or displacement. The other options listed are not appropriate treatments for this injury. This injury most commonly results from "man-versus-wall" pugilistics, but other mechanisms of injury are possible.
A 27-year-old female radiology technician developed an area of redness over the left interscapular region while visiting a friend in Paris last week. The rash has progressed to include the area shown in Figure 10 and the patient says it itches. She recalls feeling somewhat tired and achy once she arrived in Paris but attributed this to jet lag. She denies any other systemic symptoms. Your examination reveals no significant findings except for the rash.
Of the following, which one is most consistent with this patient's history and examination? (check one)

A. Guttate psoriasis
B. Tinea versicolor
C. Radiation dermatitis
D. Cutaneous T-cell lymphoma
E. Pityriasis rosea
E. Pityriasis rosea. This presentation is typical of pityriasis rosea. There was a mild prodrome, thought to be jet lag by this patient, followed by the development of an ovoid salmon-colored, slightly raised herald patch, most commonly seen on the trunk. This was followed by an outbreak of multiple smaller, similar lesions that trend along Langer's lines. In this case, clear evidence of the herald patch remains visible in the left interscapular region, which is helpful in confirming the diagnosis.

Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however, the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous, scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a nonspecific dermatitis, most commonly in men over the age of 50.

An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no residual signs other than postinflammatory hyperpigmentation.
Random Board Review Questions 25
A 46-year-old female presents to your office with a 2-week history of pain in her left shoulder. She does not recall any injury, and the pain is present when she is resting and at night. Her only chronic medical problem is type 2 diabetes mellitus.
On examination, she has limited movement of the shoulder and almost complete loss of external rotation. Radiographs of the shoulder are normal, as is her erythrocyte sedimentation rate.
Which one of the following is the most likely diagnosis?
(check one)

A. Frozen shoulder
B. Torn rotator cuff
C. Impingement syndrome
D. Chronic posterior shoulder dislocation
E. Osteoarthritis
A. Frozen shoulder. Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and 60. Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory tests and plain films are normal; the diagnosis is clinical (SOR C).

Frozen shoulder is differentiated from chronic posterior shoulder dislocation and osteoarthritis on the basis of radiologic findings. Both shoulder dislocation and osteoarthritis have characteristic plain film findings. A patient with a rotator cuff tear will have normal passive range of motion. Impingement syndrome does not affect passive range of motion, but there will be pain with elevation of the shoulder.
Intravenous magnesium is used to correct which one of the following arrhythmias? (check one)

A. Wenckebach second-degree heart block
B. Complete heart block
C. Idioventricular rhythm
D. Reentrant supraventricular tachycardia
E. Ventricular tachycardia of torsades de pointes
E. Ventricular tachycardia of torsades de pointes. A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes. Results of a meta-analysis suggest that 1.2-10.0 g of intravenous magnesium sulfate also is a safe and effective strategy for the acute management of rapid atrial fibrillation.
Which one of the following is a physiologic difference between males and females that can affect the pharmacokinetics of medications with a narrow therapeutic index? (check one)

A. A consistently higher glomerular filtration rate in women
B. The typically higher BMI in women
C. Smaller fat stores in women
D. Greater gastric acid secretion in women
E. Slower gastrointestinal transit times in women
E. Slower gastrointestinal transit times in women. There are key physiologic differences between women and men that can have important implications for drug activity. Gastrointestinal transit times are slower in women than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline.
Women also secrete less gastric acid than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole. Women usually have lower BMIs than men, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions. Women typically have higher fat stores than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action. Women also have lower glomerular filtration rates than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.
A 52-year-old female with a 60-pack-year history of cigarette smoking and known COPD presents with a 1-week history of increasing purulent sputum production and shortness of breath on exertion. Which one of the following is true regarding the management of this problem? (check one)

A. Antibiotics should be prescribed
B. Intravenous corticosteroids are superior to oral corticosteroids
C. Inhaled corticosteroids should be started or the dosage increased
D. Levalbuterol (Xopenex) is superior to albuterol
E. Acetylcysteine should be given if the patient is hospitalized
A. Antibiotics should be prescribed. Antibiotic use in moderately or severely ill patients with a COPD exacerbation reduces the risk of treatment failure or death, and may also help patients with mild exacerbations. Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures. Studies have not shown a difference between oral and intravenous corticosteroids. Inhaled corticosteroids are not helpful in the management of an acute exacerbation. Levalbuterol and albuterol have similar benefits and adverse effects. Acetylcysteine, a mucolytic agent, has not been shown to be helpful for routine treatment of COPD exacerbations.
During rounds, you notice a new rash on a full-term 2-day-old white female. It consists of 1-mm pustules surrounded by a flat area of erythema, and is located on the face, trunk, and upper arms. An examination is otherwise normal, and she does not appear ill.
Which one of the following is the most likely diagnosis?
(check one)

A. Erythema toxicum neonatorum
B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. Staphylococcus aureus sepsis
A. Erythema toxicum neonatorum. This infant has the typical "flea-bitten" rash of erythema toxicum neonatorum (ETN). Transient neonatal pustular melanosis is most common in African-American newborns, and the lesions lack the surrounding erythema typical of ETN. Acne neonatorum is associated with closed comedones, mostly on the face. As the infant described is not ill, infectious etiologies are unlikely.
Which one of the following is true concerning anterior cruciate ligament (ACL) tears? (check one)

A. The incidence of ACL tears is higher in males than in females
B. ACL tears are not associated with early-onset osteoarthritis
C. The majority of ACL tears are caused by physical contact
D. Strength training can prevent ACL tears
D. Strength training can prevent ACL tears. Three trials have shown that neuromuscular training with plyometrics and strengthening reduces anterior cruciate ligament (ACL) tears. Females have a higher rate of ACL tears than males. Early-onset osteoarthritis occurs in the affected knee in an estimated 50% of patients with ACL tears. The ACL typically pops audibly when it is torn, usually with no physical contact.
Which one of the following is recommended to reduce the risk of sudden infant death syndrome (SIDS)? (check one)

A. The use of home cardiorespiratory monitors
B. The use of soft bedding materials
C. Having the infant sleep in a prone position
D. Having the infant sleep in a separate bed
E. Maintaining a room temperature of 78°F-80°F when the infant is sleeping
D. Having the infant sleep in a separate bed. Home cardiorespiratory monitoring has not been shown to be effective for preventing sudden infant death syndrome (SIDS). The risk of SIDS increases with higher room temperatures and soft bedding. Placing the infant in a supine position will significantly decrease the risk of SIDS, and is probably the most important preventive measure that can be taken. Bed sharing has been shown to increase the risk of SIDS.
A critically ill adult male is admitted to the intensive-care unit because of sepsis. He has no history of diabetes mellitus, but his glucose level on admission is 215 mg/dL and insulin therapy is ordered.
Which one of the following is the most appropriate target glucose range for this patient?
(check one)

A. 80-120 mg/dL
B. 100-140 mg/dL
C. 120-160 mg/dL
D. 140-180 mg/dL
E. 160-200 mg/dL
D. 140-180 mg/dL. The 2009 consensus guidelines on inpatient glycemic control issued by the American Association of Clinical Endocrinologists and the American Diabetes Association recommend insulin infusion with a target glucose level of 140-180 mg/dL in critically ill patients. This recommendation is based on clinical trials in critically ill patients. In the groups studied, there was no reduction in mortality from intensive treatment targeting near-euglycemic glucose levels compared to conventional management with a target glucose level of <180 mg/dL. There also were reports of harm resulting from intensive glycemic control, including higher rates of severe hypoglycemia and even increased mortality.
Which one of the following is the recommended duration of dual antiplatelet therapy after placement of a drug-eluting coronary artery stent? (check one)

A. 1 week
B. 1 month
C. 2 months
D. 3 months
E. 1 year
E. 1 year. The recommended duration of dual antiplatelet therapy following placement of a drug-eluting coronary artery stent is 1 year (SOR C). The recommended dosages of dual antiplatelet therapy are aspirin, 162-325 mg, and clopidogrel, 75 mg, or prasugrel, 10 mg. Ticlopidine is an option for patients who do not tolerate clopidogrel or prasugrel. The minimum recommended duration of dual antiplatelet therapy is 1 month with bare-metal stents, 3 months with sirolimus-eluting stents, and 6 months with other drug-eluting stents.
A 21-year-old primigravida at 28 weeks gestation complains of the recent onset of itching. On examination she has no obvious rash. The pruritus started on her palms and soles and spread to the rest of her body. Laboratory evaluation reveals elevated serum bile acids and mildly elevated bilirubin and liver enzymes.
The most effective treatment for this condition is:
(check one)

A. triamcinolone (Kenalog) cream
B. cholestyramine (Questran)
C. diphenhydramine (Benadryl)
D. doxylamine succinate
E. ursodiol (Actigall)
E. ursodiol (Actigall). This patient's symptoms and laboratory values are most consistent with intrahepatic cholestasis of pregnancy. Ursodiol has been shown to be highly effective in controlling the pruritus and decreased liver function (SOR A) and is safe for mother and fetus. Topical antipruritics and oral antihistamines are not very effective. Cholestyramine may be effective in mild or moderate intrahepatic cholestasis, but is less effective and safe than ursodiol.
Random Board Review Questions 26
Which one of the following is an appropriate rationale for antibiotic treatment of Bordetella pertussis infections? (check one)

A. It delays progression from the catarrhal stage to the paroxysmal stage
B. It reduces the severity of symptoms
C. It reduces the duration of illness
D. It reduces the risk of transmission to others
E. It reduces the need for hospitalization
D. It reduces the risk of transmission to others. Antibiotic treatment for pertussis is effective for eradicating bacterial infection but not for reducing the duration or severity of the disease. The eradication of infection is important for disease control because it reduces infectivity. Antibiotic treatment is thought to be most effective if started early in the course of the illness, characterized as the catarrhal phase. The paroxysmal stage follows the catarrhal phase. The CDC recommends macrolides for primary treatment of pertussis. The preferred antimicrobial regimen is azithromycin for 3-5 days or clarithromycin for 7 days. These regimens are as effective as longer therapy with erythromycin and have fewer side effects. Children under 1 month of age should be treated with azithromycin. There is an association between erythromycin and hypertrophic pyloric stenosis in young infants. Trimethoprim/sulfamethoxazole can be used in patients who are unable to take macrolides or where macrolide resistance may be an issue, but should not be used in children under the age of 2 months. Fluoroquinolones have been shown to reduce pertussis in vitro but have not been shown to be
clinically effective (SOR A).
A 16-year-old female cross-country runner has pain around both ankles. On examination, pain is elicited on foot inversion and there is decreased motion of the hind foot and peroneal tightness. A rigid flat foot also is observed.
Which one of the following is the most likely diagnosis?
(check one)

A. Non-ossification of the os trigonum
B. Sever's apophysitis
C. Plantar fasciitis
D. Navicular stress fracture
E. Tarsal coalition
E. Tarsal coalition. Tarsal coalition is the fusion of two or more tarsal bones. It occurs in mid-to late adolescence and is bilateral in 50% of those affected. Pain occurs around the ankle, and there is decreased range of motion of the hindfoot and pain on foot inversion on examination. Os trigonum results from non-ossification of cartilage. It usually is unilateral and causes palpable tenderness of the heel. Sever's apophysitis is inflammation of the calcaneal apophysis, and causes pain in the heel. Plantar fasciitis causes tenderness over the anteromedial heel. Navicular stress fractures are tender over the dorsomedial navicular.
Which one of the following is true concerning breast cancer screening? (check one)

A. It is useful for detecting premalignant conditions
B. It can predict which of the discovered cancers are indolent, with a low potential for harm
C. The decrease in mortality from breast cancer can be attributed almost entirely to early detection
D. It has resulted in an increase in the diagnosis of localized disease
E. It has resulted in a significant decrease in the incidence of regional and metastatic disease
D. It has resulted in an increase in the diagnosis of localized disease. Breast cancer screening has resulted in an increase in the diagnosis of localized disease without a commensurate decrease in the incidence of more widespread disease. Unfortunately, it cannot predict which of the discovered cancers are more aggressive, and cannot accurately detect premalignant lesions. The decrease in the mortality rate of breast cancer is due both to earlier detection and better follow-up medical care.
You make a diagnosis of depression in a 26-year-old female. Her BMI is 32 kg/m² and she has been trying to lose weight. Which one of the following antidepressants would be LEAST likely to cause her to gain weight? (check one)

A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)
C. Bupropion (Wellbutrin). Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight loss. All of the other choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the most weight gain and fluoxetine with the least. Mirtazapine has been associated with more weight gain than the SSRIs.
Medicare pays for which one of the following? (check one)

A. Routine dental care
B. Custodial nursing-home care
C. Hearing aids
D. Screening mammography
D. Screening mammography. Medicare pays for some preventive measures, including pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou test every 3 years. Medicare does not pay for custodial care, nursing-home care (except limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids, routine physical checkups and related tests, or prescription drugs.
A 24-year-old female presents to your clinic with a 5-day history of fever to 103°F. She has no localizing symptoms or overt physical findings. Initial testing shows an elevated WBC count with a disproportionate number of reactive lymphocytes.
Which one of the following conditions is the most likely cause of these findings?
(check one)

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

A. Lumbar spine extension
B. Lumbar spine flexion
C. Internal hip rotation
D. Pressure against the lateral hip and trochanter
E. Walking uphill
A. Lumbar spine extension. Extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking downhill can cause this. Spinal flexion that decreases lordosis has the opposite effect, and will usually improve the pain, as will sitting.

Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin. Pain in the lateral hip is more typical of trochanteric bursitis. Increased pain walking uphill is more typical of vascular claudication.
Which one of the following is true concerning the use of short-acting inhaled β-agonists for asthma? (check one)

A. They should be given before any inhaled corticosteroid to facilitate lung delivery
B. They are ineffective in patients taking β-blockers
C. They are less effective than oral β-agonists
D. They are less effective than anticholinergic bronchodilators when given with inhaled corticosteroids
E. Their effects begin within 5 minutes and last 4-6 hours
E. Their effects begin within 5 minutes and last 4-6 hours. The effects of short-acting inhaled β-agonists begin within 5 minutes and last 4-6 hours. In the past, giving inhaled β-agonists just before inhaled corticosteroids was felt to improve the delivery and effectiveness of the corticosteroids. However, this has been proven to be ineffective and is no longer recommended. β-Blockers do diminish the effectiveness of inhaled β-agonists, but this effect is not severe enough to contraindicate using these drugs together. Oral β-agonists are less potent than inhaled forms. Similarly, anticholinergic drugs cause less bronchodilation than inhaled β-agonists and are not recommended as
first-line therapy.
Which one of the following is true regarding NSAIDs? (check one)

A. They are cardioprotective
B. They should be avoided in persons with cirrhotic liver disease
C. They are not safe in pregnancy
D. They are not safe in lactating women
B. They should be avoided in persons with cirrhotic liver disease. NSAIDs are prescribed commonly and many are available over the counter. It is important for clinicians to understand when they are not appropriate for clinical use. They should be avoided, if possible, in persons with hepatic cirrhosis (SOR C). While hepatotoxicity with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients, as they further impair platelet function. In addition, NSAIDs decrease blood flow to the kidneys and can increase the risk of renal failure in patients with cirrhosis.

NSAIDs differ from aspirin in terms of their cardiovascular effects. They have the potential to increase cardiovascular morbidity, worsen heart failure, increase blood pressure, and increase events such as ischemia and acute myocardial infarction.

There are no known teratogenic effects of NSAIDs in humans. This drug class is considered to be safe in pregnancy in low, intermittent doses, although discontinuation of NSAID use within 6-8 weeks of term is recommended. Ibuprofen, indomethacin, and naproxen are considered safe for lactating women, according to the American Academy of Pediatrics.
A 5-year-old female is seen for a kindergarten physical and is noted to be below the 3rd percentile for height. A review of her chart shows that her height curve has progressively fallen further below the 3rd percentile over the past year. She was previously at the 50th percentile for height. The physical examination is otherwise normal, but your workup shows that her bone age is delayed.
Of the following conditions, which one is the most likely cause of her short stature?
(check one)

A. Constitutional growth delay
B. Growth hormone deficiency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia
B. Growth hormone deficiency. This patient has delayed bone age coupled with a reduced growth velocity, which suggests an underlying systemic cause. Growth hormone deficiency is one possible cause for this. Although bone age can be delayed with constitutional growth delay, after 24 months of age growth curves are parallel to the 3rd percentile. Bone age would be normal with genetic short stature. Patients with Turner syndrome or skeletal dysplasia have dysmorphic features, and bone age would be normal.
Random Board Review Questions 27
The preferred method for diagnosing psychogenic nonepileptic seizures is: (check one)

A. inducing seizures by suggestion
B. postictal prolactin levels
C. EEG monitoring
D. video-electroencephalography (vEEG) monitoring
E. brain MRI
D. video-electroencephalography (vEEG) monitoring. Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.
Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.
MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.
A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior pharynx. Which one of the following is the most likely diagnosis? (check one)

A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola infantum
E. Rubella
A. Herpangina. Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area (SOR C). Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.
A 45-year-old female presents with a rash on the central portion of her face. She states that she has intermittent flushing and intense erythema that feels as if her face is stinging. She has noticed that her symptoms can be worsened by sun exposure, emotional stress, alcohol, or eating spicy foods. She has been in good health and has taken conjugated estrogens (Premarin), 0.625 mg daily, since a hysterectomy for benign reasons. A general examination is normal except for erythema of the cheeks and chin. No pustules or comedone formation is noted around her eyes, but telangiectasias are present.
Which one of the following would be appropriate in the management of this problem?
(check one)

A. Increasing her estrogen dosage
B. Referral to a rheumatologist
C. Low-potency non-fluorinated topical corticosteroids
D. Oral prednisone
E. Metronidazole gel (MetroGel)
E. Metronidazole gel (MetroGel). Rosacea is a relatively common condition seen most often in women between the ages of 30 and 60. Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules. Facial edema also may occur. Some patients develop rhinophyma due to hypertrophy of the subcutaneous glands of the nose. The usual presenting symptoms are central facial erythema and flushing that many patients find socially embarrassing. Flushing can be triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis.

