Aafp Q&a

1.
A 70-year-old male with a history oI hypertension and type 2 diabetes mellitus presents with a
2-month history oI increasing paroxysmal nocturnal dyspnea and shortness oI breath with
minimal exertion. An echocardiogram shows an eiection Iraction oI 25. Which one oI the
patients current medications should be discontinued?

A. Lisinopril (Zestril)
B. Pioglitazone (Actos)
C. Glipizide (Glucotrol)
D. Metoprolol (Toprol-XL)
E. Repaglinide (Prandin)
Your Answer: D
Correct Answer|s|: B
Result: Incorrect
Explanation: 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.
MetIormin is oIten contraindicated because oI renal insuIIiciency or heart Iailure. SulIonylureas
and other insulin secretagogues can cause hypoglycemia. Insulin can also cause hypoglycemia,
and iniecting it requires good visual and motor skills and cognitive ability on the part oI the
patient or a caregiver. TZDs should not be used in patients with New York Heart Association
class III or IV heart Iailure. ReI: American Diabetes Association: Standards oI medical care in
diabetes-2007. Diabetes Care 2007;30(Suppl 1):S4-S41.
2. Which one oI the Iollowing is the most common cause oI hypertension in children under 6
years of age?

A. Essential hypertension
B. Pheochromocytoma
C. Renal parenchymal disease
D. Hyperthyroidism
E. Excessive caIIeine use
Your Answer: C
Correct Answer|s|: C
Result: Correct
Explanation: Although essential hypertension is most common in adolescents and adults, it is
rarely Iound in children less than 10 years old and should be a diagnosis oI exclusion. The most
common cause oI 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 caIIeine use, are less common, and Iurther testing and/or investigation should be
ordered as clinically indicated. ReI: Luma GB, Spiotta RT: Hypertension in children and
adolescents. Am Fam Physician 2006;73(9):1558-1566.
4. A 72-year-old AIrican-American male with New York Heart Association Class III heart
Iailure sees you Ior Iollow-up. He has shortness oI 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 Iurosemide (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 Iew scattered bibasilar rales on examination oI the lungs, an S3 gallop on examination
oI the heart, and no edema on examination oI the legs. An EKG reveals a leIt bundle branch
block, and echocardiography reveals an eiection Iraction oI 25, but no other abnormalities.
Which one oI the Iollowing would be most appropriate at this time?

A. Increase the lisinopril dosage to 80 mg twice daily
B. Increase the carvedilol dosage to 50 mg twice daily
C. Increase the Iurosemide dosage to 160 mg daily
D. ReIer Ior coronary angiography
E. ReIer Ior cardiac resynchronization therapy
Your Answer: C
Correct Answer|s|: E
Result: Incorrect
Explanation:
This patient is already receiving maximal medical therapy. The 2002 ioint guidelines oI the
American College oI Cardiology, the American Heart Association (AHA), and the North
American Society oI Pacing and Electrophysiology endorse the use oI cardiac resynchronization
therapy (CRT) in patients with medically reIractory, symptomatic, New York Heart Association
(NYHA) class III or IV disease with a QRS interval oI at least 130 msec, a leIt ventricular end-
diastolic diameter oI at least 55 mm, and a leIt ventricular eiection Iraction (LVEF) <30.
Using a pacemaker-like device, CRT aims to get both ventricles contracting simultaneously,
overcoming the delayed contraction oI the leIt ventricle caused by the leIt bundle-branch block.
These guidelines were reIined by an April 2005 AHA Science Advisory, which stated that
optimal candidates Ior 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 Iunctional class
III or IV despite maximal medical therapy Ior heart Iailure. ReI: Jarcho JA: Biventricular pacing.
N Engl J Med 2006;355(3):288-294.

5. OI the Iollowing dietary Iactors recommended Ior the prevention and treatment oI
cardiovascular disease, which one has been shown to decrease the rate of sudden death?

A. Increased intake oI plant protein
B. Increased intake of omega-3 fats
C. Increased intake oI dietary Iiber and whole grains
D. Increased intake oI monounsaturated oils
E. Moderate alcohol consumption (1 or 2 standard drinks per day)
Your Answer: C
Result: Incorrect
Explanation: Omega-3 Iats contribute to the production oI eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), which inhibit the inIlammatory 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 oI disease, or high triglyceride levels, as well as to patients
who do not like or are allergic to Iish. The Italian GISSI study Iound that the use oI 850 mg oI
EPA and DHA daily resulted in decreased rates oI mortality, nonIatal myocardial inIarction, and
stroke, with particular decreases in the rate oI sudden death. ReI: Olendzki B, Speed C, Domino
FJ: Nutritional assessment and counseling Ior prevention and treatment oI cardiovascular
disease. Am Fam Physician 2006;73(2):257-264.
6. A 75-year-old male presents to the emergency department with a several-hour history oI back
pain in the interscapular region. His medical history includes a previous myocardial inIarction
(MI) several years ago, a history oI cigarette smoking until the time oI 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 oI an old inIerior wall MI but no acute changes.
A chest radiograph shows a widened mediastinum and a normal aortic arch, and CT oI the chest
shows a dissecting aneurysm oI the descending aorta that is distal to the proximal abdominal
aorta but does not involve the renal arteries. Which one oI the Iollowing would be the most
appropriate next step in the management oI this patient?

A. Immediate surgical intervention
B. Arteriography oI the aorta
C. Intravenous nitroprusside (Nipride)
D. A nitroglycerin drip
E. Intravenous labetalol (Normodyne, Trandate)
Your Answer: C
Result: Incorrect
Explanation: Patients with thoracic aneurysms oIten present without symptoms. With dissecting
aneurysms, however, the presenting symptom depends on the location oI the aneurysm.
Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or
embolization oI peripheral arteries Irom a thrombus within the aneurysm. Leakage oI 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
Iailure brought about by aortic regurgitation Irom aortic root dilatation and distortion oI the
annulus. Other presenting Iindings may include hoarseness, myocardial ischemia, paralysis oI 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 Iactors as those Ior coronary artery disease, particularly smokers. A chest
radiograph may show widening oI the mediastinum, enlargement oI the aortic knob, or tracheal
displacement. Transesophageal echocardiography can be very useIul when dissection is
suspected. CT with intravenous contrast is very accurate Ior showing the size, extent oI disease,
pressure oI leakage, and nearby pathology. Angiography is the preIerred method Ior evaluation
and is best Ior evaluation oI branch vessel pathology. MR angiography provides noninvasive
multiplanar image reconstruction, but does have limited availability and lower resolution than
traditional contrast angiography. cute dissection of the ascending aorta is a surgical
emergency. but dissections confined to the descending aorta are managed medically unless
the patient demonstrates progression or continued hemorrhage into the retroperitoneal
space or pleura. Initial management should reduce the systolic blood pressure to 100-120
mm Hg or to the lowest level tolerated. The use of a -blocker such as propranolol or
labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the
systolic blood pressure remains over 100 mm Hg. intravenous nitroprusside should be
added. Without prior beta-blocade. vasodilation from the nitroprusside will induce reflex
activation of the sympathetic nervous system. causing increased ventricular contraction
and increased shear stress on the aorta. For descending dissections, surgery is indicated only
Ior complications such as occlusion oI a maior aortic branch, continued extension or expansion
oI the dissection, or rupture (which may be maniIested by persistent or recurrent pain). ReI:
Libby P, Bonow RO, Mann DL, et al (eds): Braunwalds Heart Disease: A Textbook oI
Cardiovascular Medicine, ed 8. Saunders, 2008, pp 1469-1486.
7. According to the U.S. Preventive Services Task Force, which one oI the Iollowing patients
should be screened Ior an abdominal aortic aneurysm?

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 oI chronic renal Iailure
D. A 69-year-old Iemale with a history oI coronary artery disease
E. A 75-year-old Iemale with hypertension and hypothyroidism
Your Answer: E
Result: Incorrect
Explanation: The U.S. Preventive Services Task Force has released a statement summarizing
recommendations Ior screening Ior abdominal aortic aneurysm (AAA). The guideline
recommends one-time screening with ultrasonography for in men 65-75 years of age
who have ever smoked. No recommendation was made Ior or against screening women. Men
with a strong Iamily history oI AAA should be counseled about the risks and beneIits oI
screening as they approach 65 years oI age. ReI: Upchurch GR, Schaub TA: Abdominal aortic
aneurysm. Am Fam Physician 2006;73(7):1198-1204.
8. A 36-year-old white Iemale 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 Iails to respond to carotid massage or to two doses oI
intravenous adenosine (Adenocard), 6 mg and 12 mg. The most appropriate next step would be
to administer intravenous

A. amiodarone (Cordarone)
B. digoxin (Lanoxin)
C. Ilecainide (Tambocor)
D. propaIenone (Rhythmol)
E. verapamil (Calan)
Your Answer: C
Result: Incorrect
Explanation: If supraventricular tachycardia is refractory to adenosine or rapidly recurs.
the tachycardia can usually be terminated by the administration of intravenous verapamil
or a -blocker. If that fails. intravenous propafenone or flecainide may be necessary. It is
also important to look Ior and treat possible contributing causes such as hypovolemia, hypoxia,
or electrolyte disturbances. Electrical cardioversion may be necessary iI these measures Iail to
terminate the tachyarrhythmia. ReI: Delacretaz E: Supraventricular tachycardia. N Engl J Med
2006;354(10):1039-1051.
9. The blood pressure goal Ior a patient who has uncomplicated diabetes mellitus is

A. 140/80 mm Hg
B. 130/80 mm Hg
C. 120/80 mm Hg
D. 110/80 mm Hg
E. 110/70 mm Hg
Your Answer: C
Result: Incorrect
Explanation: ggressive control of blood pressure to <135/85 mm Hg in hypertensive
patients and to <130/80 mm Hg in diabetic patients is recommended. Lowering blood
pressure may reduce stroke rates by 40-52 and cardiovascular morbidity by 18-20. ReI:
Abrams J, Thadani U: Therapy oI stable angina pectoris: The uncomplicated patient. Circulation
2005;112(3):e257-e258. 2) The Seventh Report oI the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment oI High Blood Pressure. National High Blood Pressure
Education Program, 2004, NIH Publication No. 04-5230, pp 25, 36-37.
10. A 60-year-old AIrican-American Iemale has a history oI hypertension that has been well
controlled with hydrochlorothiazide. However, she has developed an allergy to the medication.
SuccessIul monotherapy Ior her hypertension would be most likely with which one oI the
Iollowing?

A. Lisinopril (Prinivil, Zestril)
B. Hydralazine (Apresoline)
C. Clonidine (Catapres)
D. Atenolol (Tenormin)
E. Diltiazem (Cardizem)
Your Answer: E
Result: Correct
Explanation: onotherapy for hypertension in frican-merican patients is more likely to
consist of diuretics or calcium channel blockers than -blockers or CE inhibitors. It has
been suggested that hypertension in AIrican-Americans is not as angiotensin II-dependent as it
appears to be in Caucasians. ReI: The Seventh Report oI the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment oI High Blood Pressure. National High Blood
Pressure Education Program, 2004, NIH Publication No. 04-5230, p 39. 2) Rao S, Cherukuri M,
Mayo HG: Clinical inquiries. What is the best treatment Ior hypertension in AIrican-Americans?
J Fam Pract 2007;56(2):149-151.

1. Treatment Ior acute otitis media. She had been taking amoxicillin, 40 mg/kg/day

3. A 4-year-old Hispanic Iemale has been discovered to have a congenital hearing loss. Her
mother is an 18-year-old migrant Iarm worker who is currently at 8 weeks' gestation with her
second pregnancy. The mother has been Iound to have cervical dysplasia on her current
Papanicolaou (Pap) smear and has also tested positive Ior Chlamydia. The most likely cause oI
this child`s hearing loss is:

A. Human parvovirus B19
B. Varicella zoster virus
C. Herpes simplex virus
D. Toxoplasmosis
E. Cytomegalovirus
Your Answer: E
Result: Correct
Explanation: Cytomegalovirus (C') is the most common congenital infection and occurs in
up to 2.2 of newborns. It is the leading cause of congenital hearing loss. The virus is
transmitted by contact with inIected blood, urine, or saliva, or by sexual contact. Risk Iactors Ior
CMV include low socioeconomic status, birth outside North America, Iirst pregnancy prior to
age 15, a history oI cervical dysplasia, and a history oI sexually transmitted diseases. InIection
can be primary or a reactivation oI a previous inIection. While the greatest risk oI inIection is
during the third trimester, those occurring in the Iirst trimester are the most dangerous to the
Ietus. ReI: Choby BA: Pregnancy Care. AAFP SelI-Assessment monograph series, 2003, no 292,
pp 40-43. 2) Rudolph CD, Rudolph AM (eds): Rudolph`s Pediatrics, ed 21. McGraw-Hill, 2003,
pp 1031-1035.
4. Within a 2-week period you see an unusually large number oI patients oI all ages who
complain oI painless loss oI central vision. You reIer them appropriately to an ophthalmologist.
The Ieedback you get is that most oI these persons have bilateral central scotomas caused by an
ophthalmoscopically visible macular deIect. Which one oI the Iollowing events would most
likely explain this problem?

A. A solar eclipse
B. A Iactory accident exposing persons over a wide area to dangerous levels oI carbon monoxide
C. A severe dust storm
D. The recent winner-take-all boxing tournament
E. The annual community Fourth oI July picnic where lots oI potato salad was consumed
Your Answer: A
Correct Answer|s|: A
Result: Correct
Explanation: Direct observation oI the sun without an adequate Iilter, which oIten occurs during
a solar eclipse, results in a speciIic type oI radiation iniury termed solar (eclipse) retinopathy.
The lens system oI the eye Iocuses the sun`s light onto a small spot on the macula, usually in one
eye only, producing a thermal burn. The resulting retinal edema may clear spontaneously
with minor functional loss. or it may cause significant tissue atrophy. leaving a defect seen
with an ophthalmoscope as a macular hole. This macular injury produces a permanent
central scotoma. Visual blurring and diIIiculty with light perception are reversible
maniIestations oI the tissue hypoxia associated with carbon monoxide poisoning. Dust and other
particulate matter can produce iniury to the cornea and coniunctiva. These lesions are painIul,
usually prompting medical attention and appropriate treatment. While severe contusions to the
globe and periorbital structures can produce retinal detachment, the clinical vignette does not
support a boxing-type iniury. Although potatoes have eyes, there is no other signiIicant
relationship between potato salad and ophthalmologic disease. ReI: Vaughan D, Asbury T,
Riordan-Eva P: General Ophthalmology, ed 15. Appleton & Lange, 1999, pp 186, 371.
5. A 73-year-old white male who is otherwise in good health noted a sudden shower oI Ilashing
lights beIore his leIt eye a Iew hours ago. He has never had this symptom beIore. The most likely
diagnosis is:

A. Migraine syndrome
B. Retinal detachment
C. Vitreous Iloaters
D. Central retinal vein thrombosis
E. Temporal lobe tumor
Your Answer: B
Result: Correct
Explanation: While all oI the conditions listed are associated with Ilashing light beIore the eyes,
a sudden shower of flashing lights is highly suggestive of retinal detachment. Migraine
syndrome rarely begins in the eighth decade, vitreous Iloaters are more likely to be perceived as
spots rather than lights, and central retinal vein thrombosis would likely cause more loss oI
vision. Emergency reIerral to an ophthalmologist is mandatory in cases oI probable retinal
detachment. ReI: Hazzard WR, Blass JP, Ettinger WH Jr, et al (eds): Principles oI Geriatric
Medicine and Gerontology, ed 4. McGraw-Hill, 1999, p 612.
6. Which one oI the Iollowing is the most common risk Iactor Ior retinal detachment?

A. Posterior detachment oI the vitreous
B. Hyphema
C. Glaucoma
D. Cataract surgery
E. Diabetic retinopathy
Your Answer: C
Result: Incorrect
Explanation: 'itreous detachment is very common after age 60 and occurs frequently in
younger persons with myopia. The separation of the posterior aspect of the vitreous from
the retina exerts traction on the retina. with the attendant risks of a retinal tear and
detachment. Symptoms of retinal detachment may include light flashes (photopsia). a
sudden appearance or increase in ~floaters. or peripheral visual field loss. any of which
should prompt an ophthalmology referral. Cataract surgery can result in premature
shrinkage of the vitreous and thereby poses an increased risk. but vitreous detachment
resulting from other processes is more common. Hyphema, glaucoma, and diabetic
retinopathy are not speciIic risk Iactors Ior retinal detachment. ReI: Gariano RE, Kim CH:
Evaluation and management oI suspected retinal detachment. Am Fam Physician
2004;69(7):1691-1697.
7. Which one oI the Iollowing is the most common cause oI visual loss in children?

A. Iritis
B. Glaucoma
C. Amblyopia
D. Eye trauma
E. Coniunctivitis
Your Answer: D
Result: Incorrect
Explanation: Evaluation of visual symptoms in children can be challenging. but is important
for identifying correctable conditions. mblyopia. or ~lazy eye. is the most common cause
of visual loss. with a prevalence of 2 in childhood. It is oIten related to strabismus, in which
the image Irom one eye is suppressed in order to eliminate diplopia. Iritis is unusual and may
have minimal symptoms; it is Irequently associated with iuvenile rheumatoid arthritis. Glaucoma
does occur in children, oIten aIter cataract surgery. Eye trauma is relatively common, especially
in boys. They may sustain abrasions, Ioreign bodies and penetrating iniuries. Coniunctivitis will
usually resolve without visual loss except when complicated by keratitis, such as in herpetic
inIections. ReI: Simon JW, Kaw P: Commonly missed diagnoses in the childhood eye
examination. Am Fam Physician 2001;64(4):623-628.
8. A 16-year-old white Iemale experiences the sudden onset oI tender, bleeding gums,
malodorous breath, and a bad taste in her mouth. On examination she is Iebrile and has cervical
lymphadenopathy and tachycardia. Her mouth has marginal punched-out, crater-like depressions
oI the interdental gingival papillae and gingival margins that are covered with a gray
pseudomembranous slough. The drug oI choice Ior treating this condition is:

A. Acyclovir (Zovirax)
B. Penicillin
C. Clotrimazole troche (Mycelex)
D. Ketoconazole (Nizoral)
E. Prednisone
Your Answer: C
Result: Incorrect
Explanation: This patient has acute necrotizing ulcerative gingivitis. The onset is sudden and
findings include tender. bleeding gums. malodorous breath. and a bad taste in the mouth.
The disease is frequently associated with systemic findings such as fever. anorexia. malaise.
tachycardia. cervical lymphadenopathy. and leukocytosis. Characteristic gingival lesions
are seen. appearing as marginal punched-out. crater-like depressions of the interdental
gingival papillae and gingival margin. They are covered with a gray pseudomembranous
slough that is demarcated from the remainder of the gingiva and bleeds when removed.
These lesions may be related to a single tooth. a group of teeth. or the gingiva throughout
the mouth. anagement includes removing predisposing factors such as stress. fatigue.
heavy smoking. and poor nutrition that can cause tissue breakdown. outh rinses with
warm half-strength hydrogen peroxide are useful. When fever and lymphadenopathy
occur. antibiotic treatment is warranted and penicillin is the drug of choice. Tetracycline
and erythromycin are good alternatives. ReI: Mandell GL, Bennett JE, Dolin R (eds):
Mandell, Douglas, and Bennett`s Principles and Practice oI InIectious Diseases, ed 5. Churchill
Livingstone, 2000, p 694.
9. A 25-year-old male has a dental inIection associated with Iacial swelling and
lymphadenopathy. Which one oI the Iollowing is the most appropriate antibiotic?

A. Cephalexin (KeIlex)
B. Tetracycline
C. Penicillin
D. CiproIloxacin (Cipro)
E. Azithromycin (Zithromax)
Your Answer: D
Result: Incorrect
Explanation: Dental infections complicated by the development of cellulitis should be
treated with oral antibiotic therapy. The antibiotic of choice is penicillin. Clindamycin
should be used if a patient is allergic to penicillin. ReI: Douglass AB, Douglass JM: Common
dental emergencies. Am Fam Physician 2003;67(3):511-516.
10. A 42-year-old AIrican-American male recently traveled to the Caribbean Ior a scuba diving
trip. Since his return he has noted brieI intermittent episodes oI vertigo not associated with
nausea or vomiting. He is concerned, however, because these episodes occurred aIter sneezing or
coughing and then a couple oI times aIter straining while liIting 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 oI this patients vertigo is

A. vestibular neuronitis
B. Menieres disease
C. benign paroxysmal positional vertigo
D. a perilymphatic Iistula
E. multiple sclerosis triggered by a rapid change in climate
Your Answer: D
Correct Answer|s|: D
Result: Correct
Explanation: 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 oI these potential Iactors. 'estibular neuronitis is a more sudden. unremitting
syndrome. enieres 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. ReIerence:
Labuguen RH: Initial evaluation oI vertigo. Am Fam Physician 2006;73(2):244-251, 254.

2. Which one oI the Iollowing is the Iirst-line antibiotic treatment for uncomplicated acute
otitis media?

A. CeItriaxone (Rocephin)
B. moxicillin
C. Azithromycin (Zithromax)
D. CeIuroxime (CeItin)
E. Trimethoprim/sulIamethoxazole (Bactrim, Septra)
Your Answer: B
Result: Correct

3. 73-year-old white female complains of difficulty reading for the past several months.
Examination reveals 20/100 near vision bilaterally. and normal visual fields by
confrontation. n ophthalmoscopic examination reveals only small yellow lesions clustered
in the retina. The most likely diagnosis is:

A. acular degeneration
B. Glaucoma
C. Cataract
D. Central retinal vein occlusion
E. Retinal detachment
Your Answer: A
Result: Correct
Explanation: Nonexudative age-related macular degeneration is characterized by variable
degrees oI atrophy and degeneration oI the outer retina, retinal pigment epithelium, Bruch`s
membrane, and choriocapillaries. OI the ophthalmoscopically visible changes in the retinal
pigment epithelium and Bruch`s membrane. drusen are the most typical. Drusen are
discrete, round, yellow-white deposits oI variable size beneath the pigment epithelium and are
scattered throughout the macula and posterior pole. Age-related macular degeneration is the
leading cause oI permanent blindness in the elderly. ReI: Vaughan D, Asbury T, Riordan-Eva P:
General Ophthalmology, ed 15. Appleton & Lange, 1999, pp 179-180. 2) Hazzard WR, Blass JP,
Ettinger WH Jr, et al (eds): Principles oI Geriatric Medicine and Gerontology, ed 4. McGraw-
Hill, 1999, pp 608-609.

4. The earliest presenting symptom in most older patients with open-angle glaucoma is:

A. Unilateral eye pain
B. Unilateral eye redness
C. Unilateral visual loss
D. Tunnel vision
E. Double vision
Your Answer: C
Result: Incorrect
Explanation: About 3 oI persons over age 55 have glaucoma, making it a leading cause oI
vision impairment. Although it is usually asymptomatic, the most common presenting symptom
is tunnel vision, a gradual loss oI peripheral vision. ReI: Distelhorst JS, Hughes GM: Open-angle
glaucoma. Am Fam Physician 2003;67(9):1937-1944.