Management includes avoidance of precipitating factors and use of sunscreen. Oral metronidazole, doxycycline, or tetracycline also can be used, especially if there are ocular symptoms. These are often ineffective for the flushing, so low-dose clonidine or a nonselective β-blocker may be added.

Topical treatments such as metronidazole and benzoyl peroxide may also be effective, particularly for mild cases. Other illnesses to consider include acne, photodermatitis, systemic lupus erythematosus, seborrheic dermatitis, carcinoid syndrome, and mastocytosis.
Which one of the following confirmed findings in a 3-year-old female is diagnostic of sexual abuse? (check one)

A. Bacterial vaginosis
B. Genital herpes
C. Gonorrhea
D. Anogenital warts
E. Hepatitis
C. Gonorrhea. The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2-3 years. Although a diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended.
A 63-year-old male with type 2 diabetes mellitus is seen in the emergency department for an acute, superficial, previously untreated infected great toe. Along with Staphylococcus aureus, which one of the following is the most common pathogen in this situation? (check one)

A. Pseudomonas
B. Streptococcus
C. Clostridium
D. Escherichia coli
E. Adenovirus
B. Streptococcus. The most common pathogens in previously untreated acute superficial foot infections in diabetic patients are aerobic gram-positive Staphylococcus aureus and β-hemolytic streptococci (groups A, B, and others). Previously treated and deep infections are often polymicrobial.
An obese, hypertensive 53-year-old physician suffers a cardiac arrest while making rounds. He is resuscitated after 15 minutes of CPR, but remains comatose.
Which one of the following is associated with the lowest likelihood of neurologic recovery in this situation?
(check one)

A. Duration of CPR >10 minutes
B. No pupillary light reflex at 30 minutes
C. No corneal reflex at 2 hours
D. No motor response to pain at 6 hours
E. Myoclonic status epilepticus at 24 hours
E. Myoclonic status epilepticus at 24 hours. It is difficult to establish a prognosis in a comatose patient after a cardiac arrest. The duration of CPR is not a factor, and the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours. Myoclonic status epilepticus at 24 hours suggests no possibility of a recovery.
A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N 8.6-10.2) on routine laboratory screening. To confirm the hypercalcemia you order an ionized calcium level, which is 1.49 mmol/L (N 1.14-1.32). Additional testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15-75) and a urine calcium excretion of 386 mg/24 hr (N 100-300).

Which one of the following is the most likely cause of the patient's hypercalcemia? (check one)

A. Primary hyperparathyroidism
B. Malignancy
C. Familial hypocalciuric hypercalcemia
D. Hypoparathyroidism
E. Hyperthyroidism
A. Primary hyperparathyroidism. Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. These conditions must be differentiated early to provide the patient with optimal treatment and an accurate prognosis. Humoral hypercalcemia of malignancy implies a very limited life expectancy—often only a matter of weeks. On the other hand, primary hyperparathyroidism has a relatively benign course. Intact parathyroid hormone (PTH) will be suppressed in cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma. Thyrotoxicosis-induced bone resorption elevates serum calcium, which also results in suppression of PTH.

Patients with familial hypocalciuric hypercalcemia (FHH) have moderate hypercalcemia but relatively low urinary calcium excretion. PTH levels can be normal or only mildly elevated despite the hypercalcemia. This mild elevation can lead to an erroneous diagnosis of primary hyperparathyroidism. The conditions can be differentiated by a 24-hour urine collection for calcium; calcium levels will be high or normal in patients with hyperparathyroidism and low in patients with FHH.
A 40-year-old male who recently immigrated from central Africa presents to a public health clinic where you are working. He was referred by a physician in the local emergency department, who made a diagnosis of type 2 diabetes mellitus. The patient has no history of fever or night sweats, weight loss, or cough. He does have a history of receiving bacille Calmette-Guérin (BCG) vaccine in the past. Screening tests for HIV and hepatitis performed in the emergency department were negative.

Which one of the following is true regarding screening for latent tuberculosis infection by in vitro interferon-gamma release assay (IGRA) compared to screening by the traditional targeted tuberculin skin test (TST) in this patient? (check one)

A. Both tests require subjective interpretation
B. BCG interferes with IGRA results
C. IGRA differentiates Mycobacterium tuberculosis from nontuberculous mycobacteria
D. IGRA results are valid if the sample is analyzed within 24 hours
E. IGRA should be done in tandem with TST
C. IGRA differentiates Mycobacterium tuberculosis from nontuberculous mycobacteria. In vitro interferon-gamma release assays (IGRAs) are a new way of screening for latent tuberculosis infection. One of the advantages of IGRA is that it targets antigens specific to Mycobacterium tuberculosis. These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results of IGRA are objective. It is unnecessary for IGRA to be done in tandem with skin testing, and it eliminates the need for two-step testing in high-risk patients. IGRAs are labor intensive, however, and the blood sample must be received by a qualified laboratory and incubated with the test antigens within 8-16 hours of the time it was drawn,depending upon the brand of cuurently available IGRAs
An 11-year-old female has been diagnosed with "functional abdominal pain" by a pediatric gastroenterologist. Her mother brings her to see you because of concerns that another diagnosis may have been overlooked despite a very thorough and completely normal evaluation for organic causes.
Which one of the following would you recommend? (check one)

A. A trial of inpatient hospital admission
B. Increased testing and levels of referral until a true diagnosis is reached
C. Removing the child from school and activities whenever symptoms occur
D. Medications to eradicate symptoms
E. Stress reduction and participation in usual activities as much as possible
E. Stress reduction and participation in usual activities as much as possible. The diagnosis of functional abdominal pain is made when no structural, infectious, inflammatory, or biochemical cause for the pain can be found. It is the most common cause of recurrent abdominal pain in children 4-16 years of age. The use of medications may be helpful in reducing (but rarely eradicating) functional symptoms, and remaining open to the possibility of a previously unrecognized organic disorder is appropriate. However, continuing to focus on organic causes, invasive tests, or physician visits can actually perpetuate a child's complaints and distress.

It is estimated that approximately 30%-50% of children with functional abdominal pain will have resolution of their symptoms within 2 weeks of diagnosis. Recommendations for managing this problem include focusing on participation in normal age-appropriate activities, reducing stress and addressing emotional distress, and teaching the family to cope with the symptoms in a way that prevents secondary gain on the part of the child.
Amiodarone (Cordarone) is most useful for which one of the following? (check one)

A. Prophylactic perioperative use for emergency surgery
B. Primary prevention of nonischemic cardiomyopathy
C. Treatment of atrial flutter
D. Treatment of multi-focal premature ventricular contractions following acute myocardial infarction
E. Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability
E. Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability. Amiodarone is one of the most frequently prescribed antiarrhythmic medications in the U.S. It is useful in the acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability. Amiodarone is appropriate first-line treatment for atrial fibrillation only in symptomatic patients with left ventricular dysfunction and heart failure. It has a very limited role in the treatment of atrial flutter. The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery. The use of prophylactic antiarrhythmic agents in the face of "warning dysrhythmias" or after myocardial infarction is no longer recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with nonischemic cardiomyopathy.
Random Board Review Questions 28
A 72-year-old male has had persistent interscapular pain with movement since rebuilding his deck 1 week ago. He rates the pain as 6 on a 10-point scale. A chest radiograph shows a thoracic vertebral compression fracture.

Which one of the following would be most appropriate at this point?
(check one)

A. Complete bed rest for 2 weeks
B. Markedly decreased activity until the pain lessens, and follow-up in 1 week
C. Referral for vertebroplasty as soon as possible
D. NSAIDs and referral for physical therapy
B. Markedly decreased activity until the pain lessens, and follow-up in 1 week. This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks. Complete bed rest is unnecessary and could lead to complications. Physical therapy is not indicated, and NSAIDs should be used with caution.
On his first screening colonoscopy, a 67-year-old male is found to have a 0.5-cm adenomatous polyp with low-grade dysplasia.

According to current guidelines, when should this patient have his next colonoscopy?
(check one)

A. 6 months
B. 1 year
C. 3 years
D. 5 years
E. Screening is no longer necessary
D. 5 years. Overuse of colonoscopy has significant costs. In response to these concerns, the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer collaborated on a consensus guideline on the use of surveillance colonoscopy. According to these guidelines, patients with one or two small (<1 cm) tubular adenomas, including those with only low-grade dysplasia, should have their next colonoscopy in 5-10 years (SOR B).
A 25-year-old female has been trying to conceive for over 1 year without success. Her menstrual periods occur approximately six times per year. Laboratory evaluation of her hormone status has been negative, and her husband has a normal semen analysis. Her only other medical problem is hirsutism, which has not responded to topical treatment. Pelvic ultrasonography of her uterus and ovaries is unremarkable.

Of the following, which one would be the most appropriate treatment for her infertility? (check one)

A. Metformin (Glucophage)
B. Danazol
C. Medroxyprogesterone (Provera)
D. Spironolactone (Aldactone)
A. Metformin (Glucophage). This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis.

Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to decrease hirsutism and improve insulin resistance and menstrual irregularities. Metformin and clomiphene alone or in combination are first-line agents for ovulation induction. Clomiphene does not improve hirsutism, however. Progesterone is not indicated for any of this patient's problems. Spironolactone will improve hirsutism and menstrual irregularities, but is not indicated for ovulation induction.
When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a spacer has been shown to result in which one of the following, compared to use of a nebulizer? (check one)

A. Higher hospitalization rates
B. Shorter stays in the emergency department
C. Higher relapse rates
D. Less improvement in peak-flow rates
E. Increases in the total dose of albuterol
B. Shorter stays in the emergency department. Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates.
A 31-year-old female who is a successful professional photographer complains of hoarseness that started suddenly 3 weeks ago. She says she can remember exactly what day it was, because her divorce became final the next day. The day the problem began, she was only able to whisper from the time she woke up, and she is able to speak only in a weak whisper while relating her history. She does not appear to strain while speaking. She does not smoke, has had no symptoms of an upper respiratory infection, and has no pain, cough, or wheezing.

She is on a proton pump inhibitor prescribed by an urgent care provider 2 weeks ago. This has not changed her symptoms. She takes no other medications and has no known allergies. A head and neck examination, including indirect laryngoscopy, is within normal limits.

Which one of the following is the most likely diagnosis?
(check one)

A. Muscle tension aphonia
B. Laryngopharyngeal reflux
C. Spasmodic dysphonia
D. Vocal abuse
E. Conversion aphonia
E. Conversion aphonia. This patient has conversion aphonia. In this condition, the patient loses his or her spoken voice, but the whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce) (SOR C).

Muscle tension aphonia presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example. The patient with laryngopharyngeal reflux presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing.

The patient with spasmodic dysphonia (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm. The hoarseness of vocal abuse is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.
A 62-year-old diabetic with stage 2 renal dysfunction is evaluated for knee pain that has mildly interfered with his usual activities over the past 3 months. On examination he is mildly tender over the medial joint line. A knee radiograph shows moderate medial joint space narrowing.
In addition to low-impact exercise, which one of the following would you recommend initially?
(check one)

A. Intra-articular hyaluronic acid
B. Intra-articular corticosteroids
C. Celecoxib (Celebrex)
D. Naproxen
E. Acetaminophen
E. Acetaminophen. Intra-articular injections should not be considered first-line treatment for symptomatic osteoarthritis of the knee. They are recommended for short-term pain control, with the evidence for hyaluronic acid being somewhat weak. Renal dysfunction is a contraindication to the use of NSAIDs. Acetaminophen is the first-line treatment in this case.
A 24-year-old female presents with pelvic pain. She says that the pain is present on most days, but is worse during her menses. Ibuprofen has helped in the past but is no longer effective. Her menses are normal and she has only one sexual partner. A physical examination is normal.

Which one of the following should be the next step in the workup of this patient? (check one)

A. Transvaginal ultrasonography
B. CT of the abdomen and pelvis
C. MRI of the pelvis
D. A CA-125 level
E. Colonoscopy
A. Transvaginal ultrasonography. The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would be indicated if the history or examination suggests a gastrointestinal source for the pain after the initial evaluation.
A 7-year-old male presents with a fever of 38.5°C (101.3°F), a sore throat, tonsillar inflammation, and tender anterior cervical adenopathy. He does not have a cough or a runny nose. His younger sister was treated for streptococcal pharyngitis last week and his mother would like him to be treated for streptococcal infection.

Which one of the following is true concerning this situation?
(check one)

A. Empiric antibiotic treatment for streptococcal pharyngitis is warranted.
B. The chance of this patient having a positive rapid antigen detection test for Streptococcus is <50%.
C. There is a generalized consensus among the various national guidelines for management of pharyngitis.
D. The patient should have a tonsillectomy when he recovers from this infection.
E. The family dog should be treated for streptococcal infection.
A. Empiric antibiotic treatment for streptococcal pharyngitis is warranted.. The patient has a score of 5 under the Modified Centor scoring system for management of sore throat. Patients with a score ≥4 are at highest risk (at least 50%) of having group A β-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with antibiotics is warranted. Various national and international organizations disagree about the best way to manage pharyngitis, with no consensus as to when or how to test for GABHS and who should receive treatment. The minimal benefit seen with tonsillectomy in reducing the incidence of recurrent GABHS pharyngitis does not justify the risks or cost of surgery. Treatment of pets for the prevention of GABHS infection has proven ineffective.
A 24-year-old female with a 2-year history of dyspnea on exertion has been diagnosed with exercise-induced asthma by another physician. Which one of the following findings on pulmonary function testing would raise concerns that she actually has vocal cord dysfunction? (check one)

A. A good response to an inhaled β-agonist
B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase
C. Flattening of the expiratory portion of the flow-volume loop, but a normal inspiratory phase
D. Flattening of both the inspiratory and expiratory portion of the flow-volume loop
E. A decreased FEV1 and a normal FVC
B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase. The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase (SOR C). A decreased FEV1 and normal FVC would be consistent with asthma.
A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-leg heel raise.
Which one of the following is true regarding this problem?
(check one)

A. The patient most likely has a medial ankle sprain
B. NSAIDs will improve the long-term outcome
C. Injecting a corticosteroid into the tendon sheath of the involved tendon is recommended
D. A lateral heel wedge should be prescribed
E. Immobilization in a cast boot for 3 weeks is indicated
E. Immobilization in a cast boot for 3 weeks is indicated. The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon's function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity.

The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture.

Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem.

While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2-3 weeks.
Random Board Review Questions 29
A 70-year-old male presents to your office for a follow-up visit for hypertension. He was started on lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC and a complete metabolic panel, were normal except for a serum creatinine level of 1.5 mg/dL (N 0.6-1.5). A follow-up renal panel obtained yesterday shows a creatinine level of 3.2 mg/dL and a BUN of 34 mg/dL (N 8-25).

Which one of the following is the most likely cause of this patient's increased creatinine level? (check one)

A. Bilateral renal artery stenosis
B. Coarctation of the aorta
C. Essential hypertension
D. Hyperaldosteronism
E. Pheochromocytoma
A. Bilateral renal artery stenosis. Classic clinical clues that suggest a diagnosis of renal-artery stenosis include the onset of stage 2 hypertension (blood pressure >160/100 mm Hg) after 50 years of age or in the absence of a family history of hypertension; hypertension associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the renin-angiotensin-aldosterone system; hypertension with repeated hospital admissions for heart failure; and drug-resistant hypertension (defined as blood pressure above the goal despite treatment with three drugs of different classes at optimal doses). The other conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE inhibitor.
A 58-year-old male presents with a several-day history of shortness of breath with exertion, along with pleuritic chest pain. His symptoms started soon after he returned from a vacation in South America. He has a history of deep-vein thrombosis (DVT) in his right leg after surgery several years ago, and also has a previous history of prostate cancer. You suspect pulmonary embolism (PE.).

Which one of the following is true regarding the evaluation of this patient? (check one)

A. CT angiography would reliably either confirm or rule out PE
B. Compression ultrasonography of the lower extremities will reveal a DVT in the majority of patients with PE
C. No further testing is needed if a ventilation-perfusion lung scan shows a low probability of PE
D. No further testing is needed if a D-dimer level is normal
E. An elevated D-dimer level would confirm the diagnosis of PE
A. CT angiography would reliably either confirm or rule out PE. This patient has a high clinical probability for pulmonary embolism (PE). About 40% of patients with PE will have positive findings for deep-vein thrombosis in the lower extremities on compression ultrasonography. A normal ventilation-perfusion lung scan rules out PE, but inconclusive findings are frequent and are not reassuring. A normal D-dimer level reliably rules out the diagnosis of venous thromboembolism in patients at low or moderate risk of pulmonary embolism, but the negative predictive value of this test is low for high-probability patients. A positive D-dimer test does not confirm the diagnosis; it indicates the need for further testing, and is thus not necessary for this patient. A multidetector CT angiogram or ventilation-perfusion lung scan should be the next test, as these are reliable to confirm or rule out PE.
A 30-year-old white gravida 2 para 1 who has had no prenatal care presents for urgent care at 33 weeks gestation. Her symptoms include vaginal bleeding, uterine tenderness, uterine pain between contractions, and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term.
Which one of the following is the most likely diagnosis? (check one)

A. Uterine rupture
B. Vasa previa
C. Placenta previa
D. Placental abruption
E. Cervical cancer
D. Placental abruption. Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental insufficiency and/or premature birth. The condition described here is placental abruption (separation of the placenta from the uterine wall before delivery).

There are several causes of vaginal bleeding that can occur in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother.

Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress. The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically painless, unless labor or placental abruption occurs.
A 43-year-old female complains of a several-month history of unpleasant sensations in her legs and an urge to move her legs. These symptoms only occur at night and improve when she gets up and stretches. The sensations often awaken her, and she feels very tired. She has no other medical problems and takes no medication. Laboratory tests reveal a serum calcium level of 8.9 mg/dL (N 8.5-10.5), a serum potassium level of 4.1 mmol/L (N 3.5-5.0), a serum ferritin level of 15 ng/mL (N 10-200), and a serum magnesium level of 1.5 mEq/L (N 1.4-2.0).

Which one of the following may improve her symptoms? (check one)

A. Iron supplementation
B. Magnesium supplementation
C. Antihistamines
D. Stopping calcium supplementation
E. Amitriptyline
A. Iron supplementation. This patient has restless legs syndrome, which includes unpleasant sensations in the legs and can cause sleep disturbances. The symptoms are relieved by movement. Recommendations for treatment include lower-body resistance training and avoiding or changing medications that may exacerbate symptoms (e.g., antihistamines, caffeine, SSRIs, tricyclic antidepressants, etc.). It is also recommended that patients with a serum ferritin level below 50 ng/mL take an iron supplement (SOR C). Magnesium supplementation does not improve restless legs syndrome. Ropinirole may be used if nonpharmacologic therapies are ineffective.
A 56-year-old female with well-controlled diabetes mellitus and hypertension presents with an 18-hour history of progressive left lower quadrant abdominal pain, low-grade fever, and nausea. She has not been able to tolerate oral intake over the last 6 hours. An abdominal examination reveals significant tenderness in the left lower quadrant with slight guarding but no rebound tenderness. Bowel sounds are hypoactive. Rectal and pelvic examinations are unremarkable.

Which one of the following is recommended as the initial diagnostic procedure in this situation? (check one)

A. CT of the abdomen and pelvis
B. Abdominal and pelvic ultrasonography
C. A barium enema
D. Colonoscopy
E. Laparoscopy
A. CT of the abdomen and pelvis. Based on the history and physical examination, this patient most likely has acute diverticulitis. CT has a very high sensitivity and specificity for this diagnosis, provides information on the extent and stage of the disease, and may suggest other diagnoses. Ultrasonography may be helpful in suggesting other diagnoses, but it is not as specific or as sensitive for diverticulitis as CT.

Limited-contrast studies of the distal colon and rectum may occasionally be useful in distinguishing between diverticulitis and carcinoma, but would not be the initial procedure of choice. Water-soluble contrast material is used in this situation instead of barium. Colonoscopy to detect other diseases, such as cancer or inflammatory bowel disease, is deferred until the acute process has resolved, usually for 6 weeks. The risk of perforation or exacerbation of the disease is greater if colonoscopy is performed acutely. Diagnostic laparoscopy is rarely needed in this situation. Laparoscopic or open surgery to drain an abscess or resect diseased tissue is reserved for patients who do not respond to medical therapy. Elective sigmoid resection may be considered after recovery in cases of recurrent episodes.
Which one of the following is true concerning Norwalk virus? (check one)

A. Outbreaks occur mostly in settings with large numbers of children, such as schools and day-care centers
B. Viral shedding continues long after the acute illness
C. The virus does not survive long on most environmental surfaces
D. An episode of Norwalk gastroenteritis leads to long-lasting immunity
E. It is a less common cause of diarrhea in adults than Shigella
B. Viral shedding continues long after the acute illness. Outbreaks of Norwalk gastroenteritis occur in a wide variety of settings, involve all ages, and are more likely to involve high-risk groups such as immunocompromised patients or the elderly. Not only does viral shedding of the Norwalk virus often precede the onset of illness, but it can continue long after the illness has clinically ended. The virus persists on environmental surfaces and can tolerate a broad range of temperatures. There are multiple strains of the virus, so a single infection does not confer immunity, and repeated infections occur throughout life. It is the most common cause of diarrhea in adults.
Patient-centered medical home is a term used to describe which one of the following developments in medical care? (check one)

A. A federally imposed restriction on family medicine's role in providing care
B. A physician-led team of care providers taking responsibility for the quality and safety of an individual's health
C. A "practice without walls" that provides primary care services in the homes of patients
D. A small group of patients paying an annual fee to have a physician be available to them at all times
E. Improving the dignity of care for nursing-home residents
B. A physician-led team of care providers taking responsibility for the quality and safety of an individual's health. The patient-centered medical home (PCMH) is a development in primary care that stresses a personal physician leading a multidisciplinary team that takes responsibility for integrating and coordinating an individual's care. Quality and safety are hallmarks of the PCMH, which stresses outcome-based and evidence-supported practices. This concept was originated by organizations in the field of pediatrics and was further developed by a collaboration of the major academies of primary care. There are institutions that accredit individual and group practices as fulfilling the role of a PCMH, which are now being compensated at a higher level by third-party payers, including Medicare.
Which one of the following Mantoux tuberculin skin test results should be read as NEGATIVE for latent tuberculosis infection? (check one)

A. 7 mm induration on an individual having recent household contact with a tuberculosis patient
B. 8 mm induration on an HIV-positive individual who has no documented previous test result
C. 10 mm induration on a nursing-home resident
D. 12 mm induration on a homeless individual
E. 9 mm induration on a hospital-based nurse who had a test with 2 mm induration 1 year ago
E. 9 mm induration on a hospital-based nurse who had a test with 2 mm induration 1 year ago. Three different cutoff levels defining a positive reaction on a tuberculin skin test are recommended by the CDC, each based on the level of risk and consideration of immunocompetence. For those who are at highest risk and/or immunocompromised, including HIV-positive patients, transplant patients, and household contacts of a tuberculosis patient, an induration ≥5 mm is considered positive. For those at low risk of exposure, a screening test is not recommended, but if one is performed, induration ≥15 mm is considered positive.

For those who have an increased probability of exposure or risk, an induration ≥10 mm should be read as positive. This group includes children; employees or residents of nursing homes, correctional facilities, or homeless shelters; recent immigrants; intravenous drug users; hospital workers; and those with chronic illnesses. For individuals who are subject to repeated testing, such as health-care workers, an increase in induration of 10 mm or more within a 2-year period would be considered positive and an indication of a recent infection with Mycobacterium tuberculosis. A nurse with a 9-mm induration would be considered to have a negative PPD.
The Health Insurance Portability and Accountability Act (HIPAA) (check one)

A. sets a federal minimum on the protection of privacy
B. requires that privacy notices be acknowledged and signed at each office visit
C. allows the patient to inspect and obtain a copy of his/her record without exception
D. requires privacy notices prior to giving emergency care
A. sets a federal minimum on the protection of privacy. HIPAA regulations set a minimum standard for privacy protection. Privacy notices must be provided at the first delivery of health services, and written acknowledgement is encouraged but not required.Exceptions to patient inspections include psychotherapy notes and instances where disclosure is likely to cause substantial harm to the patient or another individual in the judgment of a licensed health professional. Although it is not necessary to provide patients with a privacy notice before rendering emergency care, it is required that patients be provided with a privacy notice after the emergency has ended.
Estimating the 10-year risk of developing coronary heart disease with the Framingham Heart Study Score Sheet would be most reliable when applied to which one of the following individuals? (check one)

A. A 19-year-old female with a strong family history of cardiac disease
B. An obese 50-year-old male with a history of a previous myocardial infarction
C. An otherwise healthy 36-year-old white male smoker
D. A postmenopausal 54-year-old female with angina
E. A 78-year-old male with a history of hypertension
C. An otherwise healthy 36-year-old white male smoker. The 10-year risk of developing coronary heart disease can be effectively predicted with the algorithmic calculator developed using multivariable data collected over a period of more than half a century as part of the Framingham Heart Study. This iconic study defined what are now commonly known as major risk factors: elevated blood pressure, cigarette smoking, cholesterol levels, diabetes mellitus, and advancing age. Using measurements of each of these risk factors and consideration of the gender of the individual,a reliable determination of risk can be obtained in individuals 30-74 years of age who have no overt coronary heart disease. The largely white study population presumptively makes the risk determination most accurate for white patients.
Random Board Review Questions 30
A 53-year-old male presents to your office with a several-day history of hiccups. They are not severe, but have been interrupting his sleep, and he is becoming exasperated.

What should be the primary focus of treatment in this individual?
(check one)

A. Drug treatment to prevent recurrent episodes
B. Decreasing the intensity of the muscle contractions in the diaphragm
C. Finding the underlying pathology causing the hiccups
D. Improving the patient's quality of sleep
E. Suppressing the current hiccup symptoms
C. Finding the underlying pathology causing the hiccups. Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter of hours are usually benign and self-limited, and may be caused by gastric distention. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment, although only chlorpromazine is FDA-approved for this indication.

If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups. In one study, 66% of patients who experienced hiccups for longer than 2 days had an underlying physical cause. Identifying and treating the underlying disorder should be the focus of management for intractable hiccups.
An 82-year-old male nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of multi-infarct dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding.

Which one of the following is the most likely cause of this patient's bleeding?
(check one)

A. Peptic ulcer disease
B. Ischemic colitis
C. Diverticular bleeding
D. Angiodysplasia
E. Infectious colitis
B. Ischemic colitis. This patient most likely has ischemic colitis, given the abdominal pain, bloody diarrhea, and cardiovascular risks. Peptic ulcer disease is unlikely because the nasogastric aspirate was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is associated with fever.
A 62-year-old female undergoes elective surgery and is discharged on postoperative day 3. A week later she is hospitalized again with pneumonia. A CBC shows that her platelet count has dropped to 150,000/mm3 (N 150,000-300,000) from 350,000 /mm3 a week ago. She received prophylactic heparin postoperatively during her first hospitalization.

The patient is started on intravenous antibiotics for the pneumonia and subcutaneous heparin for deep-vein thrombosis prophylaxis. On hospital day 2, she has an acute onset of severe dyspnea and hypoxia; CT of the chest reveals bilateral pulmonary emboli. Her platelet count is now 80,000/mm3 .

Which one of the following would be most appropriate at this point? (check one)

A. Continue subcutaneous heparin
B. Discontinue subcutaneous heparin and start a continuous intravenous heparin drip
C. Discontinue heparin and give a platelet transfusion
D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask)
E. Discontinue unfractionated heparin and start a low molecular weight heparin such as enoxaparin (Lovenox)
D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask). This patient needs prompt evaluation and treatment for probable heparin-induced thrombocytopenia (HIT). HIT is a potentially life-threatening syndrome that usually occurs within 1-2 weeks of heparin administration and is characterized by the presence of HIT antibodies in the serum, associated with an otherwise unexplained 30%-50% decrease in the platelet count, arterial or venous thrombosis, anaphylactoid reactions immediately following heparin administration, or skin lesions at the site of heparin injections. Postoperative patients receiving subcutaneous unfractionated heparin prophylaxis are at highest risk for HIT. Because of this patient's high-risk scenario and the presence of acute thrombosis, it is advisable to begin immediate empiric treatment for HIT pending laboratory confirmation. Management should include discontinuation of heparin and treatment with a non-heparin anticoagulant.
A 64-year-old male presents with a 3-month history of difficulty sleeping. A history and physical examination, followed by appropriate ancillary testing, leads to a diagnosis of chronic primary insomnia.
Which one of the following would be most appropriate for managing this patient's problem? (check one)

B. A small glass of wine 1 hour before bedtime
C. Cognitive-behavioral therapy
D. Watching television at bedtime, with the timer set to turn off in 60 minutes
E. Reading in bed with a soft light
C. Cognitive-behavioral therapy. Chronic insomnia is defined as difficulty with initiating or maintaining sleep, or experiencing nonrestorative sleep, for at least 1 month, leading to significant daytime impairment. Primary insomnia is not caused by another sleep disorder, underlying psychiatric or medical condition, or substance abuse disorder. Cognitive-behavioral therapy is effective for managing this problem, and should be used as the initial treatment for chronic insomnia. It has been shown to produce sustained improvement at both 12 and 24 months after treatment is begun. One effective therapy is stimulus control, in which patients are taught to eliminate distractions and associate the bedroom only with sleep and sex. Reading and television watching should occur in a room other than the bedroom.

Pharmacotherapy alone does not lead to sustained benefits. SSRIs can cause insomnia, as can alcohol.
Which one of the following would be most appropriate for stroke prevention in a patient with hypertension, diabetes mellitus, and atrial fibrillation? (check one)

A. Clopidogrel (Plavix)
B. Aspirin
C. Dipyridamole (Persantine)
D. Warfarin (Coumadin)
E. Enoxaparin (Lovenox)
D. Warfarin (Coumadin). The CHADS2 score is a validated clinical prediction rule for determining the risk of stroke and who should be anticoagulated. Points are assigned based on the patient's comorbidities. One point is given for each of the following: history of congestive heart failure (C), hypertension (H), age≥75 (A), and diabetes mellitus (D). Two points are assigned for a previous stroke or TIA (S2 ).

For patients with a score of 0 or 1, the risk of stroke is low and warfarin would not be recommended. Warfarin is the agent of choice for the prevention of stroke in patients with atrial fibrillation and a score ≥2. In these patients, the risk of stroke is higher than the risks associated with taking warfarin. Enoxaparin is an expensive injectable anticoagulant and is not indicated for the long-term prevention of stroke.
An elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which vitamin? (check one)

A. Vitamin A
B. Vitamin B 6
C. Vitamin B 12
D. Vitamin D
E. Folate
C. Vitamin B 12. An elevation in serum methylmalonic acid is both sensitive and specific for cellular vitamin B 12 deficiency.
According to the guidelines of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, for hypertensive patients who also have diabetes mellitus, the blood pressure goal is below a threshold of: (check one)

A. 140/95 mm Hg
B. 135/90 mm Hg
C. 130/80 mm Hg
D. 120/75 mm Hg
C. 130/80 mm Hg. Hypertension and diabetes mellitus are very common, both separately and in combination. End-organ damage to the heart, brain, and kidneys is more common in patients with both diabetes mellitus and hypertension, occurring at lower blood pressure levels than in patients with only hypertension. JNC 7, an evidence-based consensus report, recommends that patients with diabetes and hypertension be treated to reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg for other adults.

It should be noted, however, that the recently published ACCORD blood pressure trial found no significant cardiovascular benefit from targeting systolic blood pressure at <120 mm Hg rather than <140 mm Hg in patients with type 2 diabetes. This finding may affect the JNC 8 guidelines, which are currently being developed.
A hospitalized patient is being treated with vancomycin for an infection due to methicillin-resistant Staphylococcus aureus (MRSA). Which one of the following is most important to monitor? (check one)

A. Hepatic function
B. Trough serum levels
C. Peak serum levels
D. Audiograms
B. Trough serum levels. The best predictor of vancomycin efficacy is the trough serum concentration, which should be over 10 mg/L to prevent development of bacterial resistance. Peak serum concentration is not a predictor of efficacy or toxicity. Monitoring for ototoxicity is not currently recommended. Older vancomycin products had impurities, which apparently caused the ototoxicity seen with these early formulations of the drug.
A 35-year-old male amateur rugby player seeks your advice because right hip pain of several months' duration has progressed to the point of interfering with his athletic performance. The pain is accentuated when he transitions from a seated to a standing position, and especially when he pivots on the hip while running, but he cannot recall any significant trauma to the area and finds no relief with over-the-counter analgesics. On examination his gait is stable. The affected hip appears normal and is neither tender to palpation nor excessively warm to touch. Although he has a full range of passive motion, obvious discomfort is evident with internal rotation of the flexed and adducted right hip.