5. An 85-year-old Hispanic Iemale comes to your oIIice Ior a routine annual visit. While
reviewing her medical history, you note that she began timolol (Timoptic) eye drops 3 months
ago Ior the treatment oI glaucoma. Which one oI the Iollowing Iindings is most likely related to
the eye drops?

A. Bronchospasm
B. Elevated serum creatinine
C. Hirsutism
D. Leukopenia
E. New-onset atrial Iibrillation
Your Answer: A
Result: Correct
Explanation: Ophthalmic beta-adrenergic antagonists oIten have systemic side eIIects. Beta
2
-
blockade can cause contraction oI bronchial smooth muscle, leading to bronchospasm;
respiratory Iailure and death due to bronchospastic complications have been reported,
particularly in patients with asthma or chronic obstructive pulmonary disease. ReI: Alward WL:
Medical management oI glaucoma. N Engl J Med 1998;339(18):1298-1307.

6. Approximately 3050 oI inIants born to Chlamydia-positive mothers will have:

A. Coniunctivitis
B. Dermatitis
C. Jaundice
D. Pneumonia
E. Urogenital inIection
Your Answer: A
Result: Correct
Explanation: Chlamydial genital inIection is reported in 530 oI pregnant women, with
vertical transmission to ~50 oI their inIants at birth. An inIant born to a mother with active
chlamydial inIection has a 5070 risk oI acquiring inIection at any anatomical site.
Approximately 3050 oI inIants born to Chlamydia-positive mothers will develop
coniunctivitis, and at least 50 oI these children will also have nasopharyngeal inIection. InIants
born to women with chlamydial inIection may also develop associated pneumonia, but this
aIIects only 1020 oI this population. ReI: Peipert JF: Genital chlamydial inIections. N Engl
J Med 2003;349(25):2424-2430. 2) Behrman RE, Kliegman RM, Jenson HB (eds): Nelson
Textbook oI Pediatrics, ed 17. Saunders, 2004, p 997.

7. Which one oI the Iollowing is the leading cause oI blindness in individuals over age 65 in the
U.S.?

A. Open angle glaucoma
B. Narrow angle glaucoma
C. Macular degeneration
D. Diabetic retinopathy
E. Ophthalmic artery occlusion
Your Answer: C
Result: Correct
Explanation: Age-related macular degeneration (AMD) is the leading cause oI blindness in the
U.S. in individuals over age 65. AMD currently aIIects more than 1.75 million individuals in the
U.S. Due to the rapid aging oI the population, this number will increase to almost 3 million by
2020. ReI: Eye Diseases Prevalence Research Group: Prevalence oI age-related macular
degeneration in the U.S. Arch Ophthalmol 2004;122(4):564-572. 2) Bressler NM: Age-related
macular degeneration is the leading cause oI blindness. JAMA 2004;291(15):1900-1901.

8. Which one oI the Iollowing would be most appropriate to treat a dental infection requiring
antibiotic therapy?

A. Erythromycin
B. Penicillin
C. Dicloxacillin (Dynapen)
D. Tetracycline
E. CeIixime (Suprax)
Your Answer: B
Result: Correct
Explanation: Many dental conditions causing inIlammation do not require antibiotic therapy.
Dental caries. reversible pulpitis. gingivitis. periodontitis. and periapical abscesses usually
are treated with local procedures without antibiotics. Cellulitis. however. requires either
outpatient antibiotics or inpatient antibiotic treatment if the cellulitis spreads to the deeper
spaces of the head and neck. The antibiotic oI choice, especially Ior outpatient treatment, is oral
penicillin G, 500 mg 3 times daily. ReI: Douglass AB, Douglass JM: Common dental
emergencies. Am Fam Physician 2003;67(3):5

9. A 39-year-old white male is seen in your oIIice with a history oI sudden painIul swelling oI
the right parotid gland. The patient has a temperature oI 38.2 degrees C (100.8 degrees F). The
parotid gland is tender on examination. Which one oI the Iollowing would be most appropriate at
this point?

A. Observation only
B. Asking about pets in the household
C. Tuberculin testing
D. A CT scan
E. Antibiotics
Your Answer: E
Result: Correct
Explanation: The patient has acute suppurative sialadenitis which is caused by coagulase-
positive Staphylococcus aureus, Streptococcus pneumoniae, and other bacteria. The patient
thereIore needs treatment with antibiotics. Tuberculosis is a rare cause. Cat scratch disease
involves the lymph glands, not the salivary glands. A CT scan may be indicated iI there is no
improvement, or iI a tumor is suspected. ReI: Rice DH: Salivary gland disorders: Neoplastic and
nonneoplastic. Med Clin North Am 1999;83(1):197-218.

10. Current U.S. Preventive Services Task Force recommendations Ior preventing dental caries
in preschool-aged children include which one oI the Iollowing?

A. Primary care clinicians should prescribe oral Iluoride at currently recommended doses to all
preschool-aged children
B. Oral Iluoride is not necessary iI the primary water source contains adequate Iluoride
C. Oral Iluoride supplementation should begin at birth when indicated
D. Evidence Ior Iluoride supplementation is insuIIicient to recommend Ior or against its use
Your Answer: B
Result: Correct
Explanation: The U.S. Preventive Services Task Force (USPSTF) recommends that primary care
clinicians prescribe oral Iluoride supplementation at currently recommended dosages to
preschool-aged children older than 6 months oI age whose primary water source is deIicient in
Iluoride. The USPSTF concluded that the beneIits oI caries prevention outweigh the potential
harms oI dental Iluorosis. The USPSTF also concluded that there is insuIIicient evidence to
recommend Ior or against routine risk assessment oI preschool-aged children Ior dental disease
prevention. ReI: U.S. Preventive Services Task Force: Prevention oI dental caries in preschool
children: Recommendations and rationale. Am Fam Physician 2004;70(8):1529-1532.

2. An otherwise healthy 10-year-old Iemale presents with a papulovesicular eruption on one
leg.It extends Irom the lateral buttock, down the posterolateral thigh, to the lateral calI. It is
mildly painIul. The patient`s immunizations are up to date, including varicella and MMR. Her
Iamily has a pet cat at home, and another child at her school was sent home with a rash earlier in
the week.

Which one oI the Iollowing is the most likely diagnosis?

A. Contact dermatitis
B. Herpes zoster dermatitis
C. Tinea corporis
D. Scabies
Your Answer: B
Result: Correct
Explanation: Herpes zoster can occur Irom either a wild strain or a vaccine strain oI varicella-
zoster virus in vaccinated children, but the incidence is low. All cases are mild and
uncomplicated.

3. According to the U.S. Preventive Services Task Force, which one oI the Iollowing is true
regarding prostate cancer screening?

A. Most men between the ages oI 50 and 75 should be screened Ior prostate cancer
B. Screening Ior prostate cancer is inappropriate at any age
C. The harms of screening for prostate cancer after the age of 75 outweigh the benefits
D. A digital rectal examination has greater sensitivity than prostate-speciIic antigen (PSA)
testing Ior detecting prostate cancer
E. Health outcomes are improved by monitoring PSA velocity and doubling time
Your Answer: A
Result: Incorrect
Explanation: The U.S. Preventive Services Task Force (USPSTF) concluded with moderate
certainty that the harm Irom screening Ior prostate cancer in men 75 or older outweighs the
beneIits. Potential harms include urinary incontinence, erectile dysIunction, bowel dysIunction,
and death, and the USPSTF Iound no direct evidence oI beneIits Irom screening. The USPSTF
also concluded that current evidence is insufficient to assess the benefits versus harms of
screening in men younger than age 75. ost major U.S. medical organizations. including
the merican cademy of Family Physicians. recommend individualizing decisions after
discussions with the patient. and agree that the best candidates for screening are men age
50 or older with a life expectancy [1]10 years. Prostate-specific antigen (PS) is more
sensitive than the digital rectal examination. Utilizing PS velocity and doubling time has
not been shown to improve health outcomes.

5. You are treating an 18-year-old white male college Ireshman Ior allergic rhinitis. It is
September, and he tells you that he has severe symptoms every autumn that impair his academic
perIormance. He has a strongly positive Iamily history oI atopic dermatitis.

Which one oI the Iollowing medications is considered optimal treatment Ior this condition?

A. Intranasal glucocorticoids
B. Intranasal cromolyn sodium
C. Intranasal decongestants
D. Intranasal antihistamines
Your Answer: D
Result: Incorrect
Explanation: Topical intranasal glucocorticoids are currently believed to be the most
efficacious medications for the treatment of allergic rhinitis. They are Iar superior to oral
preparations in terms oI saIety. Cromolyn sodium is also an eIIective topical agent Ior allergic
rhinitis; however, it is more eIIective iI started prior to the season oI peak symptoms. Because oI
the high risk oI rhinitis medicamentosa with chronic use oI topical decongestants, these agents
have limited useIulness in the treatment oI allergic rhinitis. Azelastine, an intranasal
antihistamine, is eIIective Ior controlling symptoms but can cause somnolence and a bitter taste.
Oral antihistamines are not as useIul Ior congestion as Ior sneezing, pruritus, and rhinorrhea.
Overall, they are not as eIIective as topical glucocorticoids.

6. You are treating a 53-year-old Iemale Ior a deep-vein thrombosis in her leIt leg. The use oI
compression stockings Ior this problem has been shown to:

A. increase the risk oI pulmonary embolism
B. increase the level oI pain
C. increase complications iI used prior to completion oI a course oI anticoagulation therapy
D. decrease the risk oI post-thrombotic syndrome
Your Answer: D
Result: Correct
Explanation: Post-thrombotic syndrome (PTS) is a complication of acute deep-vein
thrombosis (D'T). and is characterized by chronic pain. swelling. and skin changes in the
affected limb. Within 5 years of experiencing a D'T. one in three patients will develop
PTS. A Cochrane review identiIied three randomized, controlled trials examining the use oI
compression therapy in patients diagnosed with a new DVT. The use of elastic compression
stockings was associated with a highly statistically significant reduction in the incidence of
PTS. with an odds ratio oI 0.31 (conIidence interval oI 0.200.48). A separate trial cited in the
Cochrane review documented no increased incidence oI pulmonary embolism, and a reduction in
pain and swelling in the treatment group. Compression stockings should be applied when
anticoagulation therapy is started, not when it has been completed. The studies did not examine
the rates oI recurrent DVT.

7. Which one oI the Iollowing is true concerning the use oI dexamethasone to treat acute
laryngotracheitis (croup)?

A. A single dose is adequate Ior treatment
B. It commonly leads to a secondary bacterial inIection due to immunosuppression
C. It increases the need Ior hospitalization
D. It is indicated only Ior patients with severe croup
Your Answer: D
Result: Incorrect
Explanation: Treatment with corticosteroids is now routinely recommended for acute
laryngotracheitis (croup). single dose of dexamethasone. either orally or intramuscularly.
is appropriate. Prolonged courses oI corticosteroids provide no additional beneIit and may lead
to secondary bacterial or Iungal inIections. Secondary inIections rarely occur with single-dose
treatment. Corticosteroid therapy shortens emergency department stays and decreases the need
Ior return visits and hospitalizations. It is indicated Ior patients with croup oI any severity.

9. A 55-year-old male who had a recent episode oI atrial Iibrillation that converted in the
emergency department is asymptomatic and currently in sinus rhythm. He is in good health
otherwise and has no history oI hypertension, diabetes mellitus, heart Iailure, transient ischemic
attack, or stroke.

Which one oI the Iollowing would be best Ior preventing a stroke in this patient?

A. Aspirin
B. Clopidogrel (Plavix), 75 mg daily
C. WarIarin (Coumadin), with a goal INR oI 1.52.5
D. WarIarin, with a goal INR oI 2.03.0
E. WarIarin, with a goal INR oI 2.53.5
Your Answer: A
Result: Correct
Explanation: The absolute rate oI stroke depends on age and comorbid conditions. The stroke
risk index CHADS , used to quantiIy risk oI stroke Ior patients who have atrial Iibrillation and to
aid in the selection oI antithrombotic therapy, is a mnemonic Ior individual stroke risk Iactors: C
(congestive heart failure). H (hypertension). (age 75). D (diabetes mellitus). and S
(secondary prevention for prior ischemic stroke or transient attack-most experts include
patients with a systemic embolic event). Each of these clinical parameters is assigned one
point. except for secondary prevention. which is assigned 2 points. Patients are considered
to be at low risk with a score of 0. at intermediate risk with a score of 1 or 2. and at high
risk with a score 3. Experts typically prefer treatment with aspirin rather than warfarin
when the risk of stroke is low. The patient in this question has a CHDS score of 0. which
is low risk. Treatment with aspirin is therefore appropriate.

10. Which one oI the Iollowing serum proteins is typically DECREASED in a hospitalized
patient with sepsis?

A. Complement C3
B. Ferritin
C. C-reactive protein (CRP)
D. Albumin
E. Fibrinogen
Your Answer: E
Result: Incorrect
Explanation: The acute phase response reIers to the multiple physiologic changes that occur with
tissue iniury. The synthesis of acute-phase proteins by hepatocytes is altered. leading to
decreased serum levels of several of these proteins. including albumin and transferrin.
Serum levels rise for other proteins. such as ceruloplasmin. complement proteins.
haptoglobin. fibrinogen. and C-reactive protein. Serum levels of ferritin may be extremely
high in certain conditions. but are also influenced by total-body iron stores.

1. A 25-year-old Iemale is concerned about recurrent psychological and physical symptoms that
occur during the luteal phase oI her menstrual cycle and resolve by the end oI menstruation. She
wants help managing these symptoms, but does not want to take additional estrogen or
progesterone.

Which one oI the Iollowing management strategies is supported by the best clinical evidence?

A. Cognitive-behavioral therapy
B. Spironolactone during the luteal phase
C. Bright light therapy during the luteal phase
D. Evening primrose oil started 24 days prior to the luteal phase
E. Black cohosh
Your Answer: A
Result: Incorrect
Explanation: Randomized. controlled trials found that luteal-phase spironolactone
improved psychological and physical symptoms of premenstrual syndrome over 2-6
months compared with placebo. Based on existing evidence, the eIIectiveness is unknown Ior
cognitive-behavioral therapy, bright light therapy, evening primrose oil, and black cohosh.

2. A 55-year-old male is brought to the emergency department with a complaint oI pain in the
right eye and reduced vision oI about 10 minutes` duration. His eye was iniured while he was
hitting a metal stake with a sledge hammer. He was not wearing saIety goggles. On examination
you note a subconiunctival hemorrhage completely surrounding the cornea. The iris is irregular.

Which one oI the Iollowing is contraindicated prior to emergency transIer to an ophthalmologist?

A. Administering an analgesic
B. Attempting tonometry
C. A visual acuity test
D. Use oI an eye shield
E. Administering an antiemetic
Your Answer: B
Result: Correct
Explanation: The iniury and Iindings described raise the possibility oI globe rupture due to a
Iragment oI steel penetrating through the cornea and pupil and into the globe. RelieI oI pain with
an analgesic is appropriate beIore transIer. Because oI a risk oI extruding intraocular Iluid,
tonometry should not be attempted if globe rupture is suspected. A rapid assessment oI gross
visual acuity (e.g., counting Iingers, seeing light versus dark) may be perIormed. An eye shield
should be placed over the aIIected eye to avoid putting pressure on the eye during transport to
the ophthalmologist. Because the Valsalva eIIect Irom vomiting may lead to extrusion oI
intraocular contents, an antiemetic would be appropriate beIore transIer as well.

3. A 23-year-old gravida 1 para 0 at 36 weeks gestation presents to the oIIice complaining oI
ankle swelling and headache Ior the past 2 days. She denies any abdominal pain or visual
disturbances. On examination you note a Iundal height oI 35 cm, a Ietal heart rate oI 140
beats/min, 2 lower extremity edema, and a blood pressure oI 144/92 mm Hg. A urine dipstick
shows 1 proteinuria. A cervical examination reveals 2 cm dilation, 90 eIIacement, 1 station,
and vertex presentation.

Which one oI the Iollowing is the most appropriate next step in the management oI this patient?

A. Laboratory evaluation, Ietal testing, and 24-hour urine Ior total protein
B. Ultrasonography to check Ior Ietal intrauterine growth restriction
C. Initiation oI antihypertensive treatment
D. Immediate induction oI labor
E. Immediate cesarean delivery
Your Answer: A
Result: Correct
Explanation: This patient most likely has preeclampsia, which is deIined as an elevated blood
pressure and proteinuria aIter 20 weeks gestation. The patient needs Iurther evaluation, including
a 24-hour urine Ior quantitative measurement oI protein, blood pressure monitoring, and
laboratory evaluation that includes hemoglobin, hematocrit, a platelet count, and serum levels oI
transaminase, creatinine, albumin, LDH, and uric acid. A peripheral smear and coagulation
proIiles also may be obtained. Antepartum Ietal testing, such as a nonstress test to assess Ietal
well-being, would also be appropriate.

Ultrasonography should be done to assess Ior Ietal intrauterine growth restriction, but only aIter
an initial laboratory and Ietal evaluation. Delivery is the deIinitive treatment Ior preeclampsia.
The timing oI delivery is determined by the gestational age oI the Ietus and the severity oI
preeclampsia in the mother. Vaginal delivery is preIerred over cesarean delivery, iI possible, in
patients with preeclampsia. It is not necessary to start this patient on antihypertensive therapy at
this point. An obstetric consultation should be considered Ior patients with preeclampsia.

4. Which one oI the Iollowing injection sites for insulin administration is best for preventing
hypoglycemia in a 14-year-old male with diabetes mellitus who wishes to participate in
track and field running events?

A. Arm
B. bdomen
C. Hip
D. CalI
E. Thigh
Your Answer: A
Result: Incorrect
Explanation: The use oI a nonexercised iniection site Ior insulin administration, such as the
abdomen, may reduce the risk oI exercise-induced hypoglycemia. II the leg is used as an
iniection site, exercise may accelerate insulin absorption, resulting in increased levels oI plasma
insulin. However, leg exercise has no eIIect on insulin disappearance Irom the arm and may
actually reduce the rate oI insulin disappearance Irom abdominal iniection sites. Compared with
leg iniection, arm or abdominal iniection reduces the hypoglycemic eIIect oI exercise by
approximately 60 and 90, respectively.

5. Which one oI the Iollowing is the best diagnostic test for vitamin D deficiency?

A. Ionized calcium
B. Serum phosphorus
C. 24-hour urine Ior calcium
D. 1,25-hydroxyvitamin D
E. 25-hydroxyvitamin D
Your Answer: E
Result: Correct
Explanation: Undiagnosed vitamin D deIiciency is not uncommon, and 25-hydroxyvitamin D is
the barometer Ior vitamin D status. Although there is no consensus on optimal levels oI 25-
hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most experts as a
25-hydroxyvitamin D level of <20 ng/mL (50 nmol/L).
6. A 69-year-old male presents with a 2-week history oI Iever, Iatigue, weight loss, and mild
diarrhea. He is Iound to have a mildly tender mass in the leIt lower quadrant oI the abdomen.

The most likely diagnosis is:

A. Crohn`s disease
B. ulcerative colitis
C. celiac disease
D. diverticulitis
E. lymphoma
Your Answer: D
Result: Correct
Explanation: Diverticulitis commonly affects the left lower quadrant in the elderly and may
present as an abscess. Crohn`s disease primarily aIIects the distal small intestine (regional
enteritis), most typically in a young person, and usually in the second or third decade oI liIe.
Ulcerative colitis usually presents with a longer history and does not typically present with a
mass. A 2-week history oI a palpable mass is not a typical presentation Ior lymphoma. Celiac
disease does not cause a palpable leIt lower quadrant mass.

7. A 35-year-old white gravida 2 para 1 sees you Ior her initial prenatal visit. Since delivering
her Iirst child 10 years ago, she has developed type 2 diabetes mellitus. She has kept her
disease under excellent control by taking metIormin (Glucophage). A recent hemoglobin A
1c

level was 6.5.

You should now treat her diabetes with:

A. metIormin
B. acarbose (Precose)
C. pioglitazone (Actos)
D. human insulin
Your Answer: D
Result: Correct
Explanation: The saIety oI most oral hypoglycemics in pregnancy has not been established with
regard to their teratogenic potential. However, all oral agents cross the placenta (in contrast to
insulin), leading to the potential Ior severe neonatal hypoglycemia. For these reasons, plus the
requirement Ior exquisitely tight glucose control to reduce Ietal macrosomia and organ
dysgenesis, the American Diabetes Association advocates the use oI human insulin for
pregnant women. Insulin requirements generally increase throughout gestation, but the precise
dosage is unimportant as long as it is suIIicient to maintain glucose control.

9. A 12-year-old white male asthmatic has an acute episode oI wheezing. You diagnose an
acute asthma attack and prescribe an inhaled
2
-adrenergic agonist. AIter 2 hours oI treatment, he
continues to experience wheezing and shortness oI breath.
Which one oI the Iollowing is the most appropriate addition to acute outpatient management?

A. Oral theophylline (Theo-Dur)
B. Oral corticosteroids
C. An oral -adrenergic agonist
D. Inhaled cromolyn (Intal)
E. Inhaled corticosteroids
Your Answer: E
Result: Incorrect
Explanation: The treatment of choice for occasional acute symptoms of asthma is an inhaled
2-adrenergic agonist such as albuterol. terbutaline. or pirbuterol. If symptoms do not
respond to -agonists. they should be treated with a short course of systemic
corticosteroids. Theophylline has limited useIulness Ior treatment oI acute symptoms in patients
with intermittent asthma; it is a less potent bronchodilator than subcutaneous or inhaled
adrenergic drugs, and therapeutic serum concentrations can cause transient adverse eIIects such
as nausea and central nervous system stimulation in patients who have not been taking the drug
continuously. Cromolyn can decrease airway hyperreactivity, but has no bronchodilating activity
and is useIul only Ior prophylaxis. Inhaled corticosteroids should be used to suppress the
symptoms oI chronic persistent 2 asthma. Oral 2-selective agonists are less eIIective and have a
slower onset oI action than the same drugs given by inhalation.

2. A 78-year-old white male is scheduled to undergo CT with contrast. His current diagnoses
include type 2 diabetes mellitus, heart Iailure, anemia oI chronic disease, and renal insuIIiciency.
Evidence supports the use oI which one oI the Iollowing to reduce the risk oI contrast-induced
nephropathy in this patient?

A. Intravenous Iurosemide
B. Ascorbic acid
C. Calcium antagonists
D. Isotonic bicarbonate inIusion
E. High osmolar contrast media
Your Answer: D
Result: Correct
Explanation: Prospective randomized trials examining the risk Ior contrast-induced nephropathy
have identiIied signiIicant diIIerences between contrast agents due to their physiochemical
properties. Low-osmolar or iso-osmolar contrast media should be used to prevent contrast-
induced nephropathy in at-risk patients. The volume of contrast medium should be as low
as possible. Evidence also supports hydration before the procedure. preferably with
isotonic saline or isotonic sodium bicarbonate solution. There is limited evidence that any
pharmacologic intervention will prevent contrast-induced nephropathy.
3. A 70-year-old white Iemale complains oI two episodes oI urinary incontinence. On both
occasions she was unable to reach a bathroom in time to prevent loss oI urine. The Iirst episode
occurred when she was in her car and the second while she was in a shopping mall. She is
reluctant to go out because oI this problem.