Which one of the following is most strongly suggested by this clinical picture? (check one)

A. Osteoarthritis
B. Avascular necrosis
C. Bursitis
D. Impingement
E. Pathologic fracture
D. Impingement. Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with femoroacetabular impingement. Reproduction of the pain on range-of-motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding. Special radiographic imaging of the flexed and adducted hip can emphasize the anatomic abnormalities associated with impingement that may go unnoticed on standard radiographic series views. Although the pain associated with avascular necrosis is similarly insidious and heightened when bearing weight, tenderness is usually evident with hip motion in any direction. Osteoarthritis of the hip generally occurs in individuals of more advanced age than this patient, and the pain produced is typically localized to the groin area and can be elicited by flexion, abduction, and external rotation (FABER test) of the affected hip.Bursitis manifests as soreness after exercise and tenderness over the affected bursa.
A 39-year-old African-American multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.

Of the following, the most appropriate therapy at this time would be: (check one)

A. oral trimethoprim/sulfamethoxazole (Bactrim, Septra)
B. oral nitrofurantoin (Macrodantin)
C. oral levofloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceftriaxone (Rocephin)
E. intravenous ceftriaxone (Rocephin). Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Ampicillin plus gentamicin or a cephalosporin is typically used.

Sulfonamides are contraindicated late in pregnancy because they may increase the incidence of kernicterus. Tetracyclines are contraindicated because administration late in pregnancy may lead to discoloration of the child's deciduous teeth. Nitrofurantoin may induce hemolysis in patients who are deficient in G-6-PD, which includes approximately 2% of African-American women. The safety of levofloxacin in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.
Random Board Review Questions 31
A patient who takes fluoxetine (Prozac), 40 mg twice daily, develops shivering, tremors, and diarrhea after taking an over-the-counter cough and cold medication. On examination he has dilated pupils and a heart rate of 110 beats/min. His temperature is normal.
Which one of the following medications in combination with fluoxetine could contribute to this patient's symptoms? (check one)

A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)
A. Dextromethorphan. Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin syndrome. SSRIs such as fluoxetine are also associated with serotonin syndrome, and there are many other medications that increase the risk for serotonin syndrome when combined with SSRIs. The other medications listed here are not associated with serotonin syndrome, however.
Brain natriuretic peptide (BNP) is a marker for which one of the following? (check one)

A. Renal failure
B. Acute adrenal insufficiency
C. Cerebrovascular accident
D. Heart failure
E. Ureteral obstruction
D. Heart failure. Brain-type natriuretic peptide (BNP) is synthesized, stored, and released by the ventricular myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes. In addition, the availability of a bedside assay makes BNP useful for evaluating patients in the emergency department.
An 82-year-old male presents to your office because his blood pressure has been "high" when taken by a friend on several occasions. His blood pressure in your office is 173/94 mm Hg, which is similar to the levels his friend recorded. The history and physical examination are otherwise unremarkable, and a CBC, metabolic panel, and urinalysis are normal.

Which one of the following is most consistent with current evidence?
(check one)

A. This patient's mortality will not be affected by treatment of his hypertension
B. Treating this patient with an ARB for hypertension would be ineffective and dangerous
C. Treatment with a thiazide diuretic will lower this patient's risk of death
D. In this age group, treatment of hypertension in males does not reduce stroke and heart failure as it does in females
C. Treatment with a thiazide diuretic will lower this patient's risk of death. Studies have shown that the treatment of systolic and diastolic hypertension, especially with thiazide diuretics, with or without an ACE inhibitor, reduces stroke, heart failure, and death from all causes. Such treatment is effective in both sexes.
A 68-year-old female presents with a several-month history of weight loss, fatigue, decreased appetite, and vague abdominal pain. The most appropriate initial test to rule out adrenal insufficiency is: (check one)

A. morning serum cortisol
B. a cosyntropin (ACTH) stimulation test
D. an insulin tolerance test
E. a metyrapone test
A. morning serum cortisol. A single morning serum cortisol level >13µg/dL reliably excludes adrenal insufficiency. If the morning cortisol level is lower than this, further evaluation with a 1µg ACTH stimulation test is necessary, although the test is somewhat difficult. It requires dilution of the ACTH prior to administration, and requires multiple blood draws. The insulin tolerance test and metyrapone test, although historically considered to be "gold standards," are not widely available or commonly used in clinical practice. MRI does not provide information about adrenal function.
A healthy 48-year-old female consults you about continuing the use of her estrogen/progestin oral contraceptives. She has regular menstrual periods, is not hypertensive or diabetic, and does not smoke.

What advice would you give her? (check one)

A. She should stop the oral contraceptives
B. She should switch to a progestin-only pill
C. She should discontinue the contraceptive for 1 month, and if FSH is then elevated to postmenopausal levels, the pills should be stopped
D. She can safely continue to take the contraceptive if screening for thrombophilic conditions is negative
E. It is safe to continue the oral contraceptives
E. It is safe to continue the oral contraceptives. Healthy women may continue combination birth control pills into their fifties, and this patient has no contraindications. Screening for thrombophilic conditions is not indicated due to the low yield. FSH levels are not specific enough to evaluate the effect of stopping the contraceptive.
Which one of the following is necessary to make a diagnosis of polymyalgia rheumatica? (check one)

A. Joint swelling
B. Early morning stiffness
C. Reduction of symptoms with high-dose NSAID therapy
D. An erythrocyte sedimentation rate ≥60 mm/hr
E. Bilateral shoulder or hip stiffness and aching
E. Bilateral shoulder or hip stiffness and aching. There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica. Joint swelling occurs occasionally, but neither swelling nor early morning stiffness is necessary to make the diagnosis. Polymyalgia rheumatica does not respond to NSAIDs. The erythrocyte sedimentation rate should be ≥40 mm/hr.
The Centers for Disease Control and Prevention currently recommends that all patients between the ages of 13 and 64 years be screened for: (check one)

A. tuberculosis
B. hepatitis B
C. human papillomavirus infection
D. elevated serum cholesterol levels
E. HIV infection
E. HIV infection. The focus of screening for HIV has been shifted from testing only high-risk individuals to routine testing of all individuals in health-care settings. There are an estimated 1.1 million people in the United States with HIV, and 25% are undiagnosed. Only 36.6% of adults have had an HIV test. Screening for hepatitis B and for tuberculosis is recommended only for certain at-risk populations. There is no generally used test for human papillomavirus. The CDC has not made any recommendations regarding screening for high cholesterol.
A 71-year-old female with end-stage lung cancer was recently extubated and is awaiting transfer to hospice. She is awake and confused and has significant respiratory secretions.

Which one of the following medications used for reducing respiratory secretions is LEAST likely to cause central nervous system effects such as sedation? (check one)

A. Atropine
B. Transdermal scopolamine (Transderm Scop)
C. Hyoscyamine (Levsin)
D. Glycopyrrolate (Robinul)
D. Glycopyrrolate (Robinul). Glycopyrrolate does not cross the blood-brain barrier, and is therefore least likely to cause central nervous system effects such as sedation. The other medications listed do cross the blood-brain barrier.
A 25-year-old female comes to your office requesting a referral to an otolaryngologist for surgery on her nose. She states that her nose is too large and that "something must be done." She has already seen multiple family physicians, as well as several otolaryngologists. She is 168 cm (66 in) tall and weighs 64 kg (141 lb). A physical examination is normal, and even though she initially resists a nasal examination, it also is normal. The size of her nose is normal.
Which one of the following is the most likely cause of this patient's concern about her nose? (check one)

A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder
D. Body dysmorphic disorder. Body dysmorphic disorder is an increasingly recognized somatoform disorder that is clinically distinct from obsessive-compulsive disorder, eating disorders, and depression. Patients have a preoccupation with imagined defects in appearance, which causes emotional stress. Body dysmorphic disorder may coexist with anorexia nervosa, atypical depression, obsessive-compulsive disorder, and social anxiety. Cosmetic surgery is often sought. SSRIs and behavior modification may help, but cosmetic procedures are rarely helpful.
A 78-year-old male presents for a routine follow-up visit for hypertension. He is a smoker, but has no known coronary artery disease and is otherwise healthy. On examination you note an irregular pulse. An EKG reveals multiple premature ventricular contractions (PVCs), but no other abnormalities.
Current guidelines recommend which one of the following? (check one)

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

Strong evidence from randomized, controlled trials suggests that PVCs should not be suppressed with antiarrhythmic agents. The CAST I trial showed that using encainide or flecainide to suppress PVCs increases mortality (SOR A).
Random Board Review Questions 32
While playing tennis, a 55-year-old male tripped and fell, landing on his outstretched hand with his elbow in slight flexion at impact. Pronation and supination of the forearm are painful on examination, as are attempts to flex the elbow. There is tenderness of the radial head without significant swelling. A radiograph of the elbow shows no fracture, but a positive fat pad sign is noted.
Appropriate management would include: (check one)

A. a long arm cast for 2 weeks, followed by use of a brace
B. mobilization of the elbow beginning 3 weeks after the injury
C. a posterior splint for 6 weeks
D. a posterior splint and a repeat radiograph in 1-2 weeks
D. a posterior splint and a repeat radiograph in 1-2 weeks. Nondisplaced radial head fractures can be treated by the primary care physician and do not require referral. Conservative therapy includes placing the elbow in a posterior splint for 5-7 days, followed by early mobilization and a sling for comfort. Sometimes the joint effusion may be aspirated for pain relief and to increase mobility. One study compared immediate mobilization with mobilization beginning in 5 days and found no differences at 1 and 3 months, but early mobilization was associated with better function and less pain 1 week after the injury. Radiographs should be repeated in 1-2 weeks to make sure that alignment is appropriate.
The best available evidence supports which one of the following statements regarding the cardiovascular effects of hypoglycemic agents? (check one)

A. Sulfonylureas increase cardiovascular events
B. Metformin (Glucophage) reduces cardiovascular mortality rates
C. Incretin mimetics reduce the risk of cardiovascular events
D. α-Glucosidase inhibitors have no effect on cardiovascular events
B. Metformin (Glucophage) reduces cardiovascular mortality rates. Metformin is the only hypoglycemic agent shown to reduce mortality rates in patients with type 2 diabetes mellitus. A recent systematic review concluded that cardiovascular events are neither increased nor decreased with the use of sulfonylureas. The effect of incretin mimetics and incretin enhancers on cardiovascular events has not been determined. The STOP-NIDDM study suggests that α-glucosidase inhibitors reduce the risk of cardiovascular events in patients with impaired glucose tolerance.
A 46-year-old female presents to your office for follow-up of elevated blood pressure on a pre-employment examination. She is asymptomatic, and her physical examination is normal with the exception of a blood pressure of 160/100 mm Hg. Screening blood work reveals a potassium level of 3.1 mEq/L (N 3.7-5.2). You consider screening for primary hyperaldosteronism. (check one)

A. 24-hour urine aldosterone levels
B. An ACTH infusion test
C. Adrenal venous sampling
D. CT of the abdomen
E. A serum aldosterone-to-renin ratio
E. A serum aldosterone-to-renin ratio. Primary hyperaldosteronism is relatively common in patients with stage 2 hypertension (160/100 mm Hg or higher) or treatment-resistant hypertension. It has been estimated that 20% of patients referred to a hypertension specialist suffer from this condition. Experts recommend screening for this condition using a ratio of morning plasma aldosterone to plasma renin. A ratio >20:1 with an aldosterone level >15 ng/dL suggests the diagnosis. The level of these two values is affected by several factors, including medications (especially most blood pressure medicines), time of day, position of the patient, and age.
Patients who are identified as possibly having this condition should be referred to an endocrinologist for further confirmatory testing.
Pay-for-performance (P4P) programs provide financial incentives for meeting predetermined quality targets. Contracts with major payors often include these programs.
When considering P4P programs in such contracts, physicians should negotiate for which one of the following? (check one)

A. Guidelines developed by academic medicine researchers
B. Guidelines based on consensus opinions
C. Mandatory physician participation
D. Reporting of negative performance results to licensure boards
E. Taking patient compliance into account when performing the evaluation
E. Taking patient compliance into account when performing the evaluation. Pay-for-performance programs are becoming a critical part of the health care reform debate, and when the discussion began in 2005, over 100 such programs were in existence. The objective is to reward physicians for achieving goals that should lead to improved patient outcomes. In addition to evaluating clinical performance, many programs now also evaluate efficiency and information technology. However, many programs are not based on outcomes data, and have less desirable aspects such as inadequate incentive levels, withholding of payment, limited clinical focus, or unequal or unfair distribution of incentives. Plans that exclude patient compliance as a factor can lead to withholding of physician incentives because of patient nonadherence, or to physicians selectively removing such patients from their panels.

As the exact process is still being defined, all family physicians should be actively engaged in learning more about these programs, and in negotiating for appropriate measures to be included. The AAFP has seven main principles in its support for pay-for-performance programs: (1) the focus should be on improved quality of care; (2) physician-patient relationships should be supported; (3) evidence-based clinical guidelines should be utilized; (4) practicing physicians should be involved with the program design; (5) reliable, accurate, and scientifically valid data should be used; (6) physicians should be provided with positive incentives; and (7) physician participation should be voluntary. Ensuring that patient adherence is included helps prevent conflicts between patients and their physicians.
A pay-for-performance program should not result in a reduction of fees paid to the physician as a result of implementing a program. Negative results should not penalize the physician with regard to health plan credentialing, verification, or licensure.
A 45-year-old male presents with a 4-month history of low back pain that he says is not alleviated with either ibuprofen or acetaminophen. On examination he has no evidence of weakness or focal tenderness. Laboratory studies, including a CBC, erythrocyte sedimentation rate, C-reactive protein, and complete metabolic profile, are all normal. MRI of the lumbosacral region shows mild bulging of the L4-L5 disc without impingement on the thecal sac.
Which one of the following has been shown to be beneficial in this situation? (check one)

A. Traction
B. Ultrasound
C. Epidural corticosteroid injection
D. A back brace
E. Acupuncture
E. Acupuncture. Most chronic back pain (up to 70%) is nonspecific or idiopathic in origin. Treatment options that have the best evidence for effectiveness include analgesics (acetaminophen, tramadol, NSAIDs), multidisciplinary rehabilitation, and acupuncture (all SOR A).

Other treatments likely to be beneficial include herbal medications, tricyclics, antidepressants, exercise therapy, behavior therapy, massage, spinal therapy, opioids, and short-term muscle relaxants (all SOR B). There is conflicting data regarding the effectiveness of back school, low-level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy, short-wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural corticosteroid injections (all SOR C).
A 45-year-old white female with elevated cholesterol and coronary artery disease comes in for a periodic fasting lipid panel and liver enzyme levels. She began statin therapy about 2 months ago and reports no problems. Laboratory testing reveals an LDL-cholesterol level of 70 mg/dL, an HDL-cholesterol level of 55 mg/dL, an alanine aminotransferase (ALT) level of 69 U/L (N 7-30), and an aspartate aminotransferase (AST) level of 60 U/L (N 9-25).
Which one of the following would be most appropriate at this time? (check one)

A. Continue the current therapy with routine monitoring
B. Decrease the dosage of the statin and monitor liver enzymes
C. Discontinue the statin and monitor liver enzymes
D. Discontinue the statin and begin niacin
E. Substitute another statin
A. Continue the current therapy with routine monitoring. The patient is at her LDL and HDL goals and has no complaints, so she should be continued on her current regimen with routine monitoring (SOR C). Research has proven that up to a threefold increase above the upper limit of normal in liver enzymes is acceptable for patients on statins. Too often, slight elevations in liver enzymes lead to unnecessary dosage decreases, discontinuation of statin therapy, or additional testing.
The Strength-of-Recommendation Taxonomy (SORT) is used to grade key recommendations in clinical review articles. Which one of the following grades indicates that a recommendation is based on consistent, good-quality, patient-oriented evidence? (check one)

A. A
B. B
C. C
D. X
A. A. When possible, it is important for the family physician to base clinical decisions on the best evidence. Strength-of-Recommendation Taxonomy (SORT) grades in medical literature are intended to help physicians practice evidence-based medicine. SORT grades are only A, B, and C. These should not be confused with the U.S. Food and Drug Administration labeling categories for the potential teratogenic effects of medications on a fetus: pregnancy categories A, B, C, D, and X.
Strength of Recommendation (SOR) A is a recommendation that is based on consistent, good-quality, patient-oriented evidence. SOR B is a recommendation that is based on limited-quality patient-oriented evidence. SOR C is a recommendation that is based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening.
In a patient with chronic hepatitis B, which one of the following findings suggests that the infection is in the active phase? (check one)

A. A normal liver biopsy
B. Detectable levels of HBeAb
C. Detectable levels of HBsAb
D. Elevated levels of ALT
E. Undetectable levels of HBV DNA
D. Elevated levels of ALT. Chronic hepatitis B develops in a small percentage of adults who fail to recover from an acute infection, in almost all infants infected at birth, and in up to 50% of children infected between the ages of 1 and 5 years. Chronic hepatitis B has three major phases: immune-tolerant, immune-active, and inactive-carrier.There usually is a linear transition from one phase to the next, but reactivation from immune-carrier phase to immune-active phase also can be seen.

Active viral replication occurs during the immune-tolerant phase when there is little or no evidence of disease activity, and this can last for many years before progressing to the immune-active phase (evidenced by elevated liver enzymes, indicating liver inflammation, and the presence of HBeAg, indicating high levels of HBV DNA). Most patients with chronic hepatitis B eventually transition to the inactive-carrier phase, which is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.
A 42-year-old male presents with anterior neck pain. His thyroid gland is markedly tender on examination, but there is no overlying erythema. He also has a bilateral hand tremor. His erythrocyte sedimentation rate is 82 mm/hr (N 1-13) and his WBC count is 11,500/mm3 (N 4300-10,800). His free T4 is elevated, TSH is suppressed, and radioactive iodine uptake is abnormally low.

Which one of the following treatment options would be most helpful at this time? (check one)

A. Levothyroxine (Synthroid) and NSAIDs
B. Propylthiouracil
C. Prednisone
D. Nafcillin
E. Thyroidectomy
C. Prednisone. This patient has signs and symptoms of painful subacute thyroiditis, including a painful thyroid gland, hyperthyroidism, and an elevated erythrocyte sedimentation rate. It is unclear whether there is a viral etiology to this self-limited disorder. Thyroid function returns to normal in most patients after several weeks, and may be followed by a temporary hypothyroid state. Treatment is symptomatic. Although NSAIDs can be helpful for mild pain, high-dose glucocorticoids provide quicker relief for the more severe symptoms.

Levothyroxine is not indicated in this hyperthyroid state. Neither thyroidectomy nor antibiotics is indicated for this problem.
A 60-year-old female with moderate COPD presents with ongoing dyspnea in spite of treatment with both an inhaled long-acting β-agonist and a long-acting anticholinergic agent. Your evaluation reveals an oxygen saturation of 88% and a PaO2 of 55%. Echocardiography reveals a normal ejection fraction but moderate pulmonary hypertension.
Which one of the following would be most appropriate at this time? (check one)

A. No changes in the current medical regimen
B. Supplemental oxygen
C. Low-dose sildenafil (Revatio)
D. Nifedipine (Procardia)
E. Low-dose prednisone
B. Supplemental oxygen. This patient with moderate COPD and moderate nonpulmonary arterial hypertension pulmonary hypertension is hypoxic and meets the criteria for use of supplemental oxygen (SOR A). Sildenafil and nifedipine are utilized in pulmonary arterial hypertension, but evidence is lacking for their use in pulmonary hypertension associated with chronic lung disease and/or hypoxemia. Low-dose prednisone may be a future option.
Random Board Review Questions 33
A 48-year-old female with type 2 diabetes has been hospitalized for 4 days with persistent fever. Her diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw her 2 weeks ago in the office with urinary frequency, urgency, and dysuria. At that time a urinalysis showed 25 WBCs/hpf, and a urine culture subsequently grew Escherichia coli sensitive to all antibiotics. She was placed on trimethoprim/sulfamethoxazole (Bactrim, Septra) empirically, and this was continued after the culture results were reported.
She improved over the next week, but then developed flank pain, fever to 39.5°C (103.1°F), and nausea and vomiting. She was hospitalized and intravenous cefazolin (Kefzol) and gentamicin were started while blood and urine cultures were performed. This urine culture also grew E. coli sensitive to the current antibiotics. Her temperature has continued to spike to 39.5°C since admission, without any change in her symptoms.
Which one of the following would be most appropriate at this time? (check one)

A. Add vancomycin (Vancocin) to the regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen
E. Order CT of the abdomen. Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota's fascia. Mortality rates as high as 50% have been reported, usually from failure to diagnose the problem in a timely fashion. The difficulty in making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes indolent course of this disease. The diagnosis should be considered when a patient has fever and persistence of flank pain.

Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is persistence of fever for more than 4 days after initiation of antibiotic therapy. The radiologic study of choice is CT. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic). The sensitivity and specificity of CT is significantly greater than that of either ultrasonography or intravenous pyelography.

Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this condition.
A 72-year-old female sees you for preoperative evaluation prior to cataract surgery. Her history and physical examination are unremarkable, and she has no medical problems other than bilateral cataracts.
Which one of the following is recommended prior to surgery in this patient? (check one)

A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
E. No testing. According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not decrease intraoperative or postoperative complications (SOR A). The American Heart Association recommends against routine preoperative testing in asymptomatic patients undergoing low-risk procedures, since the cardiac risk associated with such procedures is less than 1%.
You see a 9-year-old female for evaluation of her asthma. She and her mother report that she has shortness of breath and wheezing 3-4 times per week, which improves with use of her albuterol inhaler. She does not awaken at night due to symptoms, and as long as she has her albuterol inhaler with her she does not feel her activities are limited by her symptoms. About once per year she requires prednisone for an exacerbation, often triggered by a viral infection.
Based on this information you classify her asthma severity as: (check one)

A. intermittent
B. mild persistent
C. moderate persistent
D. severe persistent
B. mild persistent. The 2007 update to the guidelines for the diagnosis and management of asthma published by the National Heart, Lung, and Blood Institute outlines clear definitions of asthma severity. Severity is determined by the most severe category in which any feature occurs. This patient has mild persistent asthma, based on her symptoms occurring more than 2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week, but not daily. Clinicians can use this assessment to help guide therapy.
Which one of the following is found most consistently in patients diagnosed with irritable bowel syndrome? (check one)

A. Passage of blood per rectum
B. Passage of mucus per rectum
C. Abdominal pain
D. Constipation
E. Diarrhea
C. Abdominal pain. A large review of multiple studies identified abdominal pain as the most consistent feature found in irritable bowel syndrome (IBS), and its absence makes the diagnosis less likely. Of the symptoms listed, passage of blood is least likely with IBS, and passage of mucus, constipation, and diarrhea are less consistent than abdominal pain (SOR A).
Which one of the following is diagnostic for type 2 diabetes mellitus? (check one)

A. A fasting plasma glucose level ≥126 mg/dL on two separate occasions
B. An oral glucose tolerance test (75-g load) with a 2-hour glucose level ≥160 mg/dL
C. A random blood glucose level ≥200 mg/dL on two occasions in an asymptomatic person
D. A hemoglobin A 1c ≥6.0% on two separate occasions
A. A fasting plasma glucose level ≥126 mg/dL on two separate occasions. The American Diabetes Association (ADA) first published guidelines for the diagnosis of diabetes mellitus in 1997 and updated its diagnostic criteria in 2010. With the increasing incidence of obesity, it is estimated that over 5 million Americans have undiagnosed type 2 diabetes mellitus. Given the long-term risks of microvascular (renal, ocular) and macrovascular (cardiac) complications, clear guidelines for screening are critical. The ADA recommends screening for all asymptomatic adults with a BMI >25.0 kg/m whohave one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 45.

Current criteria for the diagnosis of diabetes mellitus include a hemoglobin A1c≥6.5%, a fasting plasma glucose level ≥126 mg/dL, a 2-hour plasma glucose leve l≥200 mg/dL, or, in a symptomatic patient, a random blood glucose level ³200 mg/dL. In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.
A 42-year-old African-American male recently traveled to the Caribbean for a scuba diving trip. Since his return he has noted brief intermittent episodes of vertigo not associated with nausea or vomiting. He is concerned, however, because these episodes occurred after sneezing or coughing and then a couple of times after straining while lifting something. He has had no hearing loss, and no vertigo with positional changes such as bending over or turning over in bed. The most likely cause of this patients vertigo is (check one)

A. vestibular neuronitis
B. Menieres disease
C. benign paroxysmal positional vertigo
D. a perilymphatic fistula
E. multiple sclerosis triggered by a rapid change in climate
D. a perilymphatic fistula. A perilymphatic fistula between the middle and inner ear may be caused by barotrauma from scuba diving, as well as by direct blows, heavy weight bearing, and excessive straining (e.g., with sneezing or bowel movements.) This patients recent trip involved two of these potential factors. Vestibular neuronitis is a more sudden, unremitting syndrome. Menieres disease is manifested by episodes of vertigo, associated with hearing loss and often with nausea and vomiting. Benign paroxysmal positional vertigo is more likely in older individuals, and is associated with postural change. Multiple sclerosis requires symptoms in multiple areas and is not thought to be provoked by climate change. Reference: Labuguen RH: Initial evaluation of vertigo. Am Fam Physician 2006;73(2):244-251, 254.
An 8-year-old female is brought to your office because she has begun to limp. She has had a fever of 38.8°C (101.8°F) and says that it hurts to bear weight on her right leg. She has no history of trauma.

On examination, she walks with an antalgic gait and hesitates to bear weight on the leg. Range of motion of the right hip is limited in all directions and is painful. Her sacroiliac joint is not tender, and the psoas sign is negative. Laboratory testing reveals an erythrocyte sedimentation rate of 55 mm/hr (N 0-10), a WBC count of 15,500/mm 3 (N 4500-13,500), and a C-reactiveprotein level of 2.5 mg/dL (N 0.5-1.0).

Which one of the following will provide the most useful diagnostic information to further evaluate this patient's problem?
(check one)

C. A bone scan
D. Ultrasonography
E. Plain-film radiography
D. Ultrasonography. This child meets the criteria for possible septic arthritis. In this case ultrasonography is recommended over other imaging procedures. It is highly sensitive for detecting effusion of the hip joint. If an effusion is present, urgent ultrasound-guided aspiration should be performed. Bone scintigraphy is excellent for evaluating a limping child when the history, physical examination, and radiographic and sonographic findings fail to localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease. Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a day for the last 6 months, and has lost 6 lb over the past 2 months. Her last menstrual period was 3 months ago. Other than the fact that she appears to be slightly underweight, her examination is normal.
To fit the criteria for the female athlete triad, she must have which one of the following? (check one)

A. A formal diagnosis of an eating disorder
B. Amenorrhea for 1 year
C. A Z-score on bone-density testing of -2.5 or less
D. Withdrawal bleeding after progesterone administration
E. A history of a stress fracture resulting from minimal trauma
E. A history of a stress fracture resulting from minimal trauma. The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded. Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function.

Primary amenorrhea is defined as lack of menstruation by age 15 in females with secondary sex characteristics. Secondary amenorrhea is the absence of three or more menstrual cycles in a young woman previously experiencing menses. For those with secondary amenorrhea, a pregnancy test should be performed. If this is not conclusive, a progesterone challenge test may be performed. If there is withdrawal bleeding, the cause would be anovulation. Those who do not experience withdrawal bleeding have hypothalamic amenorrhea, and fit one criterion for the triad.

Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. Low bone mineral density for age is the term used to describe at-risk female athletes with a Z-score of -1 to -2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score <-2.
Which one of the following is the most common cause of recurrent and persistent acute otitis media in children? (check one)

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

A. Limiting intake of dairy products
B. Limiting intake of spicy foods
C. Limiting intake of wheat flour
D. Limiting intake of nuts
E. No limitations on other intake
E. No limitations on other intake. Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to reduce progression of the diverticular disease. Avoidance of nuts, corn, popcorn, and small seeds has not been shown to prevent complications of diverticular disease.
Random Board Review Questions 34
Which one of the following should be used first for ventricular fibrillation when an initial defibrillation attempt fails? (check one)

A. Amiodarone (Cordarone)
B. Lidocaine (Xylocaine)
C. Adenosine (Adenocard)
D. Vasopressin (Pitressin)
E. Magnesium
D. Vasopressin (Pitressin). For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should be given a vasopressor, which can be either epinephrine or vasopressin. Vasopressin may be substituted for the first or second dose of epinephrine.

Amiodarone should be considered for treatment of VF unresponsive to shock delivery, CPR, and a vasopressor. Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available. Magnesium may terminate or prevent torsades de pointes in patients who have a prolonged QT interval during normal sinus rhythm. Adenosine is used for the treatment of narrow complex, regular tachycardias and is not used in the treatment of ventricular fibrillation.
Which one of the following is the best radiographic test for confirming the diagnosis of renal colic? (check one)

A. A KUB radiograph
B. Ultrasonography
D. Intravenous pyelography
C. CT. CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.
A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule. There are no previous studies available.

Which one of the following would raise the most suspicion that this is a malignant lesion if found on the radiograph? . (check one)

A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
A. The absence of calcification. Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation. Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year. Features of malignant nodules include a size >10 mm, an irregular border, a "ground glass" appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year (SOR B).
A previously healthy 67-year-old male sees you for a routine health maintenance visit. During the physical examination you discover a harsh systolic murmur that is loudest over the second right intercostal space and radiates to the carotid arteries. The patient denies any symptoms of dyspnea, angina, syncope, or decreased exertional tolerance. An echocardiogram shows severe aortic stenosis, with an aortic valve area of <1 cm 2, a mean gradiant >40 mm Hg, and an ejection fraction of 60%.

Which one of the following would be most appropriate at this point?
(check one)

A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. Referral for aortic valve replacement
E. Watchful waiting
E. Watchful waiting. Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease (SOR B). This is because the surgical risk of aortic valve replacement outweighs the approximately 1% annual risk of sudden death in asymptomatic patients with aortic stenosis. Peripheral α-blockers, such as prazosin, should be avoided because of the risk of hypotension or syncope. Coronary angiography should be reserved for symptomatic patients who do not have evidence of severe aortic stenosis on echocardiography performed to evaluate their symptoms, or for preoperative evaluation prior to aortic valve replacement. Exercise stress testing is not safe with severe aortic stenosis because of the risk of death during the test.
A 43-year-old female presents to your office for evaluation of a chronic cough that has been present for the past 6 months. She is not a smoker, and is not aware of any exposure to environmental irritants. She does not have any systemic complaints such as fever or weight loss, and does not have any symptoms of heartburn or regurgitation. She is not on any regular medications.

Auscultation of the lungs and a chest radiograph show no evidence of acute disease. A trial of an inhaled bronchodilator and antihistamine therapy does not improve the patient's symptoms.

Which one of the following would be the most appropriate next step?
(check one)

A. A methacholine inhalation challenge test
B. Pulmonary function testing
C. CT of the chest
D. A trial of a proton pump inhibitor
E. 24-hour pH monitoring
D. A trial of a proton pump inhibitor. Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. Patients with chronic cough have a high likelihood of having GERD, even in the absence of gastrointestinal symptoms (level of evidence 3). In fact, up to 75% of patients with a cough caused by GERD may have no gastrointestinal symptoms. The cough is thought to be triggered by microaspiration of acidic gastric contents into the larynx and upper bronchial tree.

The American College of Chest Physicians states that patients with a chronic cough should be given a trial of antisecretory therapy (SOR B). Aggressive acid reduction using a proton pump inhibitor twice daily before meals for 3-4 months is the best way to demonstrate a causal relationship between GERD and extra-esophageal symptoms (SOR B).

Methacholine inhalation testing is not necessary in this patient, since symptomatic asthma has been ruled out by the lack of response to bronchodilator therapy. Chest CT and pulmonary function tests are not indicated given the lack of findings from the history, physical examination, and chest film to suggest underlying pulmonary disease. An initial therapeutic trial of proton pump inhibitors is favored over 24-hour pH monitoring because it is less uncomfortable to the patient and has a better clinical correlation.
A 27-year-old white male construction worker suffers from severe plaque-type psoriasis that has required systemic therapy. Which one of the following is associated with this condition? (check one)

A. A reduced overall risk of cardiovascular mortality
B. A decreased risk of skin cancer with successful treatment
C. A low likelihood of recurrence with successful treatment
D. An increased risk for the condition in the children of affected individuals
E. Low body mass index and difficulty maintaining weight
D. An increased risk for the condition in the children of affected individuals. Psoriasis is a genetic inflammatory condition that has been associated with a significant risk of cardiovascular morbidity and mortality. Children of patients with the disorder are at increased risk. This is especially true if both parents have the disorder. Life expectancy is somewhat reduced in patients with severe psoriasis, particularly if the disease had an early onset. Plaque psoriasis is usually a lifelong disease; this is in contrast to guttate psoriasis, which may be self-limited and never recur.

Cigarette smoking may increase the risk of developing psoriasis. Psoriasis is also associated with an increased likelihood of obesity, diabetes mellitus, and metabolic syndrome.
A 29-year-old gravida 2 para 1 presents for pregnancy confirmation. Her last menstrual period began 6 weeks ago. Her medical history is significant for hypothyroidism, which has been well-controlled on levothyroxine (Synthroid), 150 μg daily, for the past 2 years.