The most likely cause oI her problem is:

A. overIlow incontinence
B. stress incontinence
C. urge incontinence
D. Iunctional incontinence
Your Answer: C
Result: Correct
Explanation: In the neurologically intact individual the most common subtypes are stress
incontinence, which occurs with coughing or liIting; urge incontinence, which occurs when
patients sense the urge to void but are unable to inhibit leakage long enough to reach the toilet;
and overIlow incontinence, which occurs when the bladder cannot empty normally and becomes
overdistended. The term functional incontinence is applied to those cases where lower urinary
tract Iunction is intact but other Iactors such as immobility and severe cognitive impairment lead
to incontinence.

This patient has mild urge incontinence. The first approach to this problem should be
behavioral. In a mild case such as this. a cure can be expected. with success rates of 30-
90 in published studies. For more severe cases. various pharmacologic agents. including
anticholinergics, are useIul. Failure oI these modalities should lead to urodynamic testing and
consideration oI surgery.

5. A 42-year-old Iemale presents to the emergency department with pleuritic chest pain. Her
probability oI pulmonary embolism is determined to be low.
Which one oI the Iollowing should be ordered to Iurther evaluate this patient?

A. Brain natriuretic peptide (BNP)
B. CT pulmonary angiography
C. ELISA-based D-dimer
D. A cardiac troponin level
E. A ventilation-perIusion lung scan
Your Answer: C
Result: Correct
Explanation: Patients who have a low or moderate pretest probability of pulmonary
embolism should have d-dimer testing as the next step in establishing a diagnosis.

6. A 34-year-old white male is brought to the emergency department Iollowing an automobile
accident in which he was the only occupant oI the vehicle. He lost control oI the vehicle and hit a
utility pole. He was knocked unconscious initially, but he is now awake and combative. You note
a strong smell oI alcohol. He has a Irontal hematoma approximately 3 cm in diameter and an
actively bleeding 4-cm laceration oI the occiput. He will not permit you to examine him Iurther
and he prepares to leave the emergency department.

You should:

A. detain him in the emergency department
B. make him sign out against medical advice
C. tell him that he cannot return iI he leaves
D. tell him that iI he leaves he can return later
Your Answer: A
Result: Correct
Explanation: He has had a significant head injury. is combative and possibly intoxicated.
and therefore cannot be considered mentally sound. The physician should detain him for
his own good and provide the appropriate care.

7. A 17-year-old soccer player presents Ior a preparticipation examination. His Iamily history is
signiIicant Ior the sudden death oI his 12-year-old sister while playing basketball, and Ior his
mother and maternal grandmother having recurrent syncopal episodes.

His medical history and examination are completely normal. Prior to approving his participation
in sports, which one oI the Iollowing is recommended?

A. A resting EKG
B. A stress EKG
C. An echocardiogram
D. Pulmonary Iunction testing
E. No Iurther evaluation
Your Answer: A
Result: Correct
Explanation: family history of sudden death and recurrent syncope is highly suspicious
for genetic long-QT syndrome. It is best diagnosed with a resting EKG that shows a QTc
>460 msec in females and >440 msec in males. This syndrome especially places young people
at risk Ior sudden death. anagement may include -blockers. an implantable cardioverter-
defibrillator. and no participation in competitive sports.

8. Which one oI the Iollowing dietary supplements has the best evidence oI eIIicacy in the
treatment oI osteoarthritis oI the knee?

A. MethylsulIonylmethane (MSM)
B. Glucosamine sulIate
C. arpagophvtum procumbens (devil`s claw)
D. Curcuma longa (turmeric)
E. Zingiber officinale (ginger)
Your Answer: B
Result: Correct
Explanation: Glucosamine sulfate may be used to reduce symptoms and possibly slow
disease progression in patients with osteoarthritis of the knee (SOR B).
MethylsulIonylmethane, devil`s claw, turmeric, and ginger are not recommended because oI
insuIIicient evidence oI their eIIectiveness.
9. A 24-year-old Iemale has a history oI mood swings over the past several months, which have
created marital and Iinancial problems, in addition to ieopardizing her career as a television news
reporter. You have made a diagnosis oI bipolar disorder, and she has Iinally accepted the need
Ior treatment. However, she insists that you choose a drug that 'won`t make me Iat.

Which one oI the Iollowing would be best Ior addressing her concerns?

A. Aripiprazole (AbiliIy)
B. Olanzapine (Zyprexa)
C. Quetiapine (Seroquel)
D. Risperidone (Risperdal)
Your Answer: A
Result: Correct
Explanation: All oI the atypical antipsychotics are associated with some degree oI weight gain.
OI the choices listed, aripiprazole is associated with the least amount oI weight gain, generally
less than 1 kilogram. The other agents listed are likely to cause considerably more weight gain.

10. A 75-year-old white Iemale presents with back pain oI several months` duration, which is
worsened by movement. A physical examination is unremarkable except Ior mild pallor. She
takes Iurosemide (Lasix) Ior hypertension.

Laboratory Findings
Hemoglobin.. . . . . . . . . . . . . . . . . . . . . 10.0 g/dL (N 12.016.0)
Serum creatinine.. . . . . . . . . . . . . . . . . . 2.0 mg/dL (N 0.61.5)
BUN. . . . . . . . . . . . . . . . . . . . . . . . . . 40 mg/dL (N 825)
Serum uric acid. . . . . . . . . . . . . . . . . . . 8.0 mg/dL (N 3.07.0)
Serum calcium. . . . . . . . . . . . . . . . . . . . 12.0 mg/dL (N 8.510.5)
Total serum protein. . . . . . . . . . . . . . . . . 9.8 g/dL (N 6.08.4)
Globulin. . . . . . . . . . . . . . . . . . . . . . . . 6.1 g/dL (N 2.33.5)
Albumin. . . . . . . . . . . . . . . . . . . . . . . . 3.7 g/dL (N 3.55.0)
Serum IgG.. . . . . . . . . . . . . . . . . . . . . . 3700 mg/dL (N 6391349)
Urine. . . . . . . . . . . . . . . . . . . . . . . . . . positive Ior Bence-Jones protein

Which one oI the Iollowing would be most appropriate at this point?

A. Repeat the physical examination and laboratory evaluation every 6 months
B. Discontinue the diuretic and repeat the laboratory evaluation in 1 month
C. Obtain a bone scan
D. Obtain a bone marrow examination
E. Begin therapy with tamoxiIen (Soltamox), 20 mg daily
Your Answer: D
Result: Incorrect
Explanation: This patient has typical symptoms and laboratory Iindings oI multiple myeloma,
which accounts Ior 1 oI all malignant diseases and has a mean age at diagnosis oI 61 years.
The diagnosis is confirmed by a bone marrow examination showing >10 plasma cells in
the marrow. The serum level of monoclonal immunoglobulin is typically >3 g/dL. A bone
scan is inIerior to conventional radiography and should not be used. TamoxiIen is indicated Ior
the treatment oI breast cancer, which is unlikely given the physical and laboratory Iindings in
this case.

1. A 20-year-old nonsmoker presents to your oIIice with a sudden onset oI chest pain. You order
a chest radiograph, which shows a small (15) pneumothorax. He is in no respiratory distress
and vital signs are normal.

Pulse oximetry shows a saturation oI 98 on room air. which one oI the Iollowing would be
most appropriate initially?

A. CT oI the aIIected lung
B. Analgesics and a Iollow-up visit in 48 hours
C. Chest tube insertion
D. Hospital admission and a repeat chest Iilm in 24 hours
Your Answer: B
Result: Correct
Explanation: Practice guidelines state that a patient without apparent lung disease who
develops a spontaneous ~small pneumothorax (<15 of lung volume) can be managed as
an outpatient with analgesics and follow-up within 72 hours. CT of the lung is needed in
complicated cases. including patients with known lung disease or recurrent
pneumothoraces. chest tube is required only when the pneumothorax involves >15 of
lung volume.

2. In which one oI the Iollowing patients can a diagnosis oI osteoporosis be made?

A. A 58-year-old Iemale who Iractured her wrist when she slipped and Iell on her outstretched
hand onto a carpeted Iloor
B. A 62-year-old Iemale who sustained a pelvic Iracture in a motor vehicle accident
C. A 52-year-old Iemale with a T-score oI 2.5 on bone mineral density (BMD) testing oI her
hip
D. A 67-year-old Iemale with a T-score oI 1.7 on BMD testing oI her spine
E. A 72-year-old Iemale with a T-score oI 2.0 on BMD testing oI her spine
Your Answer: E
Result: Incorrect
Explanation: Osteoporosis is defined as a fragility or low-impact fracture. or as a spine or
hip bone mineral density (BD) 2.5 standard deviations below the mean for young.
healthy women. fracture of the radius caused by a fall from a standing position would be
considered a low-impact fracture. A Iracture resulting Irom a motor vehicle accident would be
considered a high-impact Iracture, which is not diagnostic Ior 11 osteoporosis. A T-score oI 2.5
or less is considered osteoporosis, a T-score between 1.0 and 2.5 is considered osteopenia, and
a T-score oI 1.0 or higher is considered normal.

3. At a routine visit, a 40-year-old Iemale asks about beginning an exercise regimen. She has a
Iamily history oI heart disease and hypertension. She currently has no medical problems, but she
is sedentary.

Which one oI the Iollowing would be the most appropriate recommendation Ior this patient?

. Fast walking for 30 minutes on 5 or more days per week
B. Jogging Ior 30 minutes every other day
C. Weight training once weekly
D. An exercise stress test prior to beginning exercise
E. A baseline EKG and rhythm strip
Your Answer: E
Result: Incorrect
Explanation: This patient would beneIit Irom exercise to prevent or delay the onset oI heart
disease and hypertension, and to manage her weight. Exercise stress testing is not speciIically
indicated Ior this patient. Current recommendations are Ior healthy adults to engage in 30
minutes oI accumulated moderate-intensity physical activity on 5 or more days per week.

4. A 56-year-old male with a history oI nephrolithiasis presents with a complaint oI right Ilank
pain. Further evaluation reveals a right ureteral calculus 4 mm in diameter. Laboratory tests
reveal a serum calcium level oI 12.1 mg/dL (N 8.510.5), a normal albumin level, and normal
kidney and liver Iunction tests. The patient takes no chronic medications.

Which one oI the Iollowing is most likely to reveal the cause oI this patient`s elevated calcium?

A. A 24-hour urine calcium level
B. A repeat serum calcium level in 46 weeks
C. A serum 25-hydroxyvitamin D level
D. A serum calcitonin level
E. A serum intact parathyroid hormone level
Your Answer: E
Result: Correct
Explanation: Primary hyperparathyroidism and malignancy are the most common causes of
hypercalcemia. accounting for about 90 of cases. An intact parathyroid hormone (PTH)
level should be obtained initially, as the results will indicate what kind oI additional evaluation is
needed. Vitamin D and urine calcium studies are useIul in evaluating hypercalcemia, but a PTH
level should be obtained Iirst. It would not be appropriate to wait Ior a repeat calcium level in 4
6 weeks, because this patient has nephrolithiasis and a calcium level 12 mg/dL, indicating a
possible need Ior surgery or perhaps a malignancy. Calcitonin levels generally are not necessary
in the evaluation oI hypercalcemia.

5. You are caring Ior a 70-year-old male with widespread metastatic prostate cancer. Surgery,
radiation, and hormonal therapy have Iailed to stop the cancer, and the goal oI his care is now
symptom relieI. He is being cared Ior through a local hospice. Over the past Iew days he has
been experiencing respiratory distress. His oxygen saturation is 94 on room air and his lungs
are clear to auscultation. His respiratory rate is 16/min.

Which one oI the Iollowing would be best at this point?

A. Morphine
B. Oxygen
C. Albuterol (Proventil, Ventolin)
D. Haloperidol
Your Answer: B
Result: Incorrect
Explanation: Dyspnea is a frequent and distressing symptom in terminally ill patients. In
the absence of hypoxia. oxygen is not likely to be helpful. Opiates are the mainstay of
symptomatic treatment.

6. A 72-year-old white Iemale is admitted to the hospital with her Iirst episode oI acute heart
Iailure. She has a history oI hypertension treated with a thiazide diuretic. An echocardiogram
reveals no evidence oI valvular disease and no segmental wall motion abnormalities. LeIt
ventricular hypertrophy is described, and the eiection Iraction is 55. Her pulse rate is
72beats/min.

The most likely cause oI her heart Iailure is:

A. systolic dysIunction
B. diastolic dysfunction
C. hypertrophic cardiomyopathy
D. high-output Iailure
Your Answer: A
Result: Incorrect
Explanation: Diastolic dysfunction is now recognized as an important cause of heart failure.
It is due to left ventricular hypertrophy as a response to chronic systolic hypertension. The
ventricle becomes stiII and unable to relax or Iill adequately, thus limiting its Iorward output.
The typical patient is an elderly person who has systolic hypertension. left ventricular
hypertrophy. and a normal ejection fraction (50-55).

8. You would recommend pneumococcal vaccine Ior which one oI the Iollowing?

A. A 20-year-old male who smokes 1 pack oI cigarettes daily
B. A 52-year-old male with type 2 diabetes mellitus who received pneumococcal vaccine 6 years
ago
C. A 60-year-old male who is a long-term resident oI a nursing home because oI a previous
stroke, and who received pneumococcal vaccine at age 54
D. A 62-year-old male with chronic renal Iailure who received pneumococcal vaccine at age 50
and age 55
E. A 71-year-old male with no medical problems who received pneumococcal vaccine at age 65
Your Answer: D
Result: Incorrect
Explanation:. ll persons between the ages of 19 and 64 who smoke should receive this
vaccine. One-time revaccination after 5 years is recommended for persons with chronic
renal failure. asplenia (functional or anatomic). or other immunocompromising conditions.
The patient with chronic renal Iailure in this question has already received two immunizations.
The diabetic patient and the nursing-home resident have both received one immunization
and should not receive a second dose until age 65. The 71-year-old has already been
immunized after age 65. and a repeat immunization is not recommended.

9. A 64-year-old white male presents to the emergency department with a 48-hour history oI leIt
lower quadrant pain. AIter a thorough history and a physical examination you conclude that the
patient has diverticulitis. The patient is allergic to metronidazole (Flagyl).

You recommend a clear-liquid diet, a Iollow-up visit with his primary care physician in 48 hours,
and treatment with:

A. amoxicillin
B. amoxicillin/clavulanate (Augmentin)
C. ciproIloxacin (Cipro)
D. doxycycline
E. azithromycin (Zithromax)
Your Answer: C
Result: Incorrect
Explanation: An accepted regimen for outpatient treatment of diverticulitis is
amoxicillin/clavulanate. 875 mg every 12 hours. The other regimens are not optimal treatments
because they do not include anaerobic coverage.

10. An 86-year-old mildly demented male nursing-home resident rarely leaves the Iacility. He
has Irequent Iecal incontinence that is disturbing to both him and his Iamily. He has diet-
controlled diabetes mellitus and hypertension, and a history oI transurethral resection oI the
prostate (TURP) Ior benign prostatic hypertrophy. An examination is remarkable only Ior an
empty rectum and no Iocal neurologic Iindings.

Which one oI the Iollowing is the most likely cause oI this patient`s Iecal incontinence?

A. Decreased rectal sensation secondary to diabetes mellitus
B. Decreased rectal storage capacity
C. Internal sphincter weakness
D. Puborectalis weakness
E. OverIlow
Your Answer: A
Result: Incorrect
Explanation: Overflow incontinence is common in the institutionalized elderly. and is often
due to constipating medications. Reduced storage capacity is usually seen with inIlammatory
bowel disease. Mild diabetes mellitus does not cause decreased rectal sensation, and puborectalis
and internal sphincter weakness are uncommon in males, as they usually result Irom vaginal
delivery

1. A 13-year-old male presents with a 3-week history oI leIt lower thigh and knee pain. There is
no history oI a speciIic iniury, and his past medical history is negative. He has had no Ievers,
night sweats, or weight loss, and the pain does not awaken him at night. He tried out Ior the
basketball team but had to quit because oI the pain, which was worse when he tried to run.

Which one oI the Iollowing physical examination Iindings would be pathognomonic Ior slipped
capital Iemoral epiphysis?

A. Excessive Iorward passive motion oI the tibia with the knee Ilexed
B. Lateral displacement oI the patella with active knee Ilexion
C. Limited internal rotation oI the Ilexed hip
D. Reduced hip abduction with the hip Ilexed
E. Inability to extend the hip past the neutral position
Your Answer: A
Result: Incorrect
Explanation: Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents
during the growth spurt. Physical activity. obesity. and male gender are predisposing
factors for the development of this condition. in which the femoral head is displaced
posteriorly through the growth plate. There is pain with physical activity. most commonly
in the upper thigh anteriorly. but one-third of patients present with referred lower thigh or
knee pain. which can make accurate and timely diagnosis more difficult. The hallmark of
SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even
greater limitation of internal rotation when the hip is flexed to 90. No other pediatric
condition has this physical Iinding, which makes the maneuver very useIul in children with
lower extremity pain. Orthopedic consultation is advised iI SCFE is suspected. Hip extension
and abduction are also limited in SCFE, but these Iindings are nonspeciIic. The knee Iindings in
this patient are not associated with SCFE.

2. A 74-year-old male presents with a 4-day history oI diarrhea that he had initially thought was
'a 24-hour virus. He states that the onset oI his illness included nausea, one episode oI
vomiting, and proIuse diarrhea. He has Ielt Ieverish and has been having abdominal cramps. He
does not recall eating anything unusual and has not traveled recently. On examination he appears
uncomIortable, but in no real distress. His oral temperature is 37.1C (98.8F), blood pressure
134/82 mm Hg, and pulse rate 100 beats/min. He has lost 4 kg (9 lb) since his last visit 2 months
earlier. His abdomen is soIt, with hyperactive bowel sounds and mild diIIuse tenderness on
palpation. A CBC and basic metabolic proIile are normal.

Which one oI the Iollowing is the most likely cause oI this patient's illness?

A. Norwalk-like virus (Norovirus)
B. $higella
C. Campvlobacter
D. scherichia coli O157:H7
E. $taphvloccocus aureus
Your Answer: D
Result: Incorrect
Explanation:
Campvlobacter jejuni is one oI the most common causes oI bacterial Ioodborne illnesses,
estimated to aIIect 1 million Americans annually. Undercooked or improperly handled
chicken is most oIten implicated as the source. Symptoms typically begin 2-5 days following
exposure. Diarrhea is the predominant symptom, with a lesser degree oI nausea and vomiting.
Up to 10 days is required Ior Iull recovery.
While 8cherichia coli O157:H7 and Shigella may cause a similar illness. both generally
present with bloody diarrhea. coli O157:H7 is most oIten transmitted in contaminated
undercooked beeI, and Shigella is usually spread in a Iecal-oral pattern or via contaminated
water. The peripheral WBC count is typically increased substantially in shigellosis.
$taphvlococcus aureus produces an enterotoxin in Iood that causes the onset oI nausea,
vomiting, and diarrhea within hours oI ingestion and clears within 2448 hours. Norovirus is a
very common cause oI acute viral gastroenteritis, usually with more vomiting than diarrhea. It
spreads person to person, and patients usually recover within 24 hours.

3. A 50-year-old Iemale with signiIicant Iindings oI rheumatoid arthritis presents Ior a
preoperative evaluation Ior planned replacement oI the metacarpophalangeal ioints oI her right
hand under general anesthesia. She generally enioys good health and has had ongoing medical
care Ior her illness.

OI the Iollowing, which one would be most important Ior preoperative assessment oI this
patient`s surgical risk?

A. Resting pulse rate
B. Resting oxygen saturation
C. Erythrocyte sedimentation rate
D. Rheumatoid Iactor titer
E. Cervical spine imaging
Your Answer: B
Result: Incorrect
Explanation: While all oI the options listed may have some value in evaluating the preoperative
status of a patient with long-standing rheumatoid arthritis. imaging of the patient`s
cervical spine to detect atlantoaxial subluxation would be most important for preventing a
catastrophic spinal cord injury during intubation. In many cases, cervical fusion must be
performed before other elective procedures can be contemplated. Although rheumatoid
arthritis may inIluence oxygen saturation and the erythrocyte sedimentation rate, these tests
would not alert the surgical team to the possibility oI signiIicant operative morbidity and
mortality. Resting pulse rate and rheumatoid Iactor are unlikely to be signiIicant Iactors in this
preoperative scenario.
4. A 68-year-old white male with diabetes mellitus is hospitalized aIter suIIering a right middle
cerebral artery stroke. A nurse in the intensive-care unit calls to advise you that his blood
pressure is 200/110 mm Hg. You should:

A. continue monitoring the patient
B. administer labetalol (Trandate)
C. administer nicardipine (Cardene)
D. administer nitroprusside (Nitropress)
E. administer nitroglycerin
Your Answer: D
Result: Incorrect
Explanation: Current American Heart Association guidelines Ior blood pressure control in
stroke patients advise monitoring with no additional treatment for patients with a systolic
blood pressure <220 mm Hg or a diastolic blood pressure <120 mm Hg. The elevated blood
pressure is thought to be a protective mechanism that increases cerebral perfusion. and
lowering the blood pressure may increase morbidity.

5. A 59-year-old white Iemale has a blood pressure consistently at or above 140/90 mm Hg. Her
only other signiIicant medical problem is diabetes mellitus, which is controlled by diet.

Which one oI the Iollowing is the most clearly established advantage oI angiotensin receptor
blockers (ARBs) when compared with ACE inhibitors in patients such as this?

A. Reduced risk oI persistent cough
B. Reduced risk oI headache
C. Reduced risk oI heart Iailure
D. Improved control oI blood pressure
E. Improved lipid proIile
Your Answer: A
Result: Correct
Explanation: In multiple studies, angiotensin receptor blockers (ARBs) have been shown to be
less likely to cause a chronic cough when compared with ACE inhibitors. Although this is not a
liIe-threatening danger, it is a side eIIect that can be persistent and lead to discontinuation oI
medication. ngioedema. a more dangerous side effect. was thought to be CE-inhibitor
specific. However. it is rare and there is not yet good evidence that RBs are safer. There
have been case reports of angioedema associated with RB use. The incidence of headache
is similar for the two drug classes. ARBs have not been proven superior to ACE inhibitors in
blood pressure control, eIIects on lipid proIiles, or prevention oI heart Iailure, and there is
substantially more data on ACE inhibitors Ior the prevention oI heart Iailure and proteinuria.

6. Which one oI the Iollowing is the most likely cause oI chronic unilateral nasal obstruction in
an adult?

A. Nasal septal deviation
B. Foreign-body impaction
C. Allergic rhinitis
D. Adenoidal hypertrophy
Your Answer: C
Result: Incorrect
Explanation: The most common cause oI nasal obstruction in all age groups is the common cold,
which is classiIied as mucosal disease. natomic abnormalities. however. are the most
frequent cause of constant unilateral obstruction. with septal deviation being most
common. Foreign-body impaction is an important, but inIrequent, cause oI unilateral obstruction
and purulent rhinorrhea. Mucosal disease is usually bilateral and intermittent. Adenoidal
hypertrophy is the most common tumor or growth to cause nasal obstruction, Iollowed by nasal
polyps, but both are less Irequent than true anatomic causes oI constant obstruction.

7. Which one oI the Iollowing is most consistent with a diagnosis oI iron deIiciency anemia?

A. Low iron-binding capacity
B. An elevated methylmalonic acid level
C. Increased serum Ierritin
D. Reticulocytosis about 1 week aIter administration oI iron
Your Answer: D
Result: Correct
Explanation: In iron deIiciency anemia, serum iron is low but iron-binding capacity is high.
Serum Ierritin is one-tenth oI normal. Bone marrow iron stores are depleted. Oral replacement,
which is saIer than parenteral administration and more acceptable to patients, should raise the
hemoglobin level by 0.2 g/dL/day. A reticulocyte response should be seen in a week to 10 days
unless Iactors such as a concomitant Iolic acid deIiciency prevent a Iull response to therapy.

8. Which one oI the Iollowing is the best INITIAL management Ior hypercalcemic crisis?

A. Intravenous Iurosemide
B. Intravenous pamidronate (Aredia)
C. Intravenous plicamycin (Mithramycin)
D. Intravenous saline
Your Answer: D
Result: Correct
Explanation: The initial management of hypercalcemic crisis involves volume repletion and
hydration. The combination oI inadequate Iluid intake and the inability oI hypercalcemic
patients to conserve Iree water can lead to calcium levels over 1415 mg/dL. Because patients
oIten have a Iluid deIiciency oI 45 liters, delivering 1000 mL oI normal saline during the Iirst
hour, Iollowed by 250300 mL/hour, may decrease the hypercalcemia to less than critical levels
(13 mg/dL). If the clinical status is not satisfactory after hydration alone. then renal
excretion of calcium can be enhanced by saline diuresis using furosemide. Intravenous
pamidronate. a diphosphonate. reduces the hypercalcemia of malignancy and is best used
in the semi-acute setting. since calcium levels do not start to fall for 24 hours. The same is
true for intravenous plicamycin.

9. A healthy 24-year-old male presents with a sore throat oI 2 days` duration. He reports mild
congestion and a dry cough. On examination, his temperature is 37.2C (99.0F). His pharynx is
red without exudates, and there are no anterior cervical nodes. His tympanic membranes are
normal, and his chest is clear.

You would do which one oI the Iollowing?

A. Treat with analgesics and supportive care
B. Treat with azithromycin (Zithromax)
C. PerIorm a throat culture and begin treatment with penicillin
D. PerIorm a rapid strep test
Your Answer: A
Result: Correct
Explanation: The Centers Ior Disease Control and Prevention (CDC) assembled a panel oI
national health experts to develop evidence-based guidelines Ior evaluating and treating adults
with acute respiratory disease. According to these guidelines, the most reliable clinical predictors
oI streptococcal pharyngitis are the Centor criteria. These include tonsillar exudates. tender
anterior cervical lymphadenopathy. absence of cough. and history of fever. The presence of
three or four of these criteria has a positive predictive value of 40-60. and the absence
of three or four of these criteria has a negative predictive value of 80. Patients with four
positive criteria should be treated with antibiotics. those with three positive criteria should
be tested and treated if positive. and those with 0-1 positive criteria should be treated with
analgesics and supportive care only. This patient has only one of the Centor criteria. and
according to the panel should not be tested or treated with antibiotics.

10. A 28-year-old male is seen Ior Iollow-up oI acute low back pain. He has a past history oI
substance abuse. IbuproIen and acetaminophen have helped some, but he is experiencing muscle
spasms.

It is best to avoid which one oI the Iollowing when treating this patient`s problem?

A. Chlorzoxazone (ParaIon Forte DSC)
B. Metaxalone (Skelaxin)
C. Cyclobenzaprine (Flexeril)
D. Methocarbamol (Robaxin)
E. Carisoprodol (Soma)
Your Answer: D
Result: Incorrect
Explanation: There is limited data regarding the eIIectiveness oI muscle relaxants in
musculoskeletal conditions, but strong evidence regarding their toxicity. Because the evidence
Ior comparable eIIectiveness is weak, drug selection should be based on patient preIerence, side-
eIIect proIile, drug interactions, and abuse potential. Carisoprodol is metabolized to
meprobamate. which is a class III controlled substance. It has been shown to produce both
physical and psychologic dependence.

1. You test a patient`s muscles and Iind that his maximum perIormance consists oI the ability to
move with gravity neutralized. This qualiIies as which grade oI muscle strength, on a scale oI 5?

A. 0
B. 1
C. 2
D. 3
E. 4
Your Answer: B
Result: Incorrect
Explanation:
Muscle strength is scored on a scale oI 0 to 5. The inability to contract a muscle is scored as 0.
Contraction without movement constitutes grade 1 strength. ovement with the effect of
gravity neutralized is grade 2 strength. while movement against gravity only is grade 3
strength. ovement against gravity plus some additional resistance indicates grade 4
strength. Normal. or grade 5. strength is demonstrated by movement against substantial
resistance.

A. Gallstone pancreatitis
B. Pancreatic necrosis
C. Pancreatic pseudocyst
D. Hepatitis C
E. Alcohol-induced pancreatitis
Your Answer: A
Result: Correct
Explanation:
In this setting, a threefold or greater elevation of alanine transaminase has a positive
predictive value of 95 for acute gallstone pancreatitis. High levels of C-reactive protein
are associated with pancreatic necrosis. Hepatitis C is identiIied by antibody detection or
polymerase chain reaction testing. Other markers are investigational.

3. You are asked to see a mentally challenged 45-year-old male Irom a nearby group home who
has groin pain. On examination you notice that he has large ears, a prominent iaw, and large
symmetric testicles.
These Iindings are consistent with:

A. a variant Iorm oI Down syndrome
B. Asperger`s syndrome
C. KlineIelter`s syndrome
D. homocystinuria
E. Fragile X syndrome
Your Answer: E
Result: Correct
Explanation: Fragile X syndrome accounts Ior more cases oI mental retardation in males than
any other genetic disorder except Down syndrome; about one in 40006000 males is aIIected.
Down syndrome, KlineIelter`s syndrome, and homocystinuria do not present with the described
Iindings. Asperger`s syndrome is a variant oI autism in people oI normal to high intelligence.
Patients with KlineIelter`s syndrome usually have small testicles. ReI: Tierney LM, McPhee SJ,
Papadakis MA, et al: Current Medical Diagnosis and Treatment 2006. McGraw-Hill Medical,
2005, p 1705. 2) WattendorI DJ, Muenke M: Diagnosis and management oI Iragile X syndrome.
Am Fam Phvsician 2005;72(1):111-113.

4. According to the U.S. Preventive Services Task Force, multivitamin supplements in the
geriatric age group:

A. are not recommended Ior prevention oI any disorder
B. should be prescribed to reduce elevated homocysteine levels
C. decrease coronary atherosclerosis
D. decrease the incidence oI lung cancer
E. decrease the incidence oI colon cancer
Your Answer: A
Result: Correct
Explanation:
The U.S. Preventive Services Task Force makes no speciIic recommendations Ior vitamins or
antioxidants to prevent cancer or cardiovascular disease. oreover. it makes no specific
recommendations for vitamin supplements for any condition.

5. Which one oI the Iollowing antihypertensive drugs is most likely to cause ankle edema?

A. Hydrochlorothiazide
B. Amlodopine (Norvasc)
C. Lisinopril (Prinivil, Zestril)
D. Losartan (Cozar)
E. Atenolol (Tenormin)
Your Answer: B
Result: Correct
Explanation:
The most common side effects of calcium channel blockers. such as amlodipine. are due to
vasodilation. One result of this may be peripheral edema. but it can also cause dizziness.
nausea. hypotension. cough. and pulmonary edema. These problems may decrease with time,
with reductions in dosage, or with the addition oI a diuretic or second calcium antagonist. Other
classes oI drugs are not associated with these problems.

6. A 27-year-old Korean Iemale consults you regarding several painIul ulcers she has developed
in the vaginal area. Your examination reveals multiple 0.5-cm to 1.5-cm oval ulcers with sharply
deIined borders and a yellowish-white membrane. She denies recent sexual activity. Except Ior
recurring aphthous ulcers oI her mouth, her past history is unremarkable. You obtain blood Ior a
CBC and serology. A Tzanck smear and culture oI her ulcer is negative Ior herpes simplex virus.
Two days later she returns to discuss her laboratory Iindings. She draws your attention to a
pustule with an erythematous margin at the site where the venipuncture was done.

At this time the most likely diagnosis is:

A. Reiter`s syndrome
B. Behcet`s syndrome
C. syphilis
D. mucocutaneous lymph node syndrome (Kawasaki disease)
E. AIDS
Your Answer: B
Result: Correct
Explanation: The original description oI Behcet`s syndrome included recurring genital and
oral ulcerations and relapsing uveitis. It is more common in 1apan. Korea. and the Eastern
editerranean area. and affects primarily young adults. The cause is unknown. Two-thirds
oI patients will develop ocular involvement that may progress to blindness. Patients may develop
arthritis, vasculitis, intestinal maniIestations, or neurologic maniIestations. This disease is also
associated with cutaneous hypersensitivity; 60-70 of patients will develop a sterile
pustule with an erythematous margin within 48 hours of an aseptic needle prick. Reiter`s
syndrome is not associated with genital ulcers. The ulcers oI syphilis are characteristically
painless. Mucocutaneous lymph node syndrome (Kawasaki disease) primarily aIIects children
under 6 years oI age. While AIDS causes distinctive skin lesions, genital ulcers are not a
common maniIestation oI this disease.

7. A 40-year-old runner complains oI gradually worsening pain on the lateral aspect oI his Ioot.
He runs on asphalt, and has increased his mileage Irom 2 miles/day to 5 miles/day over the last 2
weeks. Palpation causes pain over the lateral 5th metatarsal. The pain is also reproduced when he
iumps on the aIIected leg. When you ask about his shoes he tells you he bought them several
years ago.


A. Ligamentous sprain oI the arch
B. Stress Iracture
C. Plantar Iasciitis
D. Osteoarthritis oI the metatarsal ioint
Your Answer: B
Result: Correct
Explanation: Running iniuries are primarily caused by overuse due to training errors. Runners
should be instructed to increase their mileage gradually. stress fracture causes localized
tenderness and swelling in superficial bones. and the pain can be reproduced by having the
patient jump on the affected leg. Plantar fasciitis causes burning pain in the heel and there
is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.

8. A 55-year-old male is brought to the emergency department because oI conIusion and
seizures. He has a history oI hypertension and obstructive sleep apnea due to obesity. He is not
conscious and no other history is available. An examination shows no Iocal neurologic Iindings,
but a general examination is limited because oI his size. Breath sounds are diminished, and heart
sounds are diIIicult to hear. He has venous insuIIiciency changes on his lower extremities, with
brawny-type edema. Laboratory testing reveals a sodium level oI 116 mmol/L (N 135145), but
normal renal and liver Iunctions. A chest radiograph shows mild cardiomegaly. A BNP level is
pending, but immediate treatment is Ielt to be indicated.

Which one oI the Iollowing is the treatment oI choice Ior this patient?

A. Valsartan (Diovan)
B. Furosemide
C. Vasopressin (Pitressin)
D. Hypertonic saline
E. Conivaptan (Vaprisol)
Your Answer: A
Result: Incorrect
Explanation: This patient has severe hyponatremia manifested by confusion and seizures. a
life-threatening situation warranting urgent treatment with hypertonic (3) saline. The
serum sodium level should be raised by only 1-2 mmol/L per hour. to prevent serious
neurologic complications. Saline should be used only until the seizures stop. Some
authorities recommend concomitant use oI Iurosemide, especially in patients who are likely to be
volume overloaded, as this patient is, but it should not be used alone. The arginine vasopressin
antagonist conivaptan is approved Ior the treatment oI euvolemic or hypervolemic hyponatremia,
but not in patients who are obtunded or in a coma, or who are having seizures.

9. A 29-year-old gravida 1 para 0 at 8 weeks gestation is concerned about Down syndrome. She
had a sibling with Down syndrome, and she and her spouse want to know what antenatal tests are
available to them.

Which one oI the Iollowing has the best detection rate Ior Down syndrome in the Iirst trimester
oI pregnancy?

A. Serum -hCG and pregnancy-associated plasma protein A (PAPP-A), with nuchal
translucency (combined screening)
B. Maternal serum levels oI inhibin A, u-Ietoprotein, unconiugated estriol, and -hCG
(quadruple screening)
C. Ultrasonography
D. Chorionic villus sampling
E. Amniocentesis
Your Answer: A
Result: Incorrect
Explanation: In today`s environment, there are multiple screening tools and tests to detect Ietal
aneuploidy. All pregnant women, regardless oI age, should be oIIered the opportunity to undergo
some Iorm or combination oI screening to detect Ietal abnormalities (SOR B). Chorionic villus
sampling can be oIIered at 1013 weeks gestation, and has a 97.8 detection rate Ior Down
syndromethe best detection rate oI studies oIIered in the Iirst trimester (SOR C). Combined
screening can be oIIered at 1114 weeks gestation, and has a 78.789 detection rate (SOR
A). Although amniocentesis has the best detection rate oI the options listed (99.4), it cannot be
oIIered until 1618 weeks gestation (SOR C). Quadruple screening is done at 1520 weeks
gestation, and has a 6781 detection rate (SOR A); ultrasonography at 1822 weeks
gestation has a 3579 detection rate (SOR C).

10. A 72-year-old male presents to your clinic in atrial Iibrillation with a rate oI 132 beats/min.
He has hypertension, but no history oI heart Iailure or structural heart disease. He is otherwise
healthy and active.

The best INITIAL approach to his atrial Iibrillation would be:

A. rhythm control with antiarrythmics and warIarin (Coumadin) only iI he cannot be consistently
maintained in sinus rhythm
B. rhythm control with antiarrythmics and warIarin regardless oI maintenance oI sinus rhythm
C. ventricular rate control with digoxin, and warIarin Ior anticoagulation
D. ventricular rate control with digoxin, and aspirin Ior anticoagulation
E. ventricular rate control with a calcium channel blocker or -blocker. and warfarin for
anticoagulation
Your Answer: E
Result: Correct
Explanation: Randomized, controlled trials have indicated that in most patients with atrial
Iibrillation, rate control is the best initial management. Patients who were stratiIied to the rhythm
control arm oI these trials did not have lower morbidity or mortality and were more likely to
suIIer Irom adverse drug eIIects and increased hospitalizations. The most eIIicacious drugs Ior
rate control are calcium channel blockers and -blockers. Digoxin is less eIIective Ior rate
control and its role should be limited to a possible additional drug Ior those not controlled with a
-blocker or calcium channel blocker, or Ior patients with signiIicant leIt ventricular systolic
dysIunction. In patients 65 years oI age or older or with one or more risk Iactors Ior stroke, the
best choice Ior anticoagulation to prevent thromboembolic disease is warIarin. II rhythm control
is successIul and sinus rhythm is maintained, the thromboembolic rate is equivalent to that seen
with a rate control strategy. Thus, the data suggests that patients managed with a rhythm control
strategy should be maintained on anticoagulation regardless oI whether they are consistently in
sinus rhythm.

1. A 7-year-old Hispanic Iemale has a 3-day history oI a Iever oI 40.0C (104.0F), muscle
aches, vomiting, anorexia, and headache. Over the past 12 hours she has developed a painless
maculopapular rash that includes her palms and soles but spares her Iace, lips, and mouth. She
has recently returned Irom a week at summer camp in Texas. Her pulse rate is 140 beats/min,
and her blood pressure is 80/50 mm Hg in the right arm while lying down.


A. Mucocutaneous lymph node syndrome
B. Leptospirosis
C. Rocky Mountain spotted Iever
D. Scarlet Iever
E. Toxic shock syndrome
Your Answer: C
Result: Correct
Explanation: While all oI the diagnoses listed are in the diIIerential, the most likely is Rocky
ountain spotted fever (RSF) (SOR C). It occurs throughout the United States, but is
primarily Iound in the South Atlantic and south central states. It is most common in the summer
and with exposure to tall vegetation (e.g., while camping, hiking, or gardening), and is
transmitted by ticks. The diagnosis is based on clinical criteria that include fever. hypotension.
rash. myalgia. vomiting. and headache (sometimes severe). The rash associated with RSF
usually appears 2-4 days after the onset of fever and begins as small. pink. blanching
macules on the ankles. wrists. or forearms that evolve into maculopapules. It can occur
anywhere on the body, including the palms and soles, but the face is usually spared.
ucocutaneous lymph node syndrome is a similar condition in children (usually <2 years
old). but symptoms include changes in the lips and oral cavity. such as strawberry tongue.
redness and cracking of the lips. and erythema of the oropharyngeal mucosa. Leptospirosis
is usually accompanied by severe cutaneous hyperesthesia. The patient with scarlet fever
usually has prominent pharyngitis and a fine. papular. erythematous rash. Toxic shock
syndrome may present in a similar fashion. but usually in postmenarchal females.

2. A 48-year-old male who weighs 159 kg (351 lb) is admitted to the hospital with a leIt leg
deepvein thrombosis and pulmonary embolism. Treatment is begun with enoxaparin (Lovenox).

Which one oI the Iollowing would be most appropriate Ior monitoring the adequacy oI
anticoagulation in this patient

A. Anti-Iactor Xa levels
B. Activated partial thromboplastin time (aPTT)
C. Daily INRs
D. Daily Iactor VIII levels
Your Answer: B
Result: Incorrect
Explanation: In severely obese patients (>330 lb) and those with renal failure. low molecular
weight heparin therapy should be monitored with anti-factor Xa levels obtained 4 hours
after injection. ost other patients do not need monitoring. The INR is used to monitor
warIarin therapy, and the activated partial thromboplastin time (aPTT) is used to monitor
therapy with unfractionated heparin. Factor VIII levels are not used to monitor
anticoagulation therapy.

3. Under current guidelines, hospice programs are most likely to serve patients dying Irom:

A. heart Iailure
B. COPD
C. severe dementia
D. multiple strokes
E. cancer
Your Answer: E
Result: Correct
Explanation:
The general requirement for enrolling an individual in hospice is that they have a terminal
illness and an estimated life expectancy of 6 months or less. Given these criteria, it is not
surprising that over 40 oI hospice patients have a cancer diagnosis. Cancer usually has a short
period oI obvious decline at the end and is predictable to a degree. Diseases such as COPD, end-
stage liver disease, and heart Iailure result in long-term disability with periodic exacerbations,
any one oI which could result in death, but Iar less predictably. Those with severe dementia or
Irailty oIten experience a dwindling course that is also diIIicult to predict.
4. A healthy 48-year-old bookkeeper who works in a medical oIIice has a positive PPD on
routine yearly screening. Which one oI the Iollowing would be most appropriate at this point?

A. A chest radiograph
B. A repeat PPD
C. Treatment with isoniazid and one other antituberculous drug Ior 12 months
D. Anergy testing
Your Answer: A
Result: Correct
Explanation:
Clinical evaluation and a chest radiograph are recommended in asymptomatic patients
with a positive PPD (SOR C). A two-step PPD is perIormed on those at high risk whose initial
test is negative. symptomatic patients with a positive PPD and an abnormal chest film
should have a sputum culture for TB. but a culture is not required if the chest film is
negative. Persons with a PPD conversion should be encouraged to take INH for 9 months
with proper medical supervision. Patients with a negative PPD who are still at high risk Ior
TB, especially HIV-positive patients, could be evaluated Ior anergy, but it is not recommended at
this time.
5. Which one oI the Iollowing decreases the absorption oI orally administered calcium
supplements?

A. Taking calcium carbonate with meals
B. Taking calcium citrate with meals
C. Vitamin D supplementation
D. Proton pump inhibitors
Your Answer: D
Result: Correct
Explanation: Long-term histamine H -blocker or proton pump inhibitor use is associated
with decreased absorption of calcium carbonate. Patients taking these medications who
require calcium supplementation should use calcium citrate to improve absorption.
Calcium carbonate preparations should be given with a meal to improve absorption. Vitamin D is
important in calcium absorption.
6. A 16-year-old high-school Iootball player plants his leIt Ioot to make a cut and Ieels his leIt
leg give way. He Ieels a pop in the knee, Iollowed by acute pain. He is evaluated on the Iield,
and examination with the knee Ilexed 20 reveals that the tibia can be displaced Iarther anteriorly
than with the uninvolved knee.

Which one oI the Iollowing conditions is most likely?

A. Patellar tendon rupture
B. Posterior cruciate ligament tear
C. Anterior cruciate ligament tear
D. Tibial plateau Iracture
E. Patellar dislocation
Your Answer: C
Result: Correct
Explanation: Anterior cruciate ligament (ACL) tears are the most common ligament iniury
requiring surgery. Females have a significantly higher rate of CL tears. with the majority
of tears in both men and women occurring without physical contact. In addition to the
immediate problems, there is a signiIicant increase in premature osteoarthritis oI the knee.
Approximately 50 oI patients with this iniury develop osteoarthritis in 1020 years. Findings
that help make the diagnosis oI ACL tear include a noncontact mechanism oI iniury, an audible
popping sound, early swelling oI the ioint, and the inability to participate in the game aIter the
iniury. Many patients can walk normally and can perIorm such straight-plane activities as
climbing stairs, biking, or iogging.

Physical examination using the Lachman test or pivot shiIt test can be used to Iurther assess
whether the ligament is torn. MRI can be used to conIirm the diagnosis, although it is not needed
iI the diagnosis is clear Irom the history and examination. The other conditions listed are also
sports-related knee iniuries, but have diIIerent mechanisms oI iniury or physical Iindings.
Patients with patellar tendon rupture are unable to fully extend their knee and examination
shows a palpable defect in the patellar ligament and a high-riding patella. While the
mechanism oI iniury in patients with posterior cruciate ligament tears may be similar to that oI
ACL iniury, the examination would show posterior rather than anterior displacement oI the tibia
when the knee is Ilexed at 90 (the posterior drawer sign). The mechanism of injury of tibial
plateau fractures in a healthy young male generally involves a high energy collision causing
a valgus force with axial loading. Patients with patellar dislocations have symptoms similar to
those oI an ACL iniury, including an audible crack or pop and the Ieeling oI the knee giving way
aIter a twisting motion. Immediately Iollowing the iniury, however, examination would show an
obvious deIormity, but the patella may spontaneously relocate prior to the on-Iield exam. There
would be no instability on the Lachman maneuver.