Which one of the following would be the most appropriate next step in the treatment of this patient's hypothyroidism during her pregnancy? (check one)

A. Add liothyronine (Cytomel) to her current regimen
B. Decrease the levothyroxine dosage
C. Increase the levothyroxine dosage
D. Continue her current regimen
C. Increase the levothyroxine dosage. Maternal hypothyroidism can have serious effects on the fetus, so thyroid dysfunction should be treated during pregnancy. Because of hormonal and metabolic changes in early pregnancy, the levothyroxine dosage often needs to be increased at 4-6 weeks gestation, and the patient eventually may require a 30%-50% increase in dosage in order to maintain her euthyroid status.
A 37-year-old recreational skier is unable to lift his right arm after falling on his right side with his arm elevated. Radiographs of the right shoulder are negative, but diagnostic ultrasonography shows a complete rotator cuff tear.
Which one of the following is most accurate with regard to treatment? (check one)

A. Surgery is most likely to be beneficial if performed less than 6 weeks after the injury
B. Treatment with NSAIDs for 3 months is recommended before further intervention
C. Subacromial corticosteroid injections will provide functional and symptomatic relief in the majority of patients
D. Surgical repair of rotator cuff tears to restore function is necessary only in geriatric patients
E. Therapeutic ultrasound of the shoulder will make the condition tolerable during spontaneous healing
A. Surgery is most likely to be beneficial if performed less than 6 weeks after the injury. Surgery for rotator cuff tears is most beneficial in young, active patients. In cases of acute, traumatic, complete rotator cuff tears, repair is recommended in less than 6 weeks, as muscle atrophy is associated with reduced surgical benefit (SOR B). Advanced age and limited strength are also associated with reduced surgical benefit.

NSAIDs are used for analgesia. Their benefit has not been shown to exceed that of other simple analgesics, and the side-effect profile may be higher. Corticosteroid injections will not improve a complete tear. Some experts also recommend avoiding their use in partial or complete tendon tears. Therapeutic ultrasound does not add to the benefit from range-of-motion exercises and exercises to strengthen the involved muscle groups.
A 69-year-old female presents with postmenopausal bleeding. You consider whether to begin your evaluation with vaginal probe ultrasonography to assess the thickness of her endometrium.
In evaluating the usefulness of this test to either support or exclude a diagnosis of endometrial cancer, which one of the following statistics is most useful? (check one)

A. Likelihood ratio
B. Number needed to treat
C. Prevalence
D. Incidence
E. Relative risk
A. Likelihood ratio. There has been a large increase in the number of diagnostic tests available over the past 20 years. Although tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for harm. In addition, the characteristics of a particular test and how the results will affect management and outcomes must be considered. The statistics that are clinically useful for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratios.

Likelihood ratios indicate how a positive or negative test correlates with the likelihood of disease. Ratios greater than 5-10 greatly increase the likelihood of disease, and those less than 0.1-0.2 greatly decrease it. In the example given, if the patient's endometrial stripe is >25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤ 4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%.

The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. Prevalence is the existence of a disease in the current population, and incidence describes the occurrence of new cases of disease in a population over a defined time period. The relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.
A 72-year-old male with a history of hypertension and a previous myocardial infarction is diagnosed with heart failure. Echocardiography reveals systolic dysfunction, and recent laboratory tests indicated normal renal function, with a serum creatinine level of 1.1 mg/dL (N <1.5), a sodium level of 139 mEq/L (N 136-145), and a potassium level of 3.5 mEq/L (N 3.5-5.0). He is currently asymptomatic.
Which one of the following medications would be the best choice for initial management in this patient? (check one)

A. Furosemide (Lasix)
B. Isosorbide dinitrate (Isordil)
C. Spironolactone (Aldactone)
D. Digoxin
E. Lisinopril (Prinivil, Zestril)
E. Lisinopril (Prinivil, Zestril). ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both asymptomatic and symptomatic patients, in randomized, controlled trials. Unless absolutely contraindicated, ACE inhibitors should be used in all heart failure patients. No ACE inhibitor has been shown to be superior to another, and no study has failed to show benefit from an ACE inhibitor (SOR A).

Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors have been shown to be superior in randomized, controlled trials (SOR B). β-Blockers are also recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart failure.

A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus (SOR B). Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.
Random Board Review Questions 35
A 14-year-old female with a history of asthma is having daytime symptoms about once a week and symptoms that awaken her at night about once a month. Her asthma does not interfere with normal activity, and her FEV1 is >80% of predicted.

Which one of the following is the most appropriate treatment plan for this patient?
(check one)

A. A short-acting inhaled β-agonist as needed
B. Low-dose inhaled corticosteroids daily
C. A leukotriene receptor antagonist daily
D. Medium-dose inhaled corticosteroids daily
E. Low-dose inhaled corticosteroids plus a long-acting inhaled β-agonist daily
A. A short-acting inhaled β-agonist as needed. Based on this patient's reported frequency of asthma symptoms, she should be classified as having intermittent asthma. The preferred first step in managing intermittent asthma is an inhaled short-acting β-agonist as needed. Daily medication is reserved for patients with persistent asthma (symptoms >2 days per week for mild, daily for moderate, and throughout the day for severe) and is initiated in a stepwise approach, starting with a daily low-dose inhaled corticosteroid or leukotriene receptor antagonist and then progressing to a medium-dose inhaled corticosteroid or low-dose inhaled corticosteroid plus a long-acting inhaled β-agonist.
A 55-year-old female with diabetes mellitus, hypertension, and hyperlipidemia presents to your office for routine follow-up. Her serum creatinine level is 1.5 mg/dL (estimated creatinine clearance 50 mL/min).
Which one of the following diabetes medications would be contraindicated in this patient? (check one)

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

The treatment of choice for this condition is topical application of: (check one)

A. conjugated estrogens
B. fluorinated corticosteroids
C. petrolatum
D. 2% testosterone
E. fluorouracil (Efudex)
B. fluorinated corticosteroids. Lichen sclerosus is a chronic, progressive, inflammatory skin condition found in the anogenital region. It is characterized by intense vulvar itching. The treatment of choice is high-potency topical corticosteroids. Testosterone has been found to be no more effective than petrolatum. Fluorouracil is an antineoplastic agent most frequently used to treat actinic skin changes or superficial basal cell carcinomas.
Staff members of an assisted-living facility ask for your advice regarding aerobic exercise programs for their older residents. The evidence is greatest for which one of the following benefits of physical activity in the elderly? (check one)

A. Maintaining weight after weight loss
B. Improving quality of sleep
C. Increasing bone density
D. Reducing the risk of falls
D. Reducing the risk of falls. There is strong evidence that physical activity will prevent falls in the elderly. The evidence for maintaining weight, improving sleep, and increasing bone density is not as strong.
The U.S. Preventive Services Task Force (USPSTF) has stated that the potential cardiovascular benefits of daily aspirin use outweigh the potential harms of gastrointestinal hemorrhage in certain populations. The USPSTF currently recommends daily aspirin use for which one of the following populations? (check one)

A. Males 25-44 years of age
B. Males over 80 years of age
C. Females 25-44 years of age
D. Females over 45 years of age
E. Females 55-79 years of age
E. Females 55-79 years of age. The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin use for males 45-79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage, and for females 55-79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (SOR A, USPSTF A Recomendation).

The USPSTF has concluded that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (USPSTF I Recommendation). It recommends against the use of aspirin for stroke prevention in women younger than 55, and for myocardial infarction prevention in men younger than 45 (USPSTF D Recommendation).
You see a newly adopted 5-month-old for his first well child visit. The parents ask when the child can sit in a safety seat in the car facing forward.

You would advise that the child should face rearward until he is at least: (check one)

A. 12 months of age AND weighs 20 lb
B. 15 months of age AND weighs 25 lb
C. 15 months of age OR weighs 25 lb
D. 18 months of age AND weighs 30 lb
E. 18 months of age OR weighs 30 lb
A. 12 months of age AND weighs 20 lb. If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso, and hips, but the head and neck have no support. Without support, the infant's head moves rapidly forward in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a rear-facing position, the force of the crash is distributed evenly across the baby's torso, and the back of the child safety seat supports and protects the head and neck. For these reasons, the rear-facing position should be used until the child is at least 12 months old and weighs at least 20 lb (9 kg). For example, a 13-month-old child who weighs 19 lb should face rearward, and a 6-month-old child who
weighs 21 lb should also face rearward.
Which one of the following is most appropriate for the treatment of fibromyalgia syndrome? (check one)

A. Metaxalone (Skelaxin)
B. Hydrocodone
C. Naproxen
D. Tizanidine (Zanaflex)
E. Amitriptyline
E. Amitriptyline. A meta-analysis of antidepressant medications for the treatment of fibromyalgia syndrome concluded that short-term use of amitriptyline and duloxetine can be considered for the treatment of pain and sleep disturbance in patients with fibromyalgia. In addition, a 2008 evidence-based review for the management of fibromyalgia syndrome performed for the European League Against Rheumatism recommends heated pool treatment with or without exercise, tramadol for the management of pain, and certain antidepressants,including amitriptyline. Evidence for long-term effectiveness of antidepressants in fibromyalgia syndrome is lacking, however.
In the secondary prevention of ischemic cardiac events, which one of the following is most likely to be beneficial in a 68-year-old female with known coronary artery disease and preserved left ventricular function? (check one)

A. ACE inhibitors
B. Hormone therapy
C. Calcium channel blockers
D. Vitamin E
E. Oral glycoprotein IIb/IIIa receptor inhibitors
A. ACE inhibitors. Secondary prevention of cardiac events consists of long-term treatment to prevent recurrent cardiac morbidity and mortality in patients who have either already had an acute myocardial infarction or are at high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures. Effective treatments include aspirin, β-blockers after myocardial infarction, ACE inhibitors in patients at high risk after myocardial infarction, angiotensin II receptor blockers in those with coronary artery disease, and amiodarone in patients who have had a myocardial infarction and have a high risk of death from cardiac arrhythmias.

Oral glycoprotein IIb/IIIa receptor inhibitors appear to increase the risk of mortality when compared with aspirin. Calcium channel blockers, class I anti-arrhythmic agents, and sotalol all appear to increase mortality compared with placebo in patients who have had a myocardial infarction. Contrary to decades of large observational studies, multiple randomized, controlled trials show no cardiac benefit from hormone therapy in postmenopausal women.
A chest radiograph of the driver of an automobile involved in a head-on collision shows a widened mediastinum. This suggests: (check one)

A. myocardial contusion
B. spontaneous rupture of the esophagus
C. rupture of a bronchus
D. partial rupture of the thoracic aorta
E. acute heart failure
D. partial rupture of the thoracic aorta. Deceleration-type blows to the chest can produce partial or complete transection of the aorta. A chest radiograph shows an acutely widened mediastinum and/or a pleural effusion when the condition is severe. The other conditions listed would produce mediastinal emphysema (esophageal or bronchial rupture), a widened heart, or pulmonary edema (acute heart failure, myocardial contusion).
The most common initial symptom of Hodgkin lymphoma is: (check one)

A. unexplained fever
B. night sweats
C. weight loss
D. painless lymphadenopathy
E. cough
D. painless lymphadenopathy. The most common presenting symptom of Hodgkin lymphoma is painless lymphadenopathy. Approximately one-third of patients with Hodgkin lymphoma present with unexplained fever, night sweats, and recent weight loss, collectively known as "B symptoms." Other common symptoms include cough, chest pain, dyspnea, and superior vena cava obstruction caused by adenopathy in the chest and mediastinum.
Random Board Review Questions 36
A 91-year-old white male presents with a 6-month history of a painless ulcer on the dorsum of the proximal interphalangeal joint of the second toe. Examination reveals a hallux valgus and a rigid hammer toe of the second digit. His foot has mild to moderate atrophic skin changes, and the dorsal and posterior tibial pulses are absent.

Appropriate treatment includes which one of the following? (check one)

A. Surgical correction of the hammer toe
B. Custom-made shoes to protect the hammer toe
C. Bunionectomy
D. A metatarsal pad
B. Custom-made shoes to protect the hammer toe. The treatment of foot problems in the elderly is difficult because of systemic and local infirmities, the most limiting being the poor vascular status of the foot. Conservative, supportive, and palliative therapy replace definitive reconstructive surgical therapy. Surgical correction of a hammer toe and bunionectomy could be disastrous in an elderly patient with a small ulcer and peripheral vascular disease. The best approach with this patient is to prescribe custom-made shoes and a protective shield with a central aperture of foam rubber placed over the hammer toe. Metatarsal pads are not useful in the treatment of hallux valgus and a rigid hammer toe.
Hantavirus pulmonary syndrome results from exposure to the excreta of: (check one)

A. migratory fowl
B. bats
C. parrots
D. mice
E. turtles
D. mice. Hantavirus pulmonary syndrome results from exposure to rodent droppings, mainly the deer mouse in the southwestern U.S. About 10% of deer mice are estimated to be infected with hantavirus. In other parts of the country the virus is carried by the white-footed mouse. While other rodents are carriers of the virus, they are less likely to live near dwellings, and populations are less dense.
A 28-year-old white female consults you with a complaint of irregular heavy menstrual periods. A general physical examination, pelvic examination, and Papanicolaou test are normal and a pregnancy test is negative. A CBC and chemistry profile are also normal.

The next step in her workup should be: (check one)

A. endometrial aspiration
B. dilatation and curettage
C. LH and FSH assays
D. administration of estrogen
E. cyclic administration of progesterone for 3 months
E. cyclic administration of progesterone for 3 months. Abnormal uterine bleeding is a relatively common disorder that may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions. However, the patient who is younger than 30 years of age will rarely be found to have a structural uterine defect. Once pregnancy, hematologic disease, and renal impairment are excluded, administration of intramuscular or oral progesterone will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs.

Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problems or for older women. Estrogen would only increase the problem, which is usually due to anovulation with prolonged estrogen secretion, producing a hypertrophic endometrium.
A 45-year-old male with chronic nonmalignant back pain is on a chronic narcotic regimen. Which one of the following behaviors is LEAST likely to be associated with pseudoaddiction, as opposed to true addiction? (check one)

A. Requesting a specific drug
B. Aggressive complaining about needing more medication
C. Hoarding drugs during periods of reduced symptoms
D. Requesting medication exactly at prescribed times when hospitalized
E. Concurrent abuse of alcohol or illicit drugs
E. Concurrent abuse of alcohol or illicit drugs. The use of narcotics for chronic nonmalignant pain is becoming more commonplace. Guidelines have been developed to help direct the use of these medications when clinically appropriate. However, even when given appropriately, the use of opioid medications for pain relief can cause both the physician and the patient to be concerned about the possibility of addiction.

Addiction is a neurobiologic, multifactorial disease characterized by impaired control, compulsive drug use, and continued use despite harm. Pseudoaddiction is a term used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining specific medications, seem to watch the clock, or engage in other behaviors that appear to be due to inappropriate drug seeking. Pseudoaddiction can be distinguished from true addiction because the behaviors will resolve when the pain is effectively treated.

The concurrent use of alcohol and/or illicit drugs complicates the management of chronic pain in patients. If these are known problems, patients should be referred for psychiatric or pain specialty evaluation before the decision is made to use opioids. Agreements for use of chronic opioids should include the expectation that alcohol and illicit drugs will not be used concurrently, and doing so suggests addiction rather than pseudoaddiction.
Which one of the following is true regarding death certificates? (check one)

A. The immediate cause of death is the final or terminal cause of death, such as cardiac arrest
B. A physician can certify a death from a natural cause but a coroner or medical examiner must certify a death due to any other cause
C. In a case of unknown or probable cause of death, the manner of death is designated as "uncertain"
D. Death certificates are part of the patient's medical record and, as such, are confidential and regulated by HIPAA laws
E. In a case of death due to an accidental fall, the immediate attending physician must complete the death certificate
B. A physician can certify a death from a natural cause but a coroner or medical examiner must certify a death due to any other cause. It would be difficult to overstate the importance of death certificates, especially in an era of increasing reliance on evidence-based medicine, yet physicians receive inadequate training in this important area, and their performance on this task remains less than ideal. Death certificates are the primary tool for measuring the mortality rate and its many ramifications in socioeconomic matters such as research funding, estate settlement, financial matters, and other legal concerns. Most problems with death certificates stem from a failure to complete them correctly. Notably, one study showed a 50% decrease in errors after primary care physicians attended a 75-minute educational session.

Only coroners and medical examiners can complete a death certificate when the manner of death is not natural. The immediate cause of death is a specific etiology, not a general concept. "Uncertain" is not a manner of death, but "undetermined" may be used by coroners and medical examiners. The death certificate is a public document when filed.
A 10-week-old term male infant is brought to your office with a 2-day history of difficulty breathing. He has been healthy since birth, with the exception of a 3-day episode of wheezing and rhinorrhea 3 weeks ago. Your initial examination shows an alert infant with increased work of breathing, rhinorrhea, and wheezing. His oxygen saturation is 93% and his temperature is 38.4°C (101.1°F).