7. The best available evidence supports which one oI the Iollowing guidelines Ior discussing
serious illnesses?

. Physicians should delay having a detailed discussion with the patient about the expected
prognosis of cancer until staging is completed
B. For patients who are ambivalent about knowing their prognosis, the discussion should Iocus
on optimal potential outcomes and providing hope, even iI this is unrealistic
C. Physicians should delay discussions about palliative care until curative measures have Iailed
D. Physicians should respect the Iamily`s wishes regarding how much inIormation to share with
the patient
Your Answer: B
Result: Incorrect
Explanation:
It is best to discuss prognosis aIter accurate cancer staging, when speciIic details about survival
rates will give a much clearer and more accurate picture. AIter assessing the patient`s readiness
to receive prognostic inIormation, the physician should Iocus on communicating an accurate
prognosis without giving a Ialse sense oI hope. Using simultaneous-care models, physicians can
provide palliative and curative care at the same time. Physicians should initiate a discussion
about the availability oI coordinated, symptomdirected services such as palliative care early in
the disease process; as the disease progresses, patients should transition Irom curative to
palliative therapy. How much inIormation to share with the patient depends on the physician`s
assessment oI the patient`s level oI understanding about the disease and how much patients
themselves want to know.
8. A 50-year-old male presents with a 1-day history oI Iever and chest pain. The chest pain is
worse when he is in a supine position and with deep inspiration, and improves when he leans
Iorward. He has no shortness oI breath and has never had this problem beIore. His vital signs are
normal except Ior a temperature oI 37.8C (100.0F). He has no other medical problems or
allergies, and takes no medications. An EKG reveals widespread ST-segment elevation, upright
T waves, and PR-segment depression. His troponin level is normal. An echocardiogram is
pending.

Which one oI the Iollowing would be the most appropriate treatment Ior this patient?

A. Aspirin
B. Prednisone
C. Heparin
D. Enoxaparin (Lovenox)
Your Answer: A
Result: Correct
Explanation: This patient demonstrates classic clinical Ieatures oI acute pericarditis. Although
the EKG Iindings appear speciIic Ior the early stages oI pericarditis, myocardial inIarction would
also be included in the diIIerential diagnosis. However, unlike with acute pericarditis, the EKG
in myocardial inIarction typically demonstrates ST elevation that is localized and convex, oIten
has Q waves, and rarely shows PR-segment depression. A Iriction rub can be heard in up to 85
oI patients with acute pericarditis. An echocardiogram is oIten perIormed to determine the type
and amount oI eIIusion. Conventional therapy for acute pericarditis includes NSIDs. such
as aspirin and ibuprofen. Recent studies demonstrate that adding colchicine to aspirin may be
beneIicial in reducing the persistence and recurrence oI symptoms.

9. An otherwise healthy 37-year-old male presents to your oIIice with a 2-week history oI
redness and slight irritation in his groin. On examination a tender erythematous plaque with mild
scaling is seen in his right crural Iold. The area Iluoresces coral-red under a Wood`s light.

Which one oI the Iollowing would be the most appropriate treatment at this time?

A. Amoxicillin
B. Erythromycin
C. Ketoconazole
D. Nystatin (Mycostatin)
E. Triamcinolone (Kenalog)
Your Answer: C
Result: Incorrect
Explanation: The characteristics of this lesion. including coral-red fluorescence under a
Wood`s light. suggests Corvnebacterium infection. which is associated with erythrasma.
Tinea cruris caused by Micro8porum infection fluoresces green. while intertrigo and tinea
cruris caused by pidermophvton or 1richophvton infections do not fluoresce.
Erythromycin. either systemic or topical. is the treatment of choice.

10. An otherwise healthy 40-year-old male comes to your oIIice Ior Iollow-up oI elevated liver
enzymes on an insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb)
(BMI 37.7 kg/m
2
). He says he drinks about two beers per week. Findings are normal on a
physical examination, except Ior a slightly enlarged liver. AST and ALT levels are twice the
upper limits oI normal.

Which one oI the Iollowing would be the most appropriate next step?

A. A liver biopsy
B. Ultrasonography oI the liver
C. Colonoscopy
D. Testing Ior viral hepatitis
E. Repeat AST and ALT levels in 3 months
Your Answer: E
Result: Incorrect
Explanation: Nonalcoholic fatty liver disease is the most likely diagnosis in this patient. but
hepatitis B and C should be ruled out. The patient's alcohol consumption oI less than two
drinks per week makes alcoholic Iatty liver disease unlikely. A liver biopsy would not be
appropriate at this time. Liver ultrasonography should be considered aIter hepatitis B and C are
ruled out. The patient is younger than the recommended screening age Ior colonoscopy.
.
1. A 68-year-old AIrican-American male with a history oI hypertension and heart Iailure
continues to have shortness oI breath and Iatigue aIter walking only one block. He has normal
breath sounds, no murmur, and no edema on examination. His current medications include
Iurosemide (Lasix), 20 mg/day, and metoprolol extended-release (Toprol-XL), 50 mg/day. He
previously took lisinopril (Prinivil, Zestril), but it was discontinued because oI angioedema. A
recent echocardiogram showed an eiection Iraction oI 35.

Which one oI the Iollowing would be most likely to improve both symptoms and survival in this
patient?

A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)
Your Answer: A
Result: Incorrect
Explanation: In patients with systolic heart failure. the usual management includes an CE
inhibitor and a -blocker. Since this patient had angioedema with an CE inhibitor. an
angiotensin receptor blocker may cause this side effect as well. Adding metolazone is
generally not necessary unless the patient has volume overload that does not respond to increased
doses oI Iurosemide. Digoxin may improve symptoms, but has not been shown to increase
survival. For patients who cannot tolerate an CE inhibitor. especially frican-mericans.
a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred.
Verapamil has a negative inotropic eIIect and should not be used.

2. A 70-year-old white Iemale comes to your oIIice Ior an initial visit. She has taken
levothyroxine (Synthroid), 0.3 mg/day, Ior the last 20 years. Although a recent screening TSH
was Iully suppressed at 0.1 U/mL, she claims that she has Ielt 'awIul when previous
physicians have attempted to lower her levothyroxine dosage. You explain that a serious
potential complication oI her current thyroid medication is:

A. adrenal insuIIiciency
B. carcinoma oI the ovary
C. carcinoma oI the thyroid
D. hip Iracture
E. renal Iailure
Your Answer: D
Result: Correct
Explanation:
Women older than 65 years of age who have low serum TSH levels. indicating physiologic
hyperthyroidism. are at increased risk for new hip and vertebral fractures. Use oI thyroid
hormone itselI does not increase the risk oI Iracture iI TSH levels are normal.
3. A 34-year-old white male letter carrier has developed progressively worsening dysphagia Ior
liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time.
On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min,
temperature 37.8C (100.2F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His
weight is 45 kg (99 lb) and his height is 170 cm (67 in). His dentition is poor, and there is
evidence oI oral thrush. His mucous membranes are dry.

You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal
examinations are normal. You promptly consult a gastroenterologist, who perIorms upper
endoscopy, which reveals numerous small ulcers scattered throughout the esophagus with
otherwise normal mucosa.

As you continue to investigate, you take a more detailed history. Which one oI the Iollowing is
most likely to be related to the patient`s problem?

A. Intravenous drug use
B. A Iamily history oI esophageal cancer
C. Chest pain relieved by nitroglycerin
D. Recent travel to Russia
Your Answer: A
Result: Correct
Explanation:
A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is
likely to have HIV inIection. Intravenous drug use is responsible Ior over a quarter oI HIV
inIections in the United States. Esophageal disease develops in more than halI oI all patients with
advanced inIection during the course oI their illness. The most common pathogens causing
esophageal ulceration in HIV-positive patients include Candida. herpes simplex virus, and
cytomegalovirus. IdentiIying the causative agent through culture or tissue sampling is important
Ior providing prompt and speciIic therapy.
4. A 4-year-old male presents with a 3-day history oI sores on his right leg. The sores began as
small red papules but have progressed in size and now are crusting and weeping. Otherwise he is
in good health and is up to date with immunizations.

On examination he has three lesions on the right anterior lower leg that are 0.51.5 cm in
diameter, with red bases and honey-colored crusts. There is no regional lymphangitis or
lymphadenitis.

Which one oI the Iollowing is the preIerred Iirst-line therapy?

A. Oral erythromycin (Erythrocin)
B. Oral penicillin V
C. Topical hexachlorophene (pHisoHex)
D. Topical mupirocin (Bactroban)
Your Answer: A
Result: Incorrect
Explanation:
The lesions described are nonbullous impetigo. due to either Staphvlococcu8 aureu8 or
Streptococcu8 pvogene8. Topical antibiotics. such as mupirocin. but not compounds
containing neomycin. are the preferred first-line therapy for impetigo involving a limited
area. Oral antibiotics are widely used, based on expert opinion and traditional practice, but are
usually reserved Ior patients with more extensive impetigo or with systemic symptoms or signs.
Penicillin V and hexachlorophene have both been shown to be no more eIIective than placebo.
Topical antibiotics have been shown to be as eIIective as erythromycin, which has a common
adverse eIIect oI nausea.
5. A 25-year-old Iemale at 31 weeks gestation presents to the labor wing with painIul uterine
contractions every 3 minutes. On examination her cervix is 3 cm dilated and 50 eIIaced. Her
membranes are intact and Ietal heart monitoring is reassuring. She is treated with tocolysis,
betamethasone, antibiotics, and intravenous hydration, and cultured Ior group B $treptococcus.
The neonatal intensive care unit is notiIied, but the contractions ease and eventually stop. AIter 2
days oI observation, her cervix is unchanged and she is discharged home.

One week later, the patient presents with contractions Ior the last 8 hours. Her cervical Iindings
are unchanged. Her group B $treptococcus culture was negative.

Which one oI the Iollowing would be the most appropriate next step in the management oI this
patient?

A. Repeat tocolysis, betamethasone, antibiotics, and intravenous hydration
B. Betamethasone, antibiotics, and intravenous hydration only
C. Antibiotics and intravenous hydration only
D. Tocolysis only
E. Expectant management
Your Answer: E
Result: Correct
Explanation: The purpose oI obstetric management oI preterm labor beIore 34 weeks gestation is
to allow time to administer corticosteroids. Treatment does not substantially delay delivery
beyond 1 week. Repeated administration oI corticosteroids does not conIer more beneIit than a
single course. Antibiotics are administered Ior prophylaxis oI group B $treptococcus and are
useIul Ior delaying delivery iI membranes are ruptured. They do not add any beneIit otherwise,
even though subclinical amnionitis may be a causative Iactor in many cases oI preterm labor.
Prolonged and repeated tocolysis is believed to be harmIul. Tocolysis would not be indicated in
this patient because she has had no cervical change and is thereIore having preterm contractions,
not preterm labor. CareIul monitoring Ior Ietal compromise, consultation with obstetric
colleagues, and neonatal intensive-care unit involvement should be part oI expectant
management oI preterm labor cases.

6. You have decided that in addition to the counseling she has been receiving Ior depression, a
12-year-old Iemale in your practice might beneIit Irom an antidepressant medication. Which one
oI the Iollowing has shown the most Iavorable risk-to-beneIit ratio in children and adolescents?

A. Fluoxetine (Prozac)
B. Lithium
C. Amitriptyline
D. VenlaIaxine (EIIexor)
E. St. John`s wort
Your Answer: A
Result: Correct
Explanation:
SSRIs have been shown to beneIit children and adolescents with depression, but there are
concerns regarding their association with suicidal behavior. Fluoxetine seems to be the most
favorable SSRI. and is the only one recommended by the FD for treatment of depression
in children 8-17 years old. There is limited or no evidence to support the use oI lithium,
venlaIaxine, or St. John`s wort in children and adolescents. Amitriptyline and other tricyclic
antidepressants are ineIIective in children and have limited eIIectiveness in adolescents, and
saIety is an issue in both oI these groups.
7. Fibromyalgia is characterized by tender trigger points

A. along the medial border oI each scapula
B. bilaterally at the anatomic snuIIbox
C. at the insertion oI the Achilles tendon into the posterior heel
D. at the second and third web spaces on the plantar surIace oI the Ioot
Your Answer: A
Result: Correct
Explanation:
The typical fibromyalgia trigger points lie along the medial scapula borders. as well as the
posterior neck. upper outer quadrants of the gluteal muscles. and medial fat pads of the
knees. Tenderness oI the anatomic snuIIbox, Achilles tendons, or web spaces oI the toes would
most likely be related to another diagnosis.
8. A 47-year-old Iemale presents to your oIIice with a complaint oI hair loss. On examination she
has a localized 2-cm round area of complete hair loss on the top of her scalp. Further studies
do not reveal an underlying metabolic or inIectious disorder.

Which one oI the Iollowing is the most appropriate initial treatment?

A. Topical minoxidil (Rogaine)
B. Topical immunotherapy
C. Intralesional triamcinolone (Kenalog)
D. Oral Iinasteride (Proscar)
E. Oral spironolactone (Aldactone)
Your Answer: E
Result: Incorrect
Explanation:
These Iindings are consistent with alopecia areata, which is thought to be caused by a localized
autoimmune reaction to hair follicles. It occasionally spreads to involve the entire scalp
(alopecia totalis) or the entire body (alopecia universalis). Spontaneous recovery usually occurs
within 612 months, although areas oI regrowth may be pigmented diIIerently. Recovery is less
likely iI the condition persists Ior longer than a year, worsens, or begins beIore puberty. The
initial treatment of choice for patients older than 10 years of age. in cases where alopecia
areata affects less than 50 of the scalp. is intralesional corticosteroid injections. inoxidil
is an alternative for children younger than 10 years of age or for patients in whom alopecia
areata affects more than 50 of the scalp. While topical immunotherapy is the most eIIective
treatment Ior chronic severe alopecia areata, it has the potential Ior severe side eIIects and should
not be used as a Iirst-line agent. Finasteride inhibits 5 -reductase type 2, resulting in a decrease
in dihydrotestosterone levels, and is used in the treatment oI androgenic alopecia (male-pattern
baldness). Similarly, spironolactone is sometimes used Ior androgenic alopecia because it is an
aldosterone antagonist with antiandrogenic eIIects.
9. The preIerred antibiotic treatment Ior community-acquired pneumonia in a young adult in the
ambulatory setting is:

A. trimethoprim/sulIamethoxazole (Bactrim, Septra)
B. cephalexin (KeIlex)
C. azithromycin (Zithromax)
D. penicillin V
E. ciproIloxacin (Cipro)
Your Answer: C
Result: Incorrect
Explanation:
In a young adult with community-acquired pneumonia who is not sick enough to be
hospitalized, the current recommendation is to empirically treat with a macrolide antibiotic
such as azithromycin. This covers the atypical organism Mvcoplasma pneumoniae, which is
one oI the most common causes oI community-acquired pneumonia. Certain Iluoroquinolones
such as levoIloxacin also cover atypical causes. but ciprofloxacin does not. The other
antibiotics listed are also ineIIective against Mvcoplasma.
10. Which one oI the Iollowing is a risk Iactor Ior intermittent claudication?

A. Hyperthyroidism
B. Hypercalcemia
C. Diabetes mellitus
D. Hypogonadism
E. Elevated angiotensin-converting enzyme
Your Answer: C
Result: Correct
Explanation:
Diabetes mellitus and cigarette smoking are signiIicant risk Iactors Ior intermittent claudication,
as are hypertension and dyslipidemia. Hyperthyroidism, hypercalcemia, and hypogonadism are
not closely associated with intermittent claudication. Elevation oI angiotensin-converting
enzyme occurs with sarcoidosis.
ReI: White C: Intermittent claudication. N ngl J Med 2007;356(12):1241-1250.

1. The most common presenting symptom oI obstructive sleep apnea is:

A. excessive daytime sleepiness
B. snoring
C. morning headache
D. gastroesophageal reIlux
E. enuresis
Your Answer: A
Result: Correct
Explanation:
The most common presenting symptom of obstructive sleep apnea is excessive daytime
sleepiness (SOR A). Other symptoms include snoring, unreIreshing or restless sleep, witnessed
apneas and nocturnal choking, morning headache, nocturia or enuresis, gastroesophageal reIlux,
and reduced libido.
2. Which one oI the Iollowing is recommended in the treatment oI all Iour stages oI COPD, Irom
mild through very severe?

A. Scheduled oral mucolytics
B. Scheduled inhaled corticosteroids such as Iluticasone (Flovent HFA)
C. Scheduled long-acting inhaled bronchodilators such as salmeterol (Serevent)
D. Scheduled long-acting anticholinergics such as tiotropium (Spiriva)
E. Short-acting inhaled
2
-agonists such as albuterol (Ventolin HFA), as needed Ior dyspnea
Your Answer: E
Result: Correct
Explanation:
Short-acting bronchodilators such as albuterol and ipratropium are recommended on an as-
needed basis Ior treatment oI breathlessness in stage I (mild) COPD. They are also recommended
Ior as-needed use in stage II (moderate), stage III (severe), and stage IV (very severe) COPD.
Long-acting bronchodilators such as salmeterol or tiotropium are recommended Ior stages II, III,
and IV. Inhaled corticosteroids are recommended Ior stages III and IV. Mucolytics can be
considered Ior stages III and IV.
3. A 50-year-old Iemale complains oI a 6-month history of the insidious onset of right
shoulder pain and decreased range of motion. She does not respond to consistent use oI
prescription strength anti-inIlammatory medication. Radiographs are negative.
Treatment oI this patient`s condition should include:

A. physical therapy with home exercises
B. early surgical reIerral
C. a short course oI oral methylprednisolone
D. corticosteroid iniection oI the acromioclavicular ioint
Your Answer: A
Result: Correct
Explanation: This patient most likely has either adhesive capsulitis or a degenerative rotator
cuff tendinopathy. It is important to rule out osteoarthritis with radiographs. Treatment
typically includes NSIDs. subacromial cortisone injections. and physical therapy. These
problems take months to treat and should not be reIerred quickly Ior surgical evaluation, unless
the diagnosis is in question.
4. In a patient with symptoms oI thyrotoxicosis and elevated Iree thyroxine (T
4
), the presence oI
thyroid TSH receptor site antibodies would indicate which one oI the Iollowing as the cause oI
thyroid gland enlargement?

A. Toxic multinodular goiter
B. Toxic adenoma
C. Hashimoto`s (lymphadenoid) thyroiditis
D. Subacute (giant cell) thyroiditis
E. Graves` disease
Your Answer: E
Result: Correct
Explanation:
When there is a question about the etiology oI goiter and thyrotoxicosis, the presence oI thyroid
TSH receptor immunoglobulins would indicate the presence oI Graves` disease, which is
considered an autoimmune disease. The prevalence oI speciIic Iorms oI TSH receptor site
antibodies can distinguish Graves` disease Irom Hashimoto`s disease. Both are autoimmune
diseases, but in Graves` disease there is a predominance oI TSH receptor antibodies. In
Hashimoto`s disease TSH receptorblocking antibodies are more predominant. These
immunoglobulins tend to disappear during therapy.
5. In assessing the nutritional status oI an inIant it is useIul to know that birth weight is expected
to be regained within:

A. 5 days
B. 14 days
C. 21 days
D. 28 days
Your Answer: B
Result: Correct
Explanation:
helpful guideline for assessing normal growth in the very young infant is that birth
weight should be regained within 14 days.
7. A 3-year-old male is carried into the oIIice by his mother. Yesterday evening he began
complaining oI pain around his right hip. Today he has a temperature oI 37.6C (99.7F), cries
when bearing weight on his right leg, and will not allow the leg to be moved in any direction. A
radiograph oI the hip is normal.


A. A CBC and an erythrocyte sedimentation rate
B. A serum antinuclear antibody level
C. Ultrasonography oI the hip
D. MRI oI the hip
E. In-oIIice aspiration oI the hip
Your Answer: D
Result: Incorrect
Explanation:
This presentation is typical of either transient synovitis or septic arthritis of the hip.
Because the conditions have very diIIerent treatment regimens and outcomes, it is important to
diIIerentiate the two. It is recommended that after plain films. the first studies to be
performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have
shown that septic arthritis should be considered highly likely in a child who has a fever
over 38.7C (101.7F). refuses to bear weight on the leg. has a WBC count >12.000 cells/mm
. and has an ESR >40 mm/hr. II several or all oI these conditions exist, aspiration 3 oI the hip
guided by ultrasonography or Iluoroscopy should be perIormed by an experienced practitioner.
MRI may be helpIul in cases that are unclear based on standard data, or iI other etiologies need
to be excluded.
8. A 55-year-old male is Iound to have three hyperplastic polyps on a routine screening
colonoscopy. He has no personal or Iamily history oI colon cancer.
This patient`s next colonoscopy should be in:

A. 1 year
B. 3 years
C. 5 years
D. 10 years
Your Answer: B
Result: Incorrect
Explanation: Patients with hyperplastic polyps are considered to have normal colonoscopy
findings and can be followed up in 10 years, unless they have hyperplastic polyposis
syndrome. Patients with one or two small adenomas (<1 cm. with no- or low-grade
dysplasia) are considered at low risk and can be followed up in 5-10 years, depending on
Iamily history, previous colonoscopy Iindings, and patient and physician preIerence. Patients
with three or more small adenomas. or one adenoma >1 cm in size should be followed up in
3 years if the adenomas are completely removed. Patients who have had a sessile adenoma
removed piecemeal should have repeat colonoscopy in 2-6 months to make sure that the
polyp has been completely removed. Other Iactors that inIluence the screening interval include
the quality oI the preparation and the ability oI the physician to see the entire colon. Although
this patient had three hyperplastic polyps removed, he is at low risk Ior colon cancer and should
have repeat screening at the normal 10-year interval.

10. In patients with type 2 diabetes mellitus, intensive glycemic control has not been shown to be
beneIicial Ior which one oI the Iollowing diabetic complications?

A. Peripheral neuropathy
B. Foot inIections
C. Cardiovascular disease
D. ProliIerative retinopathy
E. Nephropathy
Your Answer: E
Result: Incorrect
Explanation:
Intensive management of hyperglycemia. with a goal of achieving nondiabetic glucose
levels. helps reduce microvascular complications such as retinopathy. nephropathy. and
neuropathy. Foot inIections are less common in patients without neuropathy and in patients with
good glycemic control. Intensive management of hyperglycemia also has a beneficial effect
on cardiovascular disease in patients with type 1 diabetes mellitus but. unfortunately. not
in patients with type 2 diabetes mellitus. In fact. there is data to suggest 1c that intensive
glycemic control (hemoglobin <6.5) may be detrimental in certain populations. such as
the elderly and those with cardiovascular disease.

1. A 4-week-old white male is brought to your oIIice with a 2-week history oI increasing
dyspnea, cough, and poor Ieeding. The child appears nontoxic and is aIebrile. On examination
you note coniunctivitis, and a chest examination reveals tachypnea and rales. A chest Iilm shows
hyperinIlation and diIIuse interstitial inIiltrates. A WBC count reveals eosinophilia.

What is the most likely etiologic agent?

A. $taphvlococcus species
B. Chlamvdia trachomatis
C. Respiratory syncytial virus
D. ParainIluenza virus
Your Answer: C
Result: Incorrect
Explanation: Chlamydial pneumonia is usually seen in inIants 3-16 weeks of age, and they
Irequently have been sick Ior several weeks. The inIant appears nontoxic and is afebrile, but is
tachypneic with a prominent cough. Physical examination reveals diffuse rales with few
wheezes. Conjunctivitis is present in about 50 of cases. The chest film shows
hyperinflation and diffuse interstitial or patchy infiltrates.
Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever.
At the time oI onset there may be an expiratory wheeze simulating bronchiolitis. Signs oI
abdominal distress. tachypnea. dyspnea. and localized or diffuse bronchopneumonia or
lobar disease may be present. The WBC count shows a prominent leukocytosis.
Respiratory syncytial infections start with rhinorrhea and pharyngitis. followed in 1-3 days
by cough and wheezing. Auscultation reveals diffuse rhonchi. fine rales. and wheezes. The
chest film is often normal. II the illness progresses, cough and wheezing increase, air hunger
and intercostal retractions develop, and evidence oI hyperexpansion oI the chest is seen. In some
inIants, the course oI the illness may be similar to that oI pneumonia. Rash or coniunctivitis may
occur occasionally, and Iever is an inconsistent sign. The WBC count is normal or elevated, and
the diIIerential may be normal or shiIted either to the right or leIt. Chlamydial infections may
be differentiated from respiratory syncytial infections by a history of conjunctivitis and a
subacute onset. Coughing is prominent. but wheezing is not. There may also be
eosinophilia. Fever is usually absent.
Parainfluenza virus infection presents with typical cold symptoms. Eight percent oI
inIections aIIect the upper respiratory tract. In children hospitalized Ior severe respiratory illness,
parainfluenza viruses account for about 50 of the cases of laryngotracheitis and about
15 each oI the cases oI bronchitis, bronchiolitis, and pneumonia.

3. The most common identiIiable cause oI skin and soIt-tissue inIections presenting to
metropolitan emergency departments is:

A. $taphvlococcus epidermidis
B. $treptococcus pneumoniae
C. Pseudomonas aeruginosa
D. methicillin-resistant $taphvlococcus aureus (MRSA)
E. Bacillus cereus
Your Answer: B
Result: Incorrect
Explanation:
Recent clinical experience has shown that methicillin-resistant $taphvlococcus aureus (RS)
is the most common identifiable cause of skin and soft-tissue infections among patients
presenting to emergency departments in 11 U.S. cities. The other responses should be
considered in evaluating these inIections, but they are not as common as MRSA inIections.

4. A 16-year-old male accompanied by his mother presents to your outpatient clinic with
concerns about his short stature and 'boyish looks. He is a sophomore in high school but is
Irequently mistaken Ior someone much younger. Radiographs reveal a bone age oI 14.7 years.

Which one oI the Iollowing would suggest the need Ior Iurther evaluation?

A. A Iamily history oI delayed growth
B. Height below the IiIth percentile Ior age
C. Weight below the IiIth percentile Ior age
D. Prepubescent testicular size
Your Answer: D
Result: Correct
Explanation: ost cases of short stature are due to constitutional growth delay, a term which
implies that the child is normal but delayed in his development. A hallmark of this condition is
being below the fifth percentile for height for most of childhood. Usually these children are
thin and have a Iamily history oI delayed development. Bone age would be expected to be at
least 2.5 standard deviations below the mean for age matched peers oI the same chronologic
age. However. most experts agree that if no signs of puberty are seen by 14 years of age (no
breast development in girls. no testicular enlargement in boys). then further workup for a
more serious condition should be sought. Other indications Ior evaluation would be no
menarche in a girl by 16 years oI age and underdeveloped genitalia in a boy 5 years aIter his Iirst
pubertal changes.
6. Which one oI the Iollowing nutritional interventions should be recommended to accelerate
pressure ulcer healing in the elderly?

A. Supplemental arginine
B. Oral vitamin C and zinc
C. High-dose multivitamins
D. Adequate protein intake
Your Answer: D
Result: Correct
Explanation:
Very Iew nutritional interventions have been shown to accelerate pressure ulcer healing in the
elderly. aintaining a protein intake of at least 1.2-1.5 g/kg/day is recommended. and some
authorities recommend 2 g/kg/day with stage III or I' ulcers. Increased caloric intake is
also necessary to promote healing. The role oI vitamins and minerals in preventing and treating
pressure ulcers is unclear.
8. The use oI a corticosteroid inhaler in patients with stable chronic obstructive lung disease has
been shown to:

A. increase the risk Ior osteoporotic Iracture
B. increase the risk Ior pneumonia
C. produce no change in patients` perceptions oI quality oI liIe
D. reduce overall mortality
Your Answer: D
Result: Incorrect
Explanation:
COPD is the Iourth leading cause oI death in the United States. Stopping smoking and the use
of continuous oxygen. when necessary. are the main interventions that have been shown to
lessen overall mortality in this illness. The use oI corticosteroid inhalers Ior COPD has
received mixed reviews. Studies show an increase in the incidence of pneumonia, which is
directly related to the dosage. There are also concerns about the potential Ior an increase in
Iractures; however, a meta-analysis oI multiple studies has not shown this to be the case. There
has been no improvement in overall mortality with the use of the corticosteroid inhalers;
nevertheless, on questionnaires patients indicate an improvement in quality of life and fewer
bronchitis exacerbations.
9. Which one oI the Iollowing is known to cause hyperthyroidism?

A. Propranolol (Inderal)
B. miodarone (Cordarone)
C. Methimazole (Tapazole)
D. Propylthiouracil
E. Methotrexate (Rheumatrex, Trexall)
Your Answer: D
Result: Incorrect
Explanation:
Amiodarone is 37 iodine and is the most common source oI iodine excess in the United States.
Excessive iodine intake from dietary sources. radiographic contrast media. or amiodarone
increases the production and release of thyroid hormone in iodine-deIicient individuals and
in older persons with multinodular goiter. Additionally, like other medications such as interIeron
and interleukin-2, amiodarone can trigger thyroiditis in patients with normal thyroid glands.
These characteristics combine to induce hyperthyroidism in slightly over 10 oI patients treated
with amiodarone. -Blockers such as propranolol may be useIul in controlling the symptoms oI
hyperthyroidism. Methimazole and propylthiouracil interIere with organiIication oI iodine,
thereby suppressing thyroid hormone production; they are commonly used as antithyroid agents
when treating hyperthyroidism. Research is ongoing to determine iI methotrexate plus
prednisone is an eIIective treatment Ior the ophthalmopathy associated with Graves`
hyperthyroidism.
10. A 20-year-old college wrestler is seen Ior an examination prior to the wrestling season. He
tells you that some Iriends have told him he should start taking dehydroepiandrosterone (DHEA),
and he asks Ior your advice.

Which one oI the Iollowing is true about the eIIects oI this drug?

A. It enhances perIormance but not muscle strength
B. It enhances muscle strength but not perIormance
C. It enhances both perIormance and muscle strength
D. It does not enhance either perIormance or muscle strength
Your Answer: B
Result: Incorrect
Explanation: Dehydroepiandrosterone (DHE) is illegal under the Anabolic Steroid Control
Act oI 2004, and is prohibited by the NCAA and the International Olympic Committee. Like
androstenedione, DHEA is a precursor to testosterone, but neither of these substances has
been shown to enhance either performance or strength. In Iact, they increase serum estrogen
and luteinizing hormone levels.

1. A 15-year-old white Iemale who has had regular periods since age 12 comes to your oIIice
because oI secondary amenorrhea and a milky discharge Irom her breasts. A pregnancy test is
negative.

The best test Ior initial evaluation oI the pituitary in this patient is:

A. plasma antidiuretic hormone
B. plasma ACTH
C. serum prolactin
D. serum FSH and LH
E. Iasting growth hormone
Your Answer: C
Result: Correct
Explanation:
Anterior pituitary hormone overproduction is suspected on clinical grounds and conIirmed by
appropriate laboratory evaluation. The most common secretory pituitary adenomas are
prolactinomas. They cause galactorrhea and hypogonadism, including amenorrhea, inIertility,
and impotence. Growth hormonesecreting tumors, which are the next most common secretory
pituitary tumors, cause acromegaly or gigantism. Next in Irequency are corticotropic (ACTH-
secreting) adenomas, which cause cortisol excess (Cushing`s disease). Glycoprotein hormone-
secreting pituitary adenomas (secreting TSH, LH, or FSH) are the least common. TSH-secreting
adenomas are a rare cause oI hyperthyroidism. Paradoxically. most patients with
gonadotropin-secreting adenomas have hypogonadism.
2. A 36-year-old Iemale consults you because oI concerns about 'Iatigue. AIter careIully
reviewing her history and perIorming a physical examination, which one oI the Iollowing would
be LEAST valuable in assessing this patient?

A. A baseline serum cortisol level
B. An erythrocyte sedimentation rate
C. A complete metabolic panel
D. A TSH level
E. A pregnancy test
Your Answer: B
Result: Incorrect
Explanation: In patients with fatigue, Iamily physicians should complete an appropriate history
and physical examination. Laboratory studies should be considered, although the results aIIect
management in only 5 oI patients. A baseline cortisol level would be valuable only in patients
with signiIicant Iindings oI Addison`s disease. In addition to an erythrocyte sedimentation
rate. a complete metabolic panel. and a TSH level. many physicians request a CBC and a
urinalysis. pregnancy test should be ordered for women of childbearing age. No other
tests have been shown to be useIul unless a speciIic medical condition is suspected.
3. A 45-year-old Iemale presents with a complaint oI pain and swelling in her right index Iinger
oI 2 days` duration. She reports that 5 days ago she had artiIicial nails applied, which she
removed yesterday due to the pain. She used hydrogen peroxide on the Iinger, but it did not help.
She denies any systemic symptoms or Iever. On examination there is erythema and swelling in
the lateral nail fold of the right index finger. with purulent material noted.


A. Removal oI the proximal nail Iold
B. Topical corticosteroids
C. Topical antibiotics
D. Topical antiIungals
Your Answer: C
Result: Correct
Explanation: This is a common presentation Ior acute paronychia, which typically is caused by
local trauma to the nail fold or cuticle. with resulting inoculation and infection. Topical
antibiotics, with or without topical corticosteroids, is one treatment option. Other options include
warm compresses, oral antibiotics, and incision and drainage; however, incision and drainage is
not always necessary. Removal oI the proximal nail Iold is used to treat chronic paronychia that
is not responsive to other treatments. Topical corticosteroids can be used alone for chronic
paronychia, but iI used Ior acute paronychia, they should be combined with antibiotics since
acute paronychia is typically caused by a bacterial inIection. Topical antifungals are a
treatment option for chronic paronychia. which can be associated with a fungal infection.
but not for acute paronychia.
4. A 30-year-old male complains oI the gradual onset oI anterior right knee pain on climbing the
stairs. On examination there is no eIIusion, but there is tenderness over the medial retinaculum.
There is good ligament strength, and range oI motion is normal. When the knee is extended
from 90 flexion to full extension. the patella deviates laterally.

Which one oI the Iollowing would be the best initial treatment Ior this condition?

A. Bracing
B. Taping
C. NSAIDs
D. Arthroscopic surgery
E. Physical therapy
Your Answer: E
Result: Correct
Explanation: This patient has patellofemoral stress syndrome. It is oIten called runner's knee or
anterior knee pain. The patelloIemoral ioint comprises the patella and Iemoral trochlea. The best
initial treatment is physical therapy. Bracing, taping, and medications are unlikely to have better
outcomes. Arthroscopic surgery is not indicated.

8. A 75-year-old otherwise healthy white Iemale states that she has passed out three times in the
last month while walking briskly during her daily walk with the local senior citizens mall
walkers` club. This history would suggest which one oI the Iollowing as the etiology oI her
syncope?

A. Vasovagal syncope
B. Transient ischemic attack
C. Orthostatic hypotension
D. Atrial myxoma
E. Aortic stenosis
Your Answer: E
Result: Correct
Explanation:
Syncope with exercise is a maniIestation oI organic heart disease in which cardiac output is Iixed
and does not rise (or even Iall) with exertion. Syncope. commonly on exertion, is reported in up
to 42 oI patients with severe aortic stenosis. Vasovagal syncope is associated with unpleasant
stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained
upright posture, heat, hunger, and acute blood loss. Transient ischemic attacks are not related to
exertion. Orthostatic hypotension is associated with changing Irom a sitting or lying position to
an upright position. trial myxoma is associated with syncope related to changes in position.
such as bending. lying down from a seated position. or turning over in bed.
9. Overweight and obesity in children should be determined by which one oI the Iollowing?

A. Body weight
B. BMI percentile Ior age and gender
C. Individual BMI
D. Abdominal girth
E. Percentage oI body Iat
Your Answer: B
Result: Correct
Explanation: In children, overweight and obesity is determined by the BMI percentile Ior age
and gender. In adults, BMI, body Iat percentage, and abdominal girth are used to determine a
patient`s classiIication (SOR B).
10. Which one oI the Iollowing is the preIerred treatment Ior scabies?

A. Topical benzoyl peroxide, 10
B. Topical crotamiton (Eurax), 10
C. Topical permethrin (Elimite), 5
D. Topical lindane, 1
E. Oral ivermectin (Stromectol), 200 mg
Your Answer: C
Result: Correct
Explanation:
Permethrin and lindane are the two most studied topical treatments for scabies. A Cochrane
meta-analysis oI Iour randomized trials comparing these agents indicates that a single overnight
application oI permethrin is more effective than lindane (odds ratio Ior clinical Iailure, 0.66;
95 conIidence interval, 0.460.95). The potential neurotoxicity of lindane. especially with
repeated applications. has limited its use.
Other topical treatments include benzoyl benzoate and crotamiton. Crotamiton has signiIicantly
less eIIicacy than permethrin at 4 weeks (61 versus 89). Several controlled trials have
assessed the eIIicacy oI a single dose oI ivermectin (200 g/kg) Ior the treatment oI scabies. In
one placebo-controlled trial, 37 oI 50 patients treated with ivermectin (74) were cured.

1. A 52-year-old male requests 'everything you`ve got to help him stop smoking. You review
common barriers to quitting and the beneIits oI cessation with him, and develop a plan that
includes Iollow-up. He chooses to start varenicline (Chantix) to assist with his eIIorts, and asks
about also using nicotine replacement.

Which one oI the Iollowing would be accurate advice?

. Combining these medications has not proven to be beneficial
B. The addition oI transdermal nicotine, but not nicotine gum, has proven beneIits
C. The combination is highly eIIicacious
D. Nicotine replacement doses need to be doubled in a patient taking varenicline
E. The combination oI nicotine and varenicline is potentially lethal
Your Answer: A
Result: Correct
Explanation: Varenicline works by binding to nicotine receptors in the brain, providing much
lower stimulation than nicotine itselI would. This has the eIIect oI reducing the reinIorcement
and reward that smoking provides to the brain. However, this medication also blocks the beneIit
a patient would receive Irom nicotine replacement products. Studies have shown that using
nicotine replacement products concurrently with varenicline leads to an increase in nausea.
headaches. dizziness. and fatigue.
2. Which one oI the Iollowing is more likely to occur with glipizide (Glucotrol) than with
metIormin (Glucophage)?

A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal distress
Your Answer: B
Result: Correct
Explanation:
MetIormin is a biguanide used as an oral antidiabetic agent. One oI 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 Ior the control oI
elevated glucose, which oIten cause weight gain, metIormin reduces insulin levels and more
Irequently has a weight-maintaining or even a weight loss eIIect. Gastrointestinal distress is a
common side effect of metformin. particularly early in therapy.
3. Typically, a high-grade squamous intraepithelial lesion (HSIL) oI the cervix is treated with
ablation or excision. In which one oI the Iollowing can treatment be deIerred?

A. Adolescents
B. Patients attempting to conceive
C. Patients with a history oI three previous normal Papanicolaou smears
D. Patients with a negative DNA test Ior HPV
E. Patients over the age oI 70
Your Answer: B
Result: Incorrect
Explanation:
Patients attempting to conceive are not candidates Ior conservative management oI cervical
dysplasia, because treatment oI progressive disease during pregnancy may be harmIul. When
possible, the problem should be resolved beIore conception. Patients who have had three normal
Papanicolaou (Pap) smears in succession are candidates Ior lengthened screening intervals
according to some recommendations. However, once a problem is Iound, they should be
managed the same as other cases. A negative test Ior HPV can be used to assess the risk oI
patients with atypical squamous cells oI undetermined signiIicance (ASC-US) or a low-grade
squamous intraepithelial lesion (LSIL); it does not change the management oI patients with a
high-grade intraepithelial lesion (HSIL). HPV inIection is common and transient in most young
women in their first few years of sexual activity. With careful follow-up. they can be
observed rather than treated for HSIL. Patients over 70 years oI age no longer require
screening iI they have a long history oI normal Pap smears, but when an abnormality is Iound it
should be treated.
4. A 14-year-old Iemale is brought to your oIIice by her parents because oI concerns regarding
her low Iood intake, excessive exercise, and weight loss. Her weight is less than 75 oI ideal Ior
her height.

Which one oI the Iollowing sets oI additional Iindings would indicate that the patient suIIers
Irom severe anorexia nervosa?

A. Hypertension, tachycardia, and hyperthermia
B. Hypertension, tachycardia, and hypothermia
C. Hypotension, tachycardia, and hypothermia
D. Hypotension, bradycardia, and hyperthermia
E. Hypotension. bradycardia. and hypothermia
Your Answer: E
Result: Correct
Explanation:
Characteristic vital signs in patients with severe anorexia nervosa include hypotension,
bradycardia, and hypothermia. Criteria Ior hospital admission include a heart rate 40 beats/min,
blood pressure 80/50 mm Hg, and temperature 36C (97F). Increased cardiac vagal
hyperactivity is thought to cause the bradycardia.
5. A 55-year-old Iemale has severe symptoms oI gastroesophageal reIlux disease. Upper
endoscopy with a biopsy shows severe esophagitis and Barrett`s esophagus.

Which one oI the Iollowing is true regarding this patient?

A. The severity oI her symptoms is due to the presence oI Barrett`s esophagus
B. Follow-up screening endoscopy will reduce her risk oI death Irom esophageal cancer
C. Her risk oI developing esophageal adenocarcinoma is ~90
D. Her risk oI developing esophageal adenocarcinoma is 1
Your Answer: B
Result: Incorrect
Explanation: The actual risk of adenocarcinoma from Barrett`s esophagus is less than 1.
Endoscopy does nothing to reduce the risk of death. Patients with Barrett`s esophagus can
have minimal symptoms.
6. A 45-year-old male presents with a complaint oI recent headaches. He has had Iour headaches
this week, and his description indicates that they are moderate to severe, bilateral, Irontal, and
nonthrobbing. There is no associated aura. He has had similar episodes oI recurring headachesin
the past.

Based on this limited history, which one oI the Iollowing headache types can be eliminated Irom
the diIIerential diagnosis?

A. Tension-type headache
B. Sinus headache
C. Migraine headache
D. Cluster headache
E. Headache oI intracranial neoplasm
Your Answer: E
Result: Incorrect
Explanation: Cluster headache can be removed from the differential because it is always
unilateral. although the affected side can vary. The remainder oI these headache types can be
bilateral, Irontal, and nonthrobbing. Brain tumor headaches may be similar in character to
previous headaches, but are oIten more severe or Irequent.
7. In which one oI the Iollowing scenarios is a physician most likely to be protected by a Good
Samaritan statute?

A. Assisting Ilight attendants with the care oI a Iellow passenger who develops respiratory
distress while in Ilight over the United States
B. Attending to an unconscious player while acting as an unpaid volunteer physician at a high-
school Iootball game
C. Attending to a bicyclist with heat exhaustion while volunteering at a Iirst-aid station during a
Iund-raising ride
D. Attending to the Iamily member oI a patient who slips and Ialls in the waiting room at the
physician`s oIIice
E. Attending to a nurse`s aide who collapses while the physician is staIIing the hospital
emergency department
Your Answer: A
Result: Correct
Explanation:
Generally, Good Samaritan laws apply to situations in which the physician does not have a
preexisting duty to provide care to the patient. A physician who volunteers as a standby health
care provider at an event assumes a duty to care Ior illness or iniury in the participants. Likewise,
physicians have a duty to provide emergency care to a person in need within a Iacility where
they are working, such as a medical oIIice or an emergency department. On an airplane, there is
no preexisting duty Ior a physician to attend to a Iellow passenger who becomes ill. In addition, a
speciIic Iederal law, the Aviation Medical Assistance Act, ensures that physicians have Good
Samaritan protection iI they provide medical assistance while in Ilight over the United States.
8. A 69-year-old Iemale sees you Ior an annual examination. She asks you to look at her toes,
and you note a Iungal inIection in Iive toenails. She says the condition is painIul and limits her
ability to complete her morning walks. She asks Ior treatment that will allow her to resume her
daily walks as soon as possible. Her only other medical problem is allergic rhinitis which is well
controlled.

A. Oral griseoIulvin ultramicrosize (Gris-PEG) daily Ior 12 weeks
B. Oral terbinaIine (Lamisil) daily Ior 12 weeks
C. Topical terbinaIine (Lamisil AT) daily Ior 12 weeks
D. Topical ciclopirox (Penlac Nail Lacquer) daily Ior 12 weeks
E. Toenail removal
Your Answer: A
Result: Incorrect
Explanation:
Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best
long-term resolution rate oI the therapies listed. Other agents and pulsed dosing regimens have
lower cure rates. Topical creams are not appropriate for onychomycosis because the
infection resides in the cell of the toenail. AntiIungal nail lacquers have a lower cure rate than
systemic therapy and should be used only when oral agents would not be saIe. Toenail removal
is reserved Ior patients with an isolated inIected nail or in cases involving a dermatophytoma.
9. A 24-year-old Iemale had been healthy with no signiIicant medical illnesses until about 3
months ago, when she was diagnosed with schizophrenia and treatment was initiated. She is now
concerned because she has gained 10 lb since beginning treatment. A comprehensive metabolic
panel is normal, with the exception oI a Iasting blood glucose level oI 156 mg/dL.

Which one oI the Iollowing medications would be most likely to cause these Iindings?

A. Clonazepam (Klonopin)
B. Thioridazine
C. Chlorpromazine
D. Aripiprazole (AbiliIy)
E. Olanzapine (Zyprexa)
Your Answer: E
Result: Correct
Explanation: Second-generation, or 'atypical, antipsychotics are associated with weight gain,
elevated triglycerides, and type 2 diabetes mellitus. Olanzapine and clozapine are associated with
the highest risk. Clonazepam, a benzodiazepine, does not share these risks. Thioridazine and
chlorpromazine are Iirst-generation antipsychotics, and carry less risk oI these side eIIects.
Aripiprazole, although it is a second-generation antipsychotic, has been Iound to cause weight
gain and metabolic changes similar to those seen with placebo.

1. A 40-year-old male with a 20-pack-year history oI smoking is concerned about lung cancer.
He denies any constitutional symptoms, or breathing or weight changes. You encourage him to
quit smoking and order which one oI the Iollowing?