Which one of the following would be most appropriate at this point? (check one)

A. Antigen testing or another rapid assay
B. A baseline chest radiograph
C. A trial of nebulized albuterol (AccuNeb)
D. Advising the parents that the child can safely be returned to day care tomorrow
C. A trial of nebulized albuterol (AccuNeb). The American Academy of Pediatrics guideline on the diagnosis and management of bronchiolitis recommends against the use of laboratory or radiographic studies to make the diagnosis, although additional testing may be appropriate if there is no improvement. Bronchiolitis can be caused by a number of different viruses, alone or in combination, and the knowledge gained from virologic testing rarely influences management decisions or outcomes for the vast majority of children.

While the guideline does not support routine use of bronchodilators in the management of bronchiolitis, it does allow for a trial of bronchodilators as an option in selected cases, and continuation of the treatment if the patient shows objective improvement in respiratory status. Bronchodilators have not been shown to affect the course of bronchiolitis with respect to outcomes.

The guideline places considerable emphasis on hygienic practices, including the use of alcohol-based hand sanitizers before and after contact with the patient or inanimate objects in the immediate vicinity. Education of the family about hygienic practices is recommended as well. Returning the child to day care the next day is potentially harmful.
Which one of the following is true concerning Paget's disease of bone? (check one)

A. It is a precursor of multiple myeloma
B. Both bone formation and bone resorption are increased
C. The treatment of choice for symptomatic disease is a calcium channel blocker
D. Pagetic bone pain is difficult to relieve and resistant to medical treatment
E. Extracellular calcium homeostasis is typically abnormal
B. Both bone formation and bone resorption are increased. Paget's disease of bone is a focal disorder of skeletal metabolism in which all elements of skeletal remodeling (resorption, formation, and mineralization) are increased. There is no known relationship between Paget's disease and multiple myeloma, although most cases of sarcoma in patients over 50 arise in pagetic bone. The preferred treatment for nearly all patients with symptomatic disease is one of the newer bisphosphonates. Treatment of bone pain resulting from Paget's disease is generally very satisfactory, and in fact, relief may continue for many months or years after treatment is stopped, lending support for intermittent symptomatic therapy. Finally, despite the massive bone turnover, extracellular calcium homeostasis is almost invariably normal.
The FDA recommends that over-the-counter cough and cold products not be used in children below the age of: (check one)

A. 1 year
B. 2 years
C. 3 years
D. 4 years
E. 5 years
B. 2 years. In 2008 the FDA issued a public health advisory for parents and caregivers, recommending that over-the-counter cough and cold products not be used to treat infants and children younger than 2 years of age, because serious and potentially life-threatening side effects can occur from such use. These products include decongestants, expectorants, antihistamines, and antitussives.
In a patient with hyperuricemia who has experienced an attack of gout, which one of the following is LEAST likely to precipitate another gout attack? (check one)

A. Red meat
B. Milk
C. Seafood
D. Nuts
E. Beans
B. Milk. Reducing consumption of red meat, seafood, and alcohol may help reduce the risk of a gout attack. Dairy products, in contrast to other foods high in protein, decrease the risk of another attack. Nuts and beans are high in purines and will worsen gout.
Which one of the pharmacologic effects of transdermal medications changes the LEAST with aging? (check one)

A. Liver metabolism of the drugs
B. Renal excretion of the drugs
C. Distribution within the body
D. Transdermal absorption of the drugs
D. Transdermal absorption of the drugs. Transdermal absorption of medications changes very little with age. Due to an increase in the ratio of fat to lean body weight, the volume of distribution changes with aging, especially for fat-soluble drugs. Both liver metabolism and renal excretion of drugs decrease with aging, increasing serum concentrations.
Random Board Review Questions 37
A patient presents with a pigmented skin lesion that could be a melanoma. Its largest dimension is 0.5 cm.

What should be the first step in management? (check one)

A. A shave biopsy
B. Excision with a 1-mm margin
C. Wide excision with a 1-cm margin
D. Wide excision with a 1-cm margin
E. Excision with sentinel node dissection
B. Excision with a 1-mm margin. The diagnosis of melanoma should be made by simple excision with clear margins. A shave biopsy should be avoided because determining the thickness of the lesion is critical for staging. Wide excision with or
without node dissection is indicated for confirmed melanoma, depending on the findings from the initial excisional biopsy.
Which one of the following is true regarding the treatment of generalized anxiety disorder? (check one)

A. Cognitive-behavioral therapy has been shown to be at least as effective as pharmacologic therapy
B. Buspirone (BuSpar) is as effective as SSRI therapy for patients with comorbid depression
C. Benzodiazepines are no more effective than placebo
D. Duloxetine (Cymbalta) is no more effective than placebo
E. Escitalopram (Lexapro) is no more effective than placebo
A. Cognitive-behavioral therapy has been shown to be at least as effective as pharmacologic therapy. Cognitive-behavioral therapy has been shown to be at least as effective as medication for treatment of generalized anxiety disorder (GAD), but with less attrition and more durable effects. Many SSRIs and SNRIs have proven effective for GAD in clinical trials, but only paroxetine, escitalopram, duloxetine, and venlafaxine are approved by the FDA for this indication. Benzodiazepines have been widely used because of their rapid onset of action and proven effectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneficial than benzodiazepine or buspirone therapy for patients with GAD and comorbid depression.
A 20-month-old male presents with a history of a fever up to 38.5°C (101.3°F), pulling at both ears, drainage from his right ear, and a poor appetite following several days of nasal congestion. This is his first episode of acute illness, and he has no history of drug allergies.

The fever is confirmed on examination and the child is found to be fussy but can be distracted. He is eating adequately and shows no signs of dehydration. Positive findings include mild nasal congestion, a purulent discharge from the right auditory canal, and a red, bulging, immobile tympanic membrane in the left auditory canal.
Which one of the following would be first-line treatment for this patient? (check one)

A. Ceftriaxone (Rocephin)
B. Amoxicillin/clavulanate (Augmentin)
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Penicillin VK
C. Amoxicillin. This patient has acute bilateral otitis media, with presumed tympanic membrane perforation, and qualifies by any criterion for treatment with antibiotics. Amoxicillin, 80-90 mg/kg/day, should be the first-line antibiotic for most children with acute otitis media (SOR B). The other medications listed are either ineffective because of resistance (e.g., penicillin), are second-line treatments (e.g., amoxicillin/clavulanate), or should be used in patients with a penicillin allergy or in other special situations.
The Centers for Disease Control and Prevention recommends empiric treatment of male sexual partners for which one of the following conditions? (check one)

A. Vaginal candidiasis
B. Vaginal warts
C. Pelvic inflammatory disease
D. Bacterial vaginosis
C. Pelvic inflammatory disease. The promise of a reduction in the incidence and prevalence of sexually transmitted diseases through partner notification and treatment programs remains elusive, as evidence supporting this effect is scarce and inconclusive. What is clear is that treating sexual partners does reduce reinfection of the index patient. Programs such as contact notification, counseling and scheduling of appointments for evaluation of the partner, and expedited partner therapy (EPT), in which sexual contacts of infected patients are provided antibiotics delivered by the index patient without evaluation or counseling, have demonstrated only limited effectiveness; in the case of EPT this limited benefit has been shown only with trichomoniasis. Because currently available evidence fails to demonstrate benefit from treating the male sexual contacts of women with vaginal candidiasis, vaginal warts, or bacterial vaginosis, the Centers for Disease Control and Prevention (CDC) states that treating the male partner is not indicated with these infections.

In the case of pelvic inflammatory disease (PID), evaluation and treatment of males with a history of sexual contact with the patient during the 60 days preceding the onset of symptoms is imperative because of the high risk of reinfection. Current CDC guidelines recommend empiric treatment of these male contacts with antibiotic regimens effective against both chlamydial and gonococcal infection, regardless of the presumed etiology of the PID.
An asymptomatic 68-year-old male sees you for a health maintenance visit. He is a former cigarette smoker, but quit 20 years ago.

According to the U.S. Preventive Services Task Force, evidence shows that the potential benefit exceeds the risk for which one of the following screening tests in this patient? (check one)

A. A chest radiograph
B. Abdominal ultrasonography
C. Ophthalmic tonometry
D. A prostate-specific antigen level
B. Abdominal ultrasonography. The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65-75 who have ever smoked (SOR B, USPSTF B Recommendation). The USPSTF found good evidence that screening these patients for AAA and surgical repair of large AAAs (≥5.5 cm) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms from screening and early treatment, including an increased number of operations, with associated clinically significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65-75 who have ever smoked outweighs the potential harm.

While they may be considered for making the diagnosis in patients who have symptoms, none of the other tests listed have evidence to support a net benefit from their use as routine screening tools in patients like the one described here.
A 52-year-old hypertensive male has had two previous myocardial infarctions. In spite of his best efforts, he has not achieved significant weight loss and he finds it difficult to follow a heart-healthy diet. He takes rosuvastatin (Crestor), 20 mg/day, and his last lipid profile showed a total cholesterol level of 218 mg/dL, a triglyceride level of 190 mg/dL, an HDL-cholesterol level of 45 mg/dL, and an LDL-cholesterol level of 118 mg/dL.

Which one of the following would be the most appropriate change in management? (check one)

A. Increase the rosuvastatin dosage
B. Add atorvastatin (Lipitor)
C. Add niacin
D. Add fenofibrate (Lipofen, Tricor)
E. Add ezetimibe (Zetia)
A. Increase the rosuvastatin dosage. This patient's goal LDL-cholesterol level is 70 mg/dL, and he is not at the maximum dosage of a potent statin. There is no data that shows that adding a different statin will be beneficial, and outcomes data for the other actions is lacking. For patients not at their goal LDL-cholesterol level, the maximum dosage of a statin should be reached before alternative therapy is chosen.
Screening for colon cancer would be recommended for which one of the following patients? (check one)

A. A 35-year-old male whose mother was diagnosed with colon cancer at age 52
B. A 40-year-old female whose mother was diagnosed with colon cancer at age 54
C. A 44-year-old female whose father had a tubular adenoma <1 cm in size removed during colonoscopy at age 50
D. A 46-year-old male whose paternal uncle was diagnosed with colon cancer at age 51
E. A 48-year-old female whose father was diagnosed with colon cancer at age 74
B. A 40-year-old female whose mother was diagnosed with colon cancer at age 54. A history of a first degree relative diagnosed with colon cancer before age 60 predicts a higher lifetime incidence of colorectal cancer (CRC) and a higher yield on colonoscopic screening. The overall colon cancer risk for these persons is three to four times that of the general population. Screening should consist of colonoscopy, beginning either at age 40 or 10 years before the age at diagnosis of the youngest affected relative, whichever comes first.

The 2008 update of the guidelines on screening for CRC published by the American College of Gastroenterology no longer recommends earlier screening for patients who have a single first degree relative with CRC diagnosed at 60 years of age or after. Another change in this guideline is that an increased level of screening is no longer recommended for a simple family history of adenomas in a first degree relative.
A hemoglobin A1c of 7.0% would correspond to which one of the following mean (average) plasma glucose levels? (check one)

A. 126 mg/dL
B. 154 mg/dL
C. 183 mg/dL
D. 212 mg/dL
E. 240 mg/dL
B. 154 mg/dL. A hemoglobin A1c(HbA1c) of 6.0% correlates with a mean plasma glucose level of 126 mg/dL or 7.0 1c 1c mmol/dL. A calculator to convert HbA1clevels into estimated average glucose levels is available at http://professional.diabetes.org/eAG.

A rough guide for estimating average plasma glucose levels assumes that an 1cof 6.0% equals an average glucose level of 120 mg/dL. Each percentage point increase in 1c is equivalent to a 30-mg/dL rise in average glucose. An HbA1cof 7.0% is therefore roughly equivalent to an average glucose level of 150 mg/dL, and an HbA1c of 8.0% translates to an average glucose level of 180 mg/dL.
A 50-year-old male is brought to the emergency department with shortness of breath, chest tightness, tremulousness, and diaphoresis. Aside from tachypnea, the physical examination is normal. Arterial blood gases on room air show a pO2 of 98 mm Hg (N 80-100), a pCO2 of 24 mm Hg (N 35-45), and a pH of 7.57 (N 7.38-7.44).
The most likely cause of the patient's blood gas abnormalities is: (check one)

A. carbon monoxide poisoning
B. anxiety disorder with hyperventilation
C. an acute exacerbation of asthma
D. pulmonary embolus
E. pneumothorax
B. anxiety disorder with hyperventilation. The elevated pH, normal oxygen saturation, and low pCO2 are characteristic of acute respiratory alkalosis, as seen with acute hyperventilation states. In patients with a pulmonary embolism, pO2 and pCO2 are decreased, while the pH is elevated, indicating the acute nature of the disorder. With the other diagnoses, findings on the physical examination would be different than those seen in this patient. Vital signs would be normal with carbon monoxide poisoning, and patients with an asthma exacerbation have a prominent cough and wheezing, and possibly other abnormalities. Tension pneumothorax causes severe cardiac and respiratory distress, with significant physical findings including tachycardia, hypotension, and decreased mental activity.
A 58-year-old male presents with recent behavior and personality changes, and you suspect dementia. Which one of the following is most likely to present in this manner? (check one)

A. Alzheimer's disease
B. Vascular dementia
C. Mixed Alzheimer's disease and vascular dementia
D. Frontotemporal dementia
E. Progressive supranuclear palsy
D. Frontotemporal dementia. Frontotemporal dementia is the second most common cause of early-onset dementia. It often presents with behavioral and personality changes. Examples include disinhibition, impairment of personal conduct, loss of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimer's disease presents with memory loss and visuospatial problems. Vascular dementia is associated with risk factors for stroke, or occurs in relation to a stroke, with a stepwise progression. Alzheimer's disease and vascular dementia can occur together, with features of both. Progressive supranuclear palsy is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance.
Random Board Review Questions 38
A 60-year-old female receiving home hospice care was taking oral morphine, 15 mg every 2 hours, to control pain. When this was no longer effective, she was transferred to an inpatient facility for pain control. She required 105 mg of morphine in a 24-hour period, so she was started on intravenous morphine, 2 mg/hr with a bolus of 2 mg, and was well controlled for 5 days. However, her pain has worsened over the past 2 days.

Which one of the following is the most likely cause of this patient's increased pain? (check one)

A. An inadequate initial morphine dose
B. Addiction to morphine
C. Pseudoaddiction to morphine
D. Physical dependence on morphine
E. Tolerance to morphine
E. Tolerance to morphine. This patient has become tolerant to morphine. The intravenous dose should be a third of the oral dose, so the starting intravenous dose was adequate. Addiction is compulsive narcotic use. Pseudoaddiction is inadequate narcotic dosing that mimics addiction because of unrelieved pain. Physical dependence is seen with abrupt narcotic withdrawal.
A 72-year-old white male presents with a complaint of headache, blurred vision, and severe right eye pain. His symptoms began acutely about 1 hour ago. Examination of the eye reveals a mid-dilated, sluggish pupil; a hazy cornea; and a red conjunctiva.

Which one of the following is the most likely diagnosis? (check one)

A. Retinal detachment
B. Central retinal artery occlusion
C. Mechanical injury to the globe
D. Acute angle-closure glaucoma
D. Acute angle-closure glaucoma. This patient presents with acute angle-closure glaucoma, manifested by an acute onset of severe pain, blurred vision, halos around lights, increased intraocular pressure, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea. Findings with retinal detachment include either normal vision or peripheral or central vision loss; absence of pain; increasing floaters; and a normal conjunctiva, cornea, and pupil. Central retinal artery occlusion findings include amaurosis fugax, a red conjunctiva, a pale fundus, a cherry-red spot at the fovea, and "boxcarring" of the retinal vessels. In patients with mechanical injury to the globe, findings include moderate to severe pain, normal or decreased vision, subconjunctival hemorrhage completely surrounding the cornea, and a pupil that is irregular or deviated toward the injury (SOR B).
The mother of an 8-year-old female is concerned about purple "warts" on her daughter's hands. The mother explains that the lesions started a few months ago on the right hand along the top of most of the knuckles and interphalangeal joints, and she has recently noticed them on the left hand. The child has no other complaints and the mother denies any unusual behaviors. A physical examination is unremarkable except for the slightly violaceous, flat-topped lesions the mother described.