A. No testing
B. A chest radiograph
C. Low-dose CT oI the chest
D. Sputum cytology
Your Answer: A
Result: Correct
Explanation: This patient is at risk Ior lung cancer, even with no symptoms. He should be
encouraged to stop smoking, especially iI he has concerns that may help motivate him to quit. No
study has demonstrated that screening with any oI the tests listed improves survival, and no
maior organization endorses lung cancer screening.

2. A 40-year-old white Iemale presents with pain on inspiration and dyspnea since this
morning. She has no chronic medical problems, takes no medications, has not traveled, and has
no history oI trauma. On examination the patient is aIebrile, has a heart rate oI 90 beats/min and
a respiratory rate oI 20/min, and her lungs are clear to auscultation. The pain is worse in the
supine position. Which one oI the Iollowing would you do initially?

A. Order a CBC with diIIerential
B. Order a chest film and EKG
C. Prescribe ibuproIen
D. Prescribe omeprazole (Prilosec)
E. Prescribe a bronchodilator
Your Answer: B
Result: Correct
Explanation: This patient has pleuritic chest pain, and the Iact that it is worse when supine and is
accompanied by dyspnea creates additional concern. Supine pain could be due to pericarditis,
which may be evident on an EKG. Dyspnea increases suspicion Ior pneumonia, pulmonary
embolism, pneumothorax, and myocardial inIarction, and a chest Iilm and EKG are
recommended to evaluate these possibilities. The lack oI any signiIicant medical history does not
rule out any oI these problems. Once these problems have been ruled out. a diagnosis of
pleurisy would be reasonable and can be treated with an NSID. A CBC would only
indicate the possibility that inIection or anemia is the cause oI the problem. Omeprazole or a
bronchodilator would be inappropriate treatment, as asthma and reIlux are not likely in this
patient.

3. An anxious 62-year-old white male comes to the emergency department complaining oI
extreme shortness of breath and a cough producing blood-tinged sputum. The patient denies
chest pain and Iever. On examination he is aIebrile and has expiratory wheezes and a few rales
throughout the chest. The heart is normal except for a rapid rate and an S
3
gallop. chest
radiograph reveals a right pleural effusion with enlargement of the cardiac silhouette and
redistribution of blood flow to the upper lobes. Which one oI the Iollowing tests would be
best Ior conIirming the diagnosis?

A. Troponin I
B. BNP
C. D-dimer
D. CT angiography oI the chest
E. Arterial blood gases
Your Answer: D
Result: Incorrect
Explanation: This patient has heart failure with a bronchospastic component. The S
3
gallop
occurs with a dilated leIt ventricle and a right-sided pleural eIIusion, which are common in heart
Iailure. A BNP level is useIul in diIIerentiating cardiac and pulmonary diseases, while a troponin
I level is helpIul in assessing Ior cardiac ischemia. Arterial blood gasses are not useIul in
conIirming the diagnosis. A CT angiogram oI the chest would be useIul Ior diagnosing
pulmonary embolism. A d-dimer test is helpIul to rule out venous thromboembolic disease.

5. A 49-year-old white Iemale comes to your oIIice complaining oI painIul, cold Iinger tips
which turn white when she is hanging out her laundry. While there is no approved treatment Ior
this condition at this time, which one oI the Iollowing drugs has been shown to be useIul?

B. NiIedipine (Procardia)
C. Ergotamine/caIIeine (CaIergot)
D. Methysergide (Sansert)

Your Answer: B
Result: Correct
Explanation: At present there is no approved treatment Ior Raynaud`s disease. However,
patients with this disorder reportedly experience subiective symptomatic improvement with
calcium channel antagonists. with nifedipine being the calcium channel blocker of choice. -
Blockers can produce arterial insuIIiciency oI the Raynaud type, so propranolol and atenolol
are contraindicated. Drugs such as ergotamine preparations and methysergide can produce cold
sensitivity, and should thereIore be avoided in patients with Raynaud`s disease.

6. A 54-year-old male comes to your oIIice with a 2-day history oI swelling, erythema, and pain
in his right Iirst metatarsophalangeal ioint. This is the third time this year he has had this
problem. He has treated previous episodes with over-the-counter pain medicines, ice packs, and
elevation. Your evaluation suggests gout as the diagnosis.

Which one oI the Iollowing treatments Ior gout is most likely to worsen his current symptoms?

A. Allopurinol (Zyloprim)
B. Colchicine (Colcrys)
C. Elastic compression bandages
D. Indomethacin
E. Prednisone
Your Answer: A
Result: Correct
Explanation: All oI the treatments listed are commonly used in the management oI gout with
good success. Allopurinol decreases the production oI uric acid and is eIIective in reducing the
Irequency oI acute gouty Ilare-ups. However, it should not be started during an acute attack since
Iluctuating levels oI uric acid can actually worsen inIlammation and intensiIy the patient`s pain
and swelling. Colchicine inhibits white blood cells Irom enveloping urate crystals and is
eIIective during acute attacks, as are NSAIDs such as indomethacin. Corticosteroids such as
prednisone are also considered a Iirst-line treatment Ior acute attacks. Compression as an
adiunctive therapy may help control pain and swelling.

7. A 30-year-old Iemale who had a deep venous thrombosis in her leIt leg during pregnancy has
an uneventIul delivery. During the pregnancy she was treated with low molecular weight
heparin. Just aIter delivery her leIt leg is pain Iree and is not swollen. She plans to resume
normal activities soon.

Which one oI the Iollowing would be most appropriate with regard to anticoagulation?

A. Discontinuing treatment, with no Iurther evaluation
B. Discontinuing treatment iI venous Doppler ultrasonography is negative Ior thrombus
C. Continuing low molecular weight heparin Ior 6 more weeks
D. Switching to low-dose unIractionated heparin Ior 6 weeks
E. Switching to aspirin Ior 6 weeks
Your Answer: C
Result: Correct
Explanation: The risk of pulmonary embolism continues in the postpartum period. and may
actually increase during that time. For patients who have had a deep-vein thrombosis
during pregnancy. treatment should be continued for 6 weeks after delivery. with either
warfarin or low molecular weight heparin.

8. An overweight 11-year-old male with acanthosis nigricans is Iound to have a Iasting plasma
glucose level oI 175 mg/dL on two occasions. Over the next 6 months, despite reasonable
adherence to a diet and exercise regimen, he has preprandial and bedtime Iinger-stick blood
glucose levels that average 180 mg/dL. His hemoglobin A
1c
is 9.0.
Which one oI the Iollowing oral agents would be most appropriate at this time?

A. MetIormin (Glucophage)
B. Glyburide (DiaBeta)
C. Sitagliptin (Januvia)
D. Pioglitazone (Actos)
E. Acarbose (Precose)
Your Answer: A
Result: Correct
Explanation: etformin and insulin are the only agents approved for treatment of type 2
diabetes mellitus in children.

9. A 32-year-old Iemale experiences an episode oI unresponsiveness associated with ierking
movements oI her arms and legs. Which one oI the Iollowing presentations would make a
diagnosis oI true seizure more likely?

A. Post-event conIusion
B. Eye closure during the event
C. A history oI Iibromyalgia
D. A history oI chronic back pain
E. A normal serum prolactin level aIter the event
Your Answer: A
Result: Correct
Explanation: Up to 20 oI patients diagnosed with epilepsy actually have pseudoseizures. Eye
closure throughout the event is uncommon in true seizures, and a history oI Iibromyalgia or
chronic pain syndrome is predictive oI pseudoseizures. II obtained within 20 minutes oI the
event, a serum prolactin level may be useIul in diIIerentiating a true seizure Irom a
pseudoseizure. An elevated level has a sensitivity oI 60 Ior generalized tonic-clonic seizures
and 46 Ior complex partial seizures. Other Ieatures suggestive oI seizure activity include
tongue biting, the presence oI an aura, postictal conIusion, and Iocal neurologic signs.

10. A patient dying oI cancer is suIIering Irom pain in spite oI his narcotic regimen. You
increase his dosage oI morphine, knowing it will probably hasten his death.

Which ethical principle are you Iollowing?

A. Distributive iustice
B. Double eIIect
C. Death with dignity
D. Futility
E. Autonomy
Your Answer: D
Result: Incorrect
Explanation: The concept oI 'double effect dates back to the iddle ges. It is used to
justify medical treatment designed to relieve suffering when death is an unintended but
foreseeable consequence. It is based on two basic presuppositions: first. that the doctor`s
motivation is to alleviate suffering. and second. that the treatment is appropriate to the
illness. Distributive iustice relates to the allocations oI resources. Death with dignity is a
recently introduced concept and is not a Iactor in the scenario described here. Futility reIers to
using a treatment Ior which there is no rational iustiIication. Autonomy reIers to the patient`s
ability to direct his or her own care,which is n ot an issue in this case.

2. A 25-year-old male who came to your oIIice Ior a pre-employment physical examination is
Iound to have 2 protein on a dipstick urine test. You repeat the examination three times within
the next month and results are still positive. Results oI a 24-hour urine collection show protein
excretion oI 2 g/day and normal creatinine clearance. As part oI his Iurther evaluation you
obtain split urine collections with a 16-hour daytime specimen containing an increased
concentration oI protein, and an 8-hour overnight specimen that is normal.

Additional appropriate evaluation Ior this man`s problem at this time includes which one oI the
Iollowing?

A. Serum and urine protein electrophoresis
B. Antinuclear antibody
C. Serum albumin and lipid levels
D. Renal ultrasonography
E. No speciIic additional testing
Your Answer: E
Result: Correct
Explanation: Persons younger than 30 years of age who excrete less than 2 g of protein per
day and who have a normal creatinine clearance should be tested for orthostatic
proteinuria. This benign condition occurs in about 35 oI adolescents and young adults. It
is characterized by increased protein excretion in the upright position, but normal protein
excretion when the patient is supine. It is diagnosed using split urine collections as described in
the question. The daytime specimen has an increased concentration oI protein, while the
nighttime specimen contains a normal concentration. Since this is a benign condition with
normal renal Iunction, no Iurther evaluation is necessary.

3. A 50-year-old male is brought to the emergency department because oI a syncopal
episode.Prior to the episode, he Ielt bad Ior 30 minutes, then developed nausea Iollowed by
vomiting. During a second bout oI vomiting he blacked out and Iell to the Iloor. His wiIe did not
observe any seizure activity, and he was unconscious only Ior a Iew seconds. His history is
otherwise negative, his past medical history is unremarkable, and he currently takes no
medications. A physical examination is normal.

Which one oI the Iollowing would be the most helpIul next step?

A. CT oI the head
B. Carotid ultrasonography
C. A CBC and complete metabolic proIile
D. Echocardiography
E. An EKG
Your Answer: A
Result: Incorrect
Explanation: The workup oI patients with syncope begins with a history and a physical
examination to identiIy those at risk Ior a poor outcome. Patients who have a prodrome of 5
seconds or less may have a cardiac arrhythmia. Patients with longer prodromes. nausea. or
vomiting are likely to have vasovagal syncope. which is a benign process. Patients who pass
out after standing for 2 minutes are likely to have orthostatic hypotension. In most cases.
the recommended test is an EKG. II the EKG is normal, dysrhythmias are not a likely cause oI
the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography
are not necessary unless there are speciIic Iindings in either the history or the physical
examination.
4. A 38-year-old Iemale with seasonal allergies presents with a 10-day history oI sinus pain and
purulent nasal drainage, along with temperature elevations up to 102F (39C). She has been
taking nonprescription loratidine (Claritin), but says it provides little relieI. She asks you to
prescribe an antibiotic.


A. Continuation oI symptomatic treatment only
B. In-oIIice nasal irrigation2
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Imaging oI the sinuses
Your Answer: C
Result: Correct
Explanation: The American Academy oI Otolaryngology published guidelines Ior the diagnosis
and management oI rhinosinusitis in adults in 2007. They cite reasonable evidence Ior initiating
antibiotic treatment in patients with symptoms persisting for 7-10 days that are not
improving or worsening (SOR B). moxicillin should be the first-line agent, with
azithromycin or trimethroprim/sulIamethoxazole recommended Ior penicillinallergic patients.
Broader-spectrum antibiotics such as Iluoroquinolones should be reserved Ior treatment Iailures.
Imaging is indicated only iI other etiologies are being considered or iI the problem is recurrent.

5. A 27-year-old male was roughhousing with his children when he was accidentally struck in
the leIt eye. He immediately Ielt pain in the eye, and over the next hour noted increased
tearing,pain with blinking, increasing headache, and a Ioreign-body sensation. You see the
patient the next day, and examination with Ilourescein dye and a cobalt-blue Iiltered light reveals
a corneal abrasion.
Appropriate management includes which one oI the Iollowing?

A. An eye patch Ior 2448 hours
B. Mydriasis with a short-acting agent, such as tropicamide ophthalmic (Mydriacyl)
C. A topical anesthetic instilled every 4 hours iI no Ioreign body or inIection is Iound
D. Topical corticosteroid drops
E. ReIerral to an ophthalmologist iI the edge oI the abrasion is white or gray
Your Answer: E
Result: Correct
Explanation: A white or gray appearance at the edge oI a corneal abrasion may indicate
inIection, and reIerral to an ophthalmologist is indicated. Mydriatic agents and eye patching are
ineIIective Ior corneal abrasions and are not recommended (SOR A). Progression to recurrent
corneal erosion may occur years aIter a corneal abrasion. Symptoms mimic the initial corneal
abrasion, and tearing on awakening is common. Topical anesthetics should be administered only
in the oIIice; iI a patient uses the medication at home, it can delay healing and mask
complications.

7. A 42-year-old white Iemale presents to your oIIice as a new patient. She states that she has an
8-year history oI abdominal cramps and diarrhea. Her symptoms have not responded to the usual
treatments Ior irritable bowel syndrome. She has no rectal bleeding, anemia, weight loss, or
Iever, and no Iamily history oI colon cancer. Her medical history and a review oI symptoms is
otherwise negative, and a physical examination is normal.

Which one oI the Iollowing would be the most appropriate next step in evaluating this patient?

A. A CBC
B. A TSH level
C. A complete metabolic panel
D. Serologic testing for celiac sprue
E. Stool testing Ior ova and parasites
Your Answer: B
Result: Incorrect
Explanation:
In patients who have symptoms oI irritable bowel syndrome (IBS). the differential diagnosis
includes celiac sprue. microscopic and collagenous colitis. atypical Crohn`s disease Ior
patients with diarrhea-predominant IBS, and chronic constipation (without pain) Ior those with
constipation-predominant IBS. II there are no warning signs, laboratory testing is warranted only
iI indicated by the history.
8. During a comprehensive health evaluation a 65-year-old AIrican-American male reports mild,
very tolerable symptoms oI benign prostatic hyperplasia, rated as a score oI 7 on the American
Urological Association Symptom Index. He has never smoked, and his medical history is
otherwise unremarkable. Obiective Iindings include an enlarged prostate that is Iirm and
nontender, with no nodules. A urinalysis is normal and his prostate-speciIic antigen level is
1.8ng/mL.

Based on current evidence, which one oI the Iollowing treatment options is most appropriate at
this time?

A. Observation, with repeat evaluation in 1 year
B. Saw palmetto
C. An u-receptor antagonist
D. A 5-u-reductase inhibitor
E. Urologic reIerral Ior transurethral resection oI the prostate
Your Answer: A
Result: Correct
Explanation: Watchful waiting with annual follow-up is appropriate for men with mild
benign prostatic hyperplasia (BPH). Prostate-speciIic antigen (PSA) levels correlate with
prostate volume, which may aIIect the treatment oI choice, iI indicated (SOR C). PS levels
>2.0 ng/mL for men in their 60s correlate with a prostatic volume >40 mL. In men with a
prostatic volume >40 mL. 5 -reductase inhibitors should be considered for treatment (SOR
). -Blockers provide symptomatic relief in men whose disease has progressed to the point
that they have moderate to severe BPH symptoms (SOR ). A recent high-quality,
randomized, controlled trial Iound no beneIit Irom saw palmetto with regard to symptom relieI
or urinary Ilow aIter 1 year oI therapy. The American Urological Association does not
recommend the use oI phytotherapy Ior BPH. Surgical consultation is appropriate when medical
therapy Iails or the patient develops reIractory urinary retention, persistent hematuria, or bladder
stones.

9. A 47-year-old Iemale presents with progressive diIIiculty hearing. She is employed as an
oIIice worker, has no signiIicant past medical history, and takes no medications. Physical
examination shows no gross abnormalities oI her outer ears. The external ear canals are Iree oI
cerumen, and the tympanic membranes move well to insuIIlation. Weber`s test and the Rinne test
have results that are compatible with a conductive hearing loss.

Which one oI the Iollowing is the most likely cause oI this patient`s hearing loss?

A. Noise-induced hearing loss
B. Meniere`s disease
C. Otosclerosis
D. Acoustic neuroma
E. Perilymphatic Iistula
Your Answer: C
Result: Correct
Explanation: Otosclerosis typically presents between the third and fifth decades. and is
more common in women. The chief feature of otosclerosis is a progressive conductive
hearing loss. Occasionally, when lesions impinge on the stapes Iootplate, a sensorineural loss
may occur. All oI the other choices are exclusively sensorineural in character. Meniere`s disease
also causes Iluctuating hearing loss. Noise-induced hearing loss Irequently and characteristically
is accompanied by tinnitus. Perilymphatic Iistula is associated with sudden unilateral hearing
loss with tinnitus and vertigo. Acoustic neuroma is associated with tinnitus and gradual hearing
impairment.

1. Women should be tested Ior human papillomavirus (HPV) DNA:

A. every year, when a Papanicolaou (Pap) test is perIormed
B. every 2 years, when a Pap test is perIormed
C. prior to receiving HPV vaccine (Gardasil)
D. when a Pap smear shows ASC-US
E. when genital warts are noted
Your Answer: D
Result: Correct
Explanation:
Human papillomavirus (HP') DN testing is useful for determining whether colposcopy is
needed in patients whose Papanicolaou (Pap) test shows aytpical squamous cells of
undetermined significance (SCUS). Women with a negative result for high-risk HP' can
be safely followed without colposcopy. Some recent studies suggest that screening HPV DNA
testing Ior women in their thirties may be useIul, most likely as a replacement Ior Pap smears;
however, this is in the preliminary stages oI study. Younger women would not beneIit Irom
screening Ior HPV DNA because it would identiIy the very large number oI young women who
have a transient inIection. The addition oI HPV DNA testing to Pap smears at currently
recommended intervals would not change management. The presence or absence oI HPV DNA
does not alter the indications Ior HPV vaccine, because patients with or without HPV are
candidates Ior vaccination. The vaccine protects against HPV strains that the patient may not
have contracted. Genital warts are caused by HPV, usually a low-risk strain, so testing Ior HPV
in patients with this problem does not provide useIul inIormation.

2. A 41-year-old male trips on a curb while running, sustaining an inversion ankle iniury.
According to the Ottawa ankle rules, which one oI the Iollowing would be an indication Ior
radiographic evaluation?

A. Tenderness at the anterior taloIibular ligament
B. Point tenderness over the cuboid
C. Inability to take Iour steps either immediately aIter the iniury or while in your oIIice
D. Bony tenderness at the anterior aspect oI the distal tibia
E. Point tenderness over the base oI the Iourth metatarsal
Your Answer: D
Result: Incorrect
Explanation:
The Ottawa ankle rules have been designed and validated to reduce unnecessary radiographs.
nkle X-rays are only required iI there is any pain in the malleolar zone and any one oI the
Iollowing:
O Bone tenderness along the distal 6 cm oI the posterior edge oI the tibia or tip oI the
medial malleolus, OR
O Bone tenderness along the distal 6 cm oI the posterior edge oI the Iibula or tip oI the
lateral malleolus, OR
O An inability to bear weight both immediately and in the emergency department Ior Iour
steps.
The Ottawa Ioot rules are Ior assessing whether a foot X-ray series is indicated. It states that
they are indicated iI there is any pain in the midIoot zone and any one oI the Iollowing:
O Bone tenderness at the base oI the IiIth metatarsal (Ior Ioot iniuries), OR
O Bone tenderness at the navicular bone (Ior Ioot iniuries), OR
O An inability to bear weight both immediately and in the emergency department Ior Iour
steps.

5. A 30-year-old Iemale comes to your oIIice because she is concerned about irregular menses
(Iewer than 9/year), acne, and hirsutism. Her BMI is 36.0 kg/m
2
. She has no other medical
problems and would like to have a baby. Her Iasting blood glucose level is 140 mg/dL.

Which one oI the Iollowing would be the most appropriate treatment Ior this patient`s condition
and concerns?

A. LiIestyle modiIication only
B. LiIestyle modiIication and pioglitazone (Actos)
C. LiIestyle modiIication and metIormin (Glucophage)
D. LiIestyle modiIication and an oral contraceptive
E. LiIestyle modiIication and oral testosterone
Your Answer: C
Result: Correct
Explanation: This patient has classic Ieatures oI polycystic ovary syndrome (PCOS). The
diagnosis is based on the presence of two of the following: oligomenorrhea or amenorrhea.
clinical or biochemical hyperandrogenism. or polycystic ovaries visible on
ultrasonography. LiIestyle modiIications are necessary, but medications are also needed. First-
line agents Ior the treatment of hirsutism in patients with PCOS include spironolactone.
metformin. and eflornithine (SOR A). Firstline agents Ior ovulation induction and treatment
of infertility in patients with PCOS include metformin and clomiphene, alone or in
combination with rosiglitazone (SOR A). MetIormin can also improve menstrual irregularities in
patients with PCOS (SOR A), and is probably the Iirst-line agent Ior obese patients to promote
weight reduction (SOR B). In addition, metIormin improves insulin resistance (diagnosed by
elevated Iasting blood glucose) in patients with PCOS, as do rosiglitazone and pioglitazone.
Pioglitazone would not be appropriate Ior this patient because it causes weight gain. Oral
contraceptives would improve the patient`s menstrual irregularities and hirsutism, but she wishes
to become pregnant. Testosterone would worsen the hyperandrogenism and would not treat the
PCOS.
6. Which one oI the Iollowing drugs would be the most appropriate empiric therapy Ior nursing
home-acquired pneumonia in a patient with no other underlying disease?

A. CeIazolin
B. Erythromycin
C. Ampicillin
D. Tobramycin (Nebcin)
E. Levofloxacin (Levaquin)
Your Answer: E
Result: Correct
Explanation:
The maior concern with regard to pneumonia in the nursing-home setting is the increased
Irequency oI oropharyngeal colonization by gram-negative organisms. In the absence oI
collectible or diagnostic sputum Gram`s stains or cultures, empiric therapy must cover
$treptococcus pneumoniae, $taphvlococcus aureus, aemophilus influenzae, and gram-negative
bacteria. LevoIloxacin is the best single agent Ior providing coverage against this spectrum oI
organisms.
9. A 72-year-old male is brought by ambulance to the emergency department with weakness and
numbness oI his leIt side that began earlier this morning. While in the emergency department he
becomes comatose with inIrequent, gasping breaths and is quickly intubated and placed on a
ventilator. A Iull evaluation shows an acute ischemic right-sided stroke. His wiIe states that she
wishes to have the ventilator stopped, as she believes this would be consistent with her husband`s
wishes in this circumstance. She understands that this would precipitate the patient`s death. The
wiIe presents a legally valid advance directive conIirming her as the patient`s healthcare proxy.