What is the most likely cause for this patient's finger lesions? (check one)

A. Dermatomyositis
B. Aggressive warts
C. Rubbing/wringing of the hands
D. Bulimia nervosa
E. Child abuse
A. Dermatomyositis. One of the most characteristic findings in dermatomyositis is Gottron's papules, which are flat-topped, sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal joints.
A 20-year-old patient comes to the emergency department complaining of shortness of breath. On examination his heart rate is 180 beats/min, and his blood pressure is 122/68 mm Hg. An EKG reveals a narrow complex tachycardia with a regular rhythm.
Which one of the following would be the most appropriate initial treatment? (check one)

A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion
C. Adenosine (Adenocard). After vagal maneuvers are attempted in a stable patient with supraventricular tachycardia, the patient should be given a 6-mg dose of adenosine by rapid intravenous push. If conversion does not occur, a 12-mg dose should be given. This dose may be repeated once. If the patient is unstable, immediate synchronized cardioversion should be administered.
Which one of the following is true regarding the risk of inducing cancer with CT scanning? (check one)

A. CT of the chest is associated with a greater risk than CT of the head
B. The risk increases with age at the time of the scan
C. Males have a greater risk of ultimately developing CT-induced lung cancer than females
D. Current techniques with rapid scanners make the risk comparable to that associated with standard radiographs of the same area
E. The risk in neonates is markedly reduced because of the efficiency of DNA repair processes at this age
A. CT of the chest is associated with a greater risk than CT of the head. CT of the chest or abdomen leads to significantly more radiation exposure and cancer risk than CT of the brain. Younger patients, including neonates, have a greater lifetime risk of developing cancer after radiation exposure, and CT imaging carries substantially more risk than plain radiographs of the same area. Women are at greater risk for developing lung cancer after a chest CT than men, and CT also increases their risk of developing breast cancer.
A patient complains of throbbing bone pain in her lower back and legs. She also has felt weaker recently. Which one of the following tests would confirm a vitamin D deficiency? (check one)

A. 25-hydroxyvitamin D
B. 1,25-dihydroxyvitamin D
C. Ergocalciferol (vitamin D2 )
D. Cholecalciferol (vitamin D3 )
A. 25-hydroxyvitamin D. Serum 25-hydroxyvitamin D should be obtained in any patient with suspected vitamin D deficiency because it is the major circulating form of vitamin D (SOR A). 1,25-Dihydroxyvitamin D is the most active metabolite, but levels can be increased by secondary hyperparathyroidism. In persons with vitamin D deficiency, ergocalciferol (vitamin D ) or cholecalciferol (vitamin D ) can be used to replenish stores (SOR 2 3B).
When obtaining informed consent from a patient, which one of the following is NOT required for a patient to legally have decision-making capacity? (check one)

A. The absence of mental illness
B. The ability to express choice
C. The ability to understand relevant information
D. The ability to engage in reasoning
E. The ability to appreciate the significance of information and its consequences
A. The absence of mental illness. Patients with mental illness may have decision-making capacity if they are able to understand and communicate a rational decision. The key factors to consider in determining decision-making capacity include whether the patient can express a choice, understand relevant information, appreciate the significance of the information and its consequences, and engage in reasoning as it relates to medical treatment.
A patient is sent to you by his employer after falling down some steps and twisting his ankle and foot. Which one of the following would be the most appropriate reason to obtain foot or ankle radiographs? (check one)

A. Notable swelling and discoloration over the anterior talofibular ligament
B. A complaint of marked pain with weight bearing as he walks into the examining room
C. Pain in the maleolar zone and bone tenderness of the posterior medial malleolus
D. The absence of passive plantar foot flexion when the calf is squeezed (Thompson test)
C. Pain in the maleolar zone and bone tenderness of the posterior medial malleolus. The Ottawa ankle and foot rules are prospectively validated decision rules that help clinicians decrease the use of radiographs for foot and ankle injuries without increasing the rate of missed fracture. The rules apply in the case of blunt trauma, including twisting injuries, falls, and direct blows.

According to these guidelines, an ankle radiograph series is required only if there is pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus. Inability to bear weight for four steps, both immediately after the injury and in the emergency department, is also an indication for ankle radiographs. Foot radiographs are required only if there is pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular, or if the patient is unable to bear weight both immediately after the injury and in the emergency department.

A positive Thompson sign, seen with Achilles tendon rupture, is the absence of passive plantar foot flexion when the calf is squeezed.
A 77-year-old white male complains of urinary incontinence of more than one year's duration. The incontinence occurs with sudden urgency. No association with coughing or positional change has been noted, and there is no history of fever or dysuria. He underwent transurethral resection of the prostate (TURP) for benign prostatic hypertrophy a year ago, and he says his urinary stream has improved. A rectal examination reveals a smoothly enlarged prostate without nodularity, and normal sphincter tone. No residual urine is found with post-void catheterization.

Which one of the following is the most likely cause of this patient's incontinence?
(check one)

A. Detrusor instability
B. Urinary tract infection
C. Overflow
D. Fecal impaction
E. Recurrent bladder outlet obstruction
A. Detrusor instability. In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy.

Infection is unlikely as the cause of persistent incontinence in this patient in the absence of fever or symptoms of urinary tract infection. Overflow is unlikely in the absence of residual urine. Impaction is a relatively rare cause of urinary incontinence, and associated findings would be present on rectal examination. Normalization of the urinary stream and the absence of residual urine reduce the likelihood of recurrent obstruction. The prostate would be expected to remain enlarged on rectal examination after transurethral resection of the prostate (TURP).
A 47-year-old male is preparing for a 3-day trip to central Mexico to present the keynote address for an international law symposium. He asks you for an antibiotic to be taken prophylactically to prevent bacterial diarrhea.

Which one of the following would you recommend? (check one)

A. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
B. Rifaximin (Xifaxan)
C. Doxycycline
D. Nitrofurantoin (Macrobid)
B. Rifaximin (Xifaxan). While prophylactic antibiotics are not generally recommended for prevention of traveler's diarrhea, they may be useful under special circumstances for certain high-risk hosts, such as the immunocompromised, or for those embarking on critical short trips for which even a short period of diarrhea might cause undue hardship. Rifaximin, a nonabsorbable antibiotic, has been shown to reduce the risk for traveler's diarrhea by 77%. Trimethoprim/sulfamethoxazole and doxycycline are no longer considered effective antimicrobial agents against enteric bacterial pathogens. Increasing resistance to the fluoroquinolones, especially among Campylobacter species, is limiting their use as prophylactic agents.
Random Board Review Questions 39
A 40-year-old white male presents with a 5-year history of periodic episodes of severe right-sided headaches. During the most recent episode the headaches occurred most days during January and February and lasted about 1 hour.
The most likely diagnosis is which one of the following? (check one)

A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia
B. Cluster headache. Cluster headache is predominantly a male disorder. The mean age of onset is 27-30 years. Attacks often occur in cycles and are unilateral. Migraine headaches are more common in women, start at an earlier age (second or third decade), and last longer (4-24 hours). Temporal arteritis occurs in patients above age 50. Trigeminal neuralgia usually occurs in paroxysms lasting 20-30 seconds.
A 24-year-old male presents with a fever of 38.9°C (102.0°F), generalized body aches, a sore throat, and a cough. His symptoms started 24 hours ago. He is otherwise healthy. You suspect novel influenza A H1N1 infection, as there have been numerous cases in your community recently. A rapid influenza diagnostic test is positive, and you recommend over-the-counter symptomatic treatment. You see him 2 days later after he is admitted to the hospital through the emergency department with dehydration and mild respiratory distress. A specimen is sent to the state laboratory for PCR testing.
Which one of the following would be most appropriate at this point? (check one)

A. Oseltamivir (Tamiflu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment
A. Oseltamivir (Tamiflu). The currently circulating novel influenza A H1N1 virus is almost always susceptible to neuraminidase inhibitors (oseltamivir and zanamivir) and resistant to the adamantanes (amantadine and rimantadine). Zanamivir should not be used in patients with COPD, asthma, or respiratory distress. Antiviral treatment of influenza is recommended for all persons with clinical deterioration requiring hospitalization, even if the illness started more than 48 hours before admission. Antiviral treatment should be started as soon as possible. Waiting for laboratory confirmation is not recommended.
A 59-year-old white male is being evaluated for hypertension. His blood pressure is 150/95 mm Hg. His medical history includes impotence, asthma, gout, first degree heart block, diet-controlled diabetes mellitus, and depression, but he is currently taking no medications. He has a past history of alcohol abuse, but quit drinking 10 years ago.
Which one of the following would be the best choice for INITIAL therapy of his hypertension? (check one)

A. Propranolol (Inderal)
B. Verapamil (Calan, Isoptin)
C. Clonidine (Catapres)
D. Hydrochlorothiazide/triamterene (Dyazide)
E. Enalapril (Vasotec)
E. Enalapril (Vasotec). Because of their favorable side-effect profile, ACE inhibitors (e.g., enalapril) may be the drugs of first choice for the majority of unselected hypertensive patients. ACE inhibitors are not associated with depression or sedation, and they are safe to use in patients with diabetes mellitus. Centrally-acting α-blockers can be associated with depression. Calcium-channel blockers, β-blockers, and other sympatholytic drugs affect cardiac conductivity.β-Blockers are contraindicated in patients with asthma, and are also associated with impotence. Thiazide diuretics raise uric acid and blood glucose levels.
A 51-year-old immigrant from Vietnam presents with a 3-week history of nocturnal fever, sweats, cough, and weight loss. A chest radiograph reveals a right upper lobe cavitary infiltrate. A PPD produces 17 mm of induration, and acid-fast bacilli are present on a smear of induced sputum.
While awaiting formal laboratory identification of the bacterium, which one of the following would be most appropriate? (check one)

A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin), and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin), and pyrazinamide. Leading authorities, including experts from the American Thoracic Society, CDC, and Infectious Diseases Society of America, mandate aggressive initial four-drug treatment when tuberculosis is suspected. Delays in diagnosis and treatment not only increase the possibility of disease transmission, but also lead to higher morbidity and mortality. Standard regimens including INH, ethambutol, rifampin, and pyrazinamide are recommended, although one regimen does not include pyrazinamide but extends coverage with the other antibiotics. Treatment regimens can be modified once culture results are available.
An incidental 2-cm adrenal nodule is discovered on renal CT performed to evaluate hematuria in a 57-year-old female with flank pain. She has no past medical history of palpitations, headache, hirsutism, sweating, osteoporosis, diabetes mellitus, or hypertension. A physical examination is normal, with the exception of a blood pressure of 144/86 mm Hg. Laboratory evaluation reveals a serum sodium level of 140 mmol/L (N 135-145) and a serum potassium level of 3.8 mmol/L (N 3.5-5.0).
What is the most appropriate next step in the evaluation of this patient? (check one)

A. Repeat CT in 12 months
B. Evaluation for adrenal hormonal secretion
C. Fine-needle aspiration of the nodule
D. MRI of the abdomen
E. Referral to a general surgeon for exploratory laparotomy
B. Evaluation for adrenal hormonal secretion. The incidental discovery of adrenal masses presents a common clinical challenge. Such masses are found on abdominal CT in 4% of cases, and the incidence of adrenal masses increases to 7% in adults over 70 years of age. While the majority of masses are benign, as many as 11% are hypersecreting tumors and approximately 7% are malignant tumors; the size of the mass and its appearance on imaging are major predictors of malignancy. Once an adrenal mass is identified, adrenal function must be assessed with an overnight dexamethasone suppression test. A morning cortisol level >5 μg/dL after a 1-mg dose indicates adrenal hyperfunction. Additional testing should include 24-hour fractionated metanephrines and catecholamines to rule out pheochromocytoma. If the patient has hypertension, morning plasma aldosterone activity and plasma renin activity should be assessed to rule out a primary aldosterone-secreting adenoma.

Nonfunctioning masses require assessment with CT attenuation, chemical shift MRI, and/or scintigraphy to distinguish malignant masses. PET scanning is useful to verify malignant disease. Nonfunctioning benign masses can be monitored for changes in size and for the onset of hypersecretory states, although the appropriate interval and studies are controversial. MRI may be preferred over CT because of concerns about excessive radiation exposure. Fine-needle aspiration of the mass can be performed to differentiate between adrenal and non-adrenal tissue after malignancy and pheochromocytoma have been excluded.
Which one of the following has been shown to benefit from screening for asymptomatic bacteriuria? (check one)

A. Women with diabetes mellitus
B. Men with prostatic enlargement on examination
C. All adults with newly diagnosed hypertension
D. Nursing-home residents with an indwelling Foley catheter
E. Women who are pregnant
E. Women who are pregnant. Clinical guidelines published by the U.S. Preventive Services Task Force in 2008 reaffirmed the 2004 recommendations regarding screening for asymptomatic bacteriuria in adults. The only group in which screening is recommended is asymptomatic pregnant women at 12-16 weeks gestation, or at the first prenatal visit if it occurs later (SOR A).
In a patient with microcytic anemia, which one of the following patterns of laboratory abnormalities would be most consistent with iron deficiency as the underlying cause? (check one)

A. Ferritin low, total iron binding capacity (TIBC) low, serum iron low
B. Ferritin low, TIBC low, serum iron high
C. Ferritin low, TIBC high, serum iron low
D. Ferritin high, TIBC low, serum iron low
C. Ferritin low, TIBC high, serum iron low. Ferritin and serum iron levels fall with iron deficiency. Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the plasma protein that binds to iron for transport throughout the body) when iron levels are low.
A 16-year-old male is brought to your office by his mother for "stomachaches." On the review of systems he also complains of headaches, occasional bedwetting, and trouble sleeping. His examination is within normal limits. His mother says that he is often in the nurse's office at school, and doesn't seem to have any friends. When you discuss these problems with him, he admits to being teased and called names at school.

Which one of the following would be most appropriate? (check one)

A. Explain that he must try to conform to be more popular
B. Explain that these symptoms are a stress reaction and will lessen with time
C. Explore whether his school counselor has a process to address this problem
D. Order a TSH level
C. Explore whether his school counselor has a process to address this problem. Childhood bullying has potentially serious implications for bullies and their targets. The target children are typically quiet and sensitive, and may be perceived to be weak and different. Children who say they are being bullied must be believed and reassured that they have done the right thing in acknowledging the problem. Parents should be advised to discuss the situation with school personnel.

Bullying is extremely difficult to resolve. Confronting bullies and expecting victims to conform are not successful approaches. The presenting symptoms are not temporary, and in fact can progress to more serious problems such as suicide, substance abuse, and victim-to-bully transformation. These are not signs or symptoms of thyroid disease.

The Olweus Bullying Prevention Program developed in Norway is a well documented, effective program for reducing bullying among elementary and middle-school students by altering social norms and by changing school responses to bullying incidents, including efforts to protect and support victims. Students who have been bullied regularly are more likely to carry weapons to school, be in frequent fights, and eventually be injured.
A 12-year-old female is brought to your office with an 8-day history of sore throat and fever, along with migratory aching joint pain. She is otherwise healthy and has no history of travel, tick exposure, or prior systemic illness. A physical examination is notable for exudative pharyngitis; a blanching, sharply demarcated macular rash over her trunk; and a III/VI systolic ejection murmur. Joint and neurologic examinations are normal. A rapid strep test is positive and her C-reactive protein level is elevated.
Of the following, the most likely diagnosis is: (check one)

A. juvenile rheumatoid arthritis
B. infective endocarditis
C. Kawasaki syndrome
D. acute rheumatic fever
E. Lyme disease
D. acute rheumatic fever. Acute rheumatic fever is very common in developing nations. It was previously rare in the U.S., but had a resurgence in the mid-1980s. It is most common in children ages 5-15 years. The diagnosis is based on the Jones criteria. Two major criteria, or one major criterion and two minor criteria, plus evidence of a preceding streptococcal infection, indicate a high probability of the disease.

Major criteria include carditis, migratory polyarthritis, erythema marginatum, chorea, and subcutaneous nodules. Minor criteria include fever, arthralgia, an elevated erythrocyte sedimentation rate or C-reactive protein (CRP) level, and a prolonged pulse rate interval on EKG. The differential diagnosis is extensive and there is no single laboratory test to confirm the diagnosis. This patient meets one major criterion (erythema marginatum rash) and three minor criteria (fever, elevated CRP levels, and arthralgia). Echocardiography should be performed if the patient has cardiac symptoms or an abnormal cardiac examination, to rule out rheumatic carditis.
A 73-year-old female presents with complaints of dyspnea and decreasing exercise tolerance over the past few months. She says she has to prop herself up on two pillows in order to breathe better. She also complains of palpitations, even at rest. She has long-standing hypertension, but has not taken any antihypertensive medications for several years. She has no history of ischemic heart disease. On examination her blood pressure is 155/92 mm Hg, her pulse rate is 108 beats/min and irregular, and her lungs have bibasilar crackles. An EKG reveals atrial fibrillation, but no changes of acute ischemia.
Which one of the following would be most useful for determining her initial treatment? (check one)

A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level
C. Echocardiography. This patient's history and clinical examination suggest heart failure. The most important distinction to make is whether it is diastolic or systolic, as the drug treatment may be somewhat different. Physical findings and chest radiographs do not distinguish systolic from diastolic heart failure. An echocardiogram is the study of choice, as it will assess left ventricular function.

In diastolic dysfunction, the left ventricular ejection fraction is normal or slightly el