Which one oI the Iollowing responses to the wiIe`s request is most ethically appropriate?

A. Withdraw the ventilator as requested
B. Contact the hospital ethics committee to initiate the legal requirements to process the wiIe`s
request
C. InIorm the wiIe that all liIe-sustaining care should be given until the patient`s condition has
been determined to be irreversible
D. InIorm the wiIe that intubation may have been avoided in the emergency department, but
once liIe-sustaining care has been initiated it should not be withdrawn
E. Promptly contact hospital security or the local law enIorcement agency to report the wiIe`s
request
Your Answer: C
Result: Incorrect
Explanation: Competent adult patients have the right to reIuse any medical intervention, even iI
Iorgoing this treatment may result in their death. Legally and ethically it does not matter whether
the patient requests that care be withheld beIore it is started or that it be withdrawn once it is
begun. All states currently allow competent patients to legally designate a health-care proxy to
make these decisions Ior them iI they become unable to communicate or are no longer competent
to decide Ior themselves. The patient in this example has instituted such a legal advance directive
and his proxy`s request should be respected as his own and the care withdrawn. II there were no
advance directive the decision in this case would become more diIIicult, and might require a
Iamily conIerence or the involvement oI an ethics committee. patient`s condition does not
need to be terminal or irreversible to allow the removal of life-sustaining therapy. Legal
involvement is rarely required in situations where advance directives are already available and
valid.
10. Which one oI the Iollowing is most likely to be oI beneIit in patients with essential tremor oI
the hand?

A. Isoniazid
B. Diazepam (Valium)
C. Topiramate (Topamax)
D. Clonidine (Catapres)
E. Gabapentin (Neurontin)
Your Answer: D
Result: Incorrect
Explanation:
Treatments likely to be beneIicial Ior essential tremor of the hands include propranolol and
topiramate. Topiramate has been shown to improve tremor scores aIter 2 weeks oI treatment,
but is associated with appetite suppression. weight loss. and paresthesias. Medications with
unknown eIIectiveness include benzodiazepines, -blockers other than propranolol, calcium
channel blockers, clonidine, gabapentin, and isoniazid.

1. A 24-year-old AIrican-American male presents with a history oI several weeks oI dyspnea,
cough productive oI bloody streaks, and malaise. His examination is normal except Ior bilateral
Iacial nerve palsy. A CBC and urinalysis are normal. A chest radiograph reveals bilateral lymph
node enlargement.This presentation is most consistent with:

A. polyarteritis nodosa
B. Goodpasture`s syndrome
C. sarcoidosis
D. pulmonary embolus
Your Answer: C
Result: Correct
Explanation: Sarcoidosis, a disease oI unknown etiology, aIIects young to middle-age adults
(predominantly 20-29 years old). In the U.S. it is more common in frican-mericans. It is
asymptomatic in 30-50 oI patients, and is oIten diagnosed on a routine chest Iilm. About
one-third of cases will present with fever. malaise. weight loss. cough. and dyspnea. The
pulmonary system is the main organ system aIIected, and Iindings may include bilateral hilar
lymphadenopathy and discrete. noncaseating epithelial granulomas. Facial nerve palsy is
seen in <5 of patients. and usually occurs late in the process. BeIore Lyme disease was
recognized, bilateral Iacial nerve palsy was almost always due to sarcoidosis. Hemoptysis does
not generally occur until late in the course of sarcoidosis. and is usually related to
spergillus infection or cavitation. Renal involvement rarely results in significant
proteinuria or hematuria. Polyarteritis nodosa may involve the lungs. Although pneumonic
episodes may be associated with hemoptysis in a small percentage oI patients, the chest
radiograph is more likely to reveal granulomatous lesions rather than patchy inIiltrates.
Goodpasture`s syndrome is characterized by pulmonary hemorrhage. glomerulonephritis.
and antiglomerular basement membrane antibodies. Hemoptysis. pulmonary alveolar
infiltrates. dyspnea. and iron-deficiency anemia are frequent presenting features. Within
days or weeks. the pulmonary findings are generally followed by hematuria. proteinuria.
and the rapid loss of renal function. Pulmonary embolus is an acute event, and would present
with dyspnea and possibly hemoptysis, but not hilar lymphadenopathy.
2. An elderly male patient takes aspirin, 81 mg daily, Ior prevention oI a heart attack. He also
takes herbal supplements.

Which one oI the Iollowing supplements can have a negative interaction with aspirin?

A. Kava
B. Yohimbine
C. Saw palmetto
D. Echinacea
E. Ginkgo biloba
Your Answer: B
Result: Incorrect
Explanation: Herbal and dietary supplements can aIIect the absorption, metabolism, and
disposition oI other drugs. Ginkgo biloba has been associated with serious intracerebral
bleeding. In most oI these patients, concurrent anticoagulant drugs were being used. Ginkgo has
been shown in vitro to inhibit platelet aggregation and has been associated with case reports oI
spontaneous bleeding. Caution is recommended when using this supplement with aspirin or
other anticoagulants. Kava is associated with gastrointestinal side effects and skin rashes.
Yohimbine is associated with hypertension. Saw palmetto and echinacea are not associated
with bleeding.

3. An 8-year-old male presents to your oIIice 2 days aIter returning Irom a trip to Mexico with
his Iamily. He developed watery, nonbloody diarrhea on the day oI departure. He has mild
abdominal cramping, but no Iever or vomiting. His mother had similar symptoms, which were
milder and resolved with over-the-counter treatments.

Which one oI the Iollowing would be most appropriate to treat this patient`s condition?

A. Metronidazole (Flagyl)
B. CiproIloxacin (Cipro)
D. Mebendazole
E. Metoclopramide (Reglan)
Your Answer: B
Result: Incorrect
Explanation: Traveler`s diarrhea commonly occurs in travelers to Mexico and developing
countries. It is usually caused by bacterial organisms such as scherichia coli. Campvlobacter.
$higella, and $almonella. Viral and parasitic organisms are less common causes, unless the
diarrhea persists Ior 2 weeks. ppropriate medications include antidiarrheal agents such as
loperamide. bismuth subsalicylate. and antibiotics. Fluoroquinolones are effective in adults.
but should not be used in an 8-year-old. zithromycin is generally effective and safe in
children. Metronidazole, mebendazole, and metoclopramide would not be likely to successIully
treat bacterial traveler`s diarrhera.
4. Secondary causes oI osteoporosis in males include which one oI the Iollowing?

A. Weekly consumption oI 36 alcoholic drinks
B. Male hormone supplementation
C. Vitamin D excess
D. Obesity
E. Corticosteroid use
Your Answer: E
Result: Correct
Explanation: Corticosteroids are among the common secondary causes oI osteoporosis in men.
Other causes include excessive alcohol use. hypogonadism. vitamin D deficiency. and
decreased body mass index.

5. The preIerred site Ior an emergency airway is:

A. the thyrohyoid membrane
B. the cricothyroid membrane
C. immediately below the cricoid cartilage
D. through the Iirst and second tracheal rings
E. at the level oI the thyroid isthmus
Your Answer: B
Result: Correct
Explanation:
Fortunately, emergency tracheotomy is not oIten necessary, but should one be necessary the best
site Ior the incision is directly above the cricoid cartilage, through the cricothyroid membrane.
Strictly speaking, this is not a tracheotomy, because it is actually above the trachea. However, it
is below the vocal cords and bypasses any laryngeal obstruction. The thyrohyoid membrane lies
well above the vocal cords, making this an impractical site. The area directly below the cricoid
cartilagewhich includes the second, third, and Iourth tracheal rings, as well as the thyroid
isthmusis the preIerred tracheotomy site under controlled circumstances, but excessive
bleeding and diIIiculty Iinding the trachea may signiIicantly impede the procedure in an
emergency.
6. A 60-year-old male complains oI multiple episodes oI lightheadedness over the past 3 months,
saying he Ielt as iI he might 'pass out while sitting at his desk. His past medical history and a
physical examination are unremarkable. An EKG shows right bundle branch block and leIt
anterior hemiblock.


A. Echocardiography
B. Cardiac event monitoring
C. Hospital admission Ior pacemaker insertion
D. Immediate initiation oI aspirin and metoprolol (Lopressor)
Your Answer: A
Result: Incorrect
Explanation: This patient`s EKG demonstrates a right bundle branch block, as well as a leIt
anterior hemiblock. This 'triIascicular block puts the patient at risk Ior tachyarrhythmias and
bradyarrhythmias. Given the patient`s complaint oI near-syncope. a heart monitoring study
would be most appropriate. An echocardiogram may be helpIul eventually to assess cardiac
Iunction. Although the patient is at risk Ior heart block, immediate hospitalization is not
indicated.

7. A 45-year-old Iemale had myalgias, a sore throat, and a Iever 2 weeks ago. She now has
anterior neck tenderness and swelling, with pain radiating up to her ears. An examination reveals
a tender goiter.

Which one oI the Iollowing would support a diagnosis oI subacute granulomatous thyroiditis?

A. Pretibial myxedema
B. Exophthalmos
C. A thyroid bruit
D. Low radioactive iodine uptake (5)
Your Answer: D
Result: Correct
Explanation: Subacute granulomatous thyroiditis is the most common cause of thyroid pain.
Free T is elevated early 4 in the disease, as it is in Graves` disease; however, later in the disease
T becomes depressed and then returns to normal as the disease resolves. Pretibial myxedema,
exophthalmos, and a thyroid thrill or bruit can all be Iound in Graves` disease, but not in
subacute granulomatous thyroiditis. Patients with subacute granulomatous thyroiditis will have a
low radioactive iodine uptake (RAIU) at 24 hours, but patients with Graves` disease will have an
elevated RAIU (SOR C).

8. You are examining a patient with a chronically painIul shoulder. You forward flex the arm
to 90 with the elbow bent to 90. You then internally rotate the arm, which causes pain in
the shoulder.

This Iinding suggests:

A. glenohumeral instability
B. anterior shoulder dislocation
C. impingement/rotator cuII disorder
D. acromioclavicular ioint osteoarthritis
E. acromioclavicular ioint separation
Your Answer: C
Result: Correct
Explanation: The maneuver described is Hawkins` impingement test. Pain with this maneuver
may signify subacromial impingement. including a rotator cuff tendinopathy or tear.

10. In a patient with hypertriglyceridemia, the National Cholesterol Education Program
recommends that a reasonable goal Ior non-HDL cholesterol is no more than

A. 30 mg/dL above the LDL-cholesterol level
B. 40 mg/dL above the LDL-cholesterol level
C. 50 mg/dL above the LDL-cholesterol level
D. 60 mg/dL above the LDL-cholesterol level
E. 90 mg/dL above the LDL-cholesterol level
Your Answer: C
Result: Incorrect
Explanation:
The National Cholesterol Education Program`s Adult Treatment Panel III recommends a goal
non-HDLcholesterol level of no more than 30 mg/dL greater than the LDL-cholesterol
level. This is based on a 'normal very low density lipoprotein cholesterol level being deIined as
that present when triglycerides are 150 mg/dL. This value typically is 30 mg/dL. Conversely,
when triglyceride levels are ~150 mg/dL, very low density lipoprotein is usually ~30 mg/dL.

1. A 14-year-old Iemale sees you Ior Iollow-up aIter hypercalcemia is Iound on a chemistry
proIile obtained during a 5-day episode oI vomiting and diarrhea. She is now asymptomatic, but
her serum calcium level at this visit is 11.0 mg/dL (N 8.510.5). Her aunt underwent
unsuccessIul parathyroid surgery Ior hypercalcemia a Iew years ago.

Which one of the following laboratory findings would suggest a diagnosis other than
primary hyperparathyroidism?

A. Low 24-hour urine calcium
B. Decreased serum phosphate
C. High-normal to increased serum chloride
D. Elevated alkaline phosphatase
E. Elevated parathyroid hormone
Your Answer: A
Result: Correct
Explanation: Low urine 24-hour calcium levels or a low urine calcium to urine creatinine
ratio is not characteristic of hyperparathyroidism. This finding should suggest familial
hypocalciuric hypercalcemia (SOR C). Awareness oI this condition is important to avoid
unnecessary surgery. The parathyroid hormone level may be mildly elevated. Parathyroid
hormone is elevated in hyperparathyroidism. Serum chloride tends to be high normal or mildly
elevated. Alkaline phosphatase may be elevated in more severe cases, while serum phosphate
levels tend to be low.

2. A 70-year-old AIrican-American male who has been hospitalized Ior 2 weeks Ior heart
Iailure develops severe, persistent diarrhea. For the past 3 days he has had abdominal cramps and
proIuse, semi-Iormed stools without mucus or blood.

The patient`s current medications include captopril (Capoten), digoxin, Iurosemide (Lasix),
subcutaneous heparin, spironolactone (Aldactone), and loperamide (Imodium). He has coronary
artery disease, but has been relatively pain Iree since undergoing coronary artery bypass surgery
4 years ago. An appendectomy and cholecystectomy were perIormed in the past, and the patient
has since been Iree oI gastrointestinal disease.

On physical examination his blood pressure is 100/80 mm Hg, pulse 100 beats/min and regular,
and temperature 37.0C (98.6F). He has mild iugular venous distention and crackles at both
lung bases. Examination oI his heart is unremarkable, although there is 1 dependent edema.
His abdomen is diIIusely tender without masses or organomegaly. Findings on a rectal
examination are normal.

The results oI routine laboratory tests, including a CBC, chemistry proIile, EKG, and urinalysis,
are all normal. The stool examination shows numerous white blood cells.

OI the Iollowing, the most likely diagnosis is:

A. viral gastroenteritis
B. Clostridium difficile colitis
C. ulcerative colitis
D. gluten-sensitive enteropathy (celiac sprue)
E. digoxin toxicity
Your Answer: A
Result: Incorrect
Explanation: This patient most likely has Clo8tridium difficile colitis. suggested by semiformed
rather than watery stool. fecal leukocytes (not seen in viral gastroenteritis or sprue). and a
hospital stay greater than 2 weeks. While this disease has traditionally been associated with
antibiotic use. it is posing an increasing threat to patients in hospitals and chronic-care
facilities who have not been given antibiotics. The primary sources Ior inIection in such cases
have been toilets, bedpans, Iloors, and the hands oI hospital personnel. Prompt recognition and
treatment is essential to prevent patient relapse and to minimize intramural epidemics. The
diarrhea oI ulcerative colitis usually contains blood and occurs intermittently over a protracted
course. Digoxin toxicity is likely to be accompanied by electrocardiographic and laboratory
abnormalities, particularly hyper- or hypokalemia.

3. A 63-year-old Iemale with type 2 diabetes mellitus presents to the emergency department with
unstable angina. Her blood pressure is 150/90 mm Hg, her pulse rate is 70 beats/min, and her
lungs are clear to auscultation.

The patient expresses a preIerence Ior conservative (i.e.. noninvasive) therapy. In addition to
aspirin. which one of the following agents should be administered at this time?

A. Clopidogrel (Plavix) orally
B. Indomethacin (Indocin) orally
C. NiIedipine (Procardia) immediate-release, orally
D. Abciximab (ReoPro) intravenously
E. Enalaprilat intravenously
Your Answer: A
Result: Correct
Explanation: An oral loading dose oI clopidogrel should be administered as soon as possible in
patients with unstable angina/NSTEMI who are to be treated conservatively. The standard
dosage should then be prescribed, to be taken daily Ior at least 1 month along with aspirin (SOR
B).

Immediate-release calcium channel antagonists such as nifedipine are not indicated. If -
blockers are contraindicated. verapamil or diltiazem would be the preferred agents.
Intravenous CE inhibitors may induce shock and should be avoided in the first 24 hours.
bciximab is used for patients who will undergo rapid catheterization with a significant
chance of acute coronary intervention. NSAIDs are contraindicated because they may weaken
areas oI damaged myocardium and increase the risk oI rupture, and may also increase the risk oI
inIarction or extension. They have been used in the past Ior treatment oI associated pericarditis,
which most Irequently develops a Iew days aIter presentation, but are now avoided.

5. A 25-year-old Iemale has an annular rash on the dorsal surIace oI both hands. The rash does
not respond to initial treatment with an antiIungal medication, and a biopsy reveals granuloma
annulare.
Which one oI the Iollowing would be the most appropriate advice Ior this patient?

A. Allow the rash to resolve without Iurther treatment
B. Cover the rash because it is contagious
C. Treat the rash with systemic corticosteroids
D. Treat the rash with a stronger antiIungal medication
Your Answer: A
Result: Correct
Explanation: Granuloma annulare is a self-limited condition. It is not contagious, and
thereIore would not need to be covered to prevent transmission. Treatments may include
injected or topical corticosteroids. but oral corticosteroids have not been specifically
recommended. It may be necessary to reIer the patient to a dermatologist because many oI the
potential treatments can have serious side eIIects.

6. A 24-year-old Iemale who works at a day-care Iacility presents to your oIIice to discuss ways
to avoid getting 'all the inIections the kids get. She plans to enroll her child in the Iacility. She
is speciIically concerned about diarrheal illnesses, and a Iriend has suggested the use oI
probiotics.

A. can lessen the severity and duration oI inIectious diarrhea
B. are recommended only Ior patients who are immunocompromised
C. have no known side eIIects
D. oIten interact with common prescription medications
E. are not appropriate Ior use in children
Your Answer: E
Result: Incorrect
Explanation:
Probiotics are microorganisms with likely health beneIits, based on recent randomized,
controlled trials. Good evidence suggests that probiotics reduce the incidence. duration. and
severity of antibiotic-associated and infectious diarrhea. Common side effects include
flatulence and abdominal pain. Contraindications include short-gut syndromes and
immunocompromised states. There are no known drug interactions, and these agents appear saIe
Ior all ages (SOR A).

7. The recommended time to screen Ior gestational diabetes in asymptomatic women with no risk
Iactors Ior this condition is:

A. in the Iirst trimester
B. at 1620 weeks gestation
C. at 2428 weeks gestation
D. at 3537 weeks gestation
Your Answer: C
Result: Correct
Explanation: The recommended time to screen for gestational diabetes is 24-28 weeks
gestation. The patient may be given a 50-g oral glucose load Iollowed by a glucose
determination 1 hour later.

8. The 1990 Patient Self-Determination ct requires that:

A. the process Ior advance directives be standardized Ior all 50 states
B. a living will be implemented Ior patients upon admission to the hospital
C. hospitals ask patients about advance directives
D. verbally expressed wishes be honored Ior individuals who do not have a written advance
directive
Your Answer: C
Result: Correct
Explanation: The 1990 Patient SelI-Determination Act (PSDA) requires hospitals, nursing
homes, and health care programs to ask patients about advance directives and then incorporate
the inIormation into medical records. The living will, a written advance directive, allows a
competent person to indicate his or her health care preIerences while cognitively and physically
healthy. A living will may list medical interventions the patient wishes to have withheld or
withdrawn when he or she becomes unable to communicate. Another type oI advance directive,
the durable power oI attorney Ior health care, allows persons to designate a proxy (or surrogate)
to make decisions Ior them iI they become incapacitated.

Although PSDA mandates that patients be asked about their advance directive status upon
admission to the hospital, it does not require hospitals or individual physicians to oIIer patients
an opportunity to complete an advance directive. The acceptance and precision oI verbal
preIerences varies Irom state to state. Although verbal discussions are binding in many states,
Iive states require 'clear and convincing evidence oI patient preIerences. In CaliIornia,
Delaware, Michigan, Missouri, and New York, advance directives must include such evidence
regarding a speciIic condition and/or treatment, even iI a durable power oI attorney states prior
general verbal preIerences. ThereIore, lack oI an advance directive may result in continued
medical interventions to preserve liIe even iI the patient may not want such treatment.

9. A 55-year-old male consults you because he wants to begin an exercise program. He is
asymptomatic, but because oI his Iamily history you determine that he should undergo a stress
test with echocardiography.

Which one oI the Iollowing would be considered a normal ejection fraction in this patient?

A. 48
B. 65
C. 76
D. 84
E. 92
Your Answer: B
Result: Correct
Explanation: The eiection Iraction value is an important measure oI leIt ventricular Iunction,
especially with regard to previous cardiac events, medications, exercise tolerance, and
preoperative risk. The normal predicted value is 55-75 when measured by
echocardiography in a healthy asymptomatic patient. There is no gender diIIerence, but there is a
decline with age. It may be as low as 15 in patients with leIt ventricular dysIunction. Ischemic
and valvular heart disease may signiIicantly reduce the eiection Iraction.
10. A 42-year-old asymptomatic Iemale presents Ior a routine evaluation. On examination her
uterus is irregularly enlarged to the size seen at approximately 8 weeks gestation. Pelvic
ultrasonography shows several uterine Iibroid tumors measuring 5 cm. The patient does not
desire Iuture Iertility.

Which one oI the Iollowing would be the most appropriate treatment option?

A. Laparoscopic myomectomy
B. Hysterectomy
C. A gonadotropin-releasing hormone (GnRH) agonist
D. An oral contraceptive
E. Observation
Your Answer: A
Result: Incorrect
Explanation: Uterine Iibroid tumors (leiomyomas) are the most common Iemale reproductive
tract tumors, with some evidence suggesting that the cumulative incidence in women ages 2545
is approximately 30. Symptoms related to Iibroids can include menorrhagia, pelvic pain,
obstructive symptoms, inIertility, or pregnancy loss. However, many fibroids are
asymptomatic and are discovered incidentally. with expectant management being the
treatment of choice in this situation (SOR B). The risk oI malignant leiomyosarcoma is
exceedingly small (0.23 in one study) and there is a risk oI side eIIects or complications Irom
other treatment modalities.
For women who are symptomatic, the data is insuIIicient to allow conclusions to be made about
the most appropriate therapy. Surgical options include myomectomy, hysterectomy, uterine
artery embolization, and myolysis, but data to allow direct comparison is lacking. With the
exception oI trials oI GnRH-agonist therapy as an adiunct to surgery, there is not enough
randomized trial data to support the use oI medical therapies (oral contraceptives, NSAIDs,
progestins) in the treatment oI women with symptomatic Iibroids.

2. A 24-year-old male sustains a boxer's fracture of the fifth metacarpal. A radiograph
shows no rotational deformity and 25 of volar angulation. After an attempt at closed
reduction the angulation remains unchanged.
Which one of the following would be most appropriate at this time?

A. Open reduction
B. Placement of a pin to prevent further displacement
C. A short arm-thumb spica cast
D. An ulnar gutter splint
Your Answer: A
Correct Answer[s]: D
Result: ncorrect
Explanation: Up to 40 of volar angulation is acceptable for fifth metacarpal fractures.
For second and third metacarpal fractures, less angulation is acceptable. Appropriate
treatment is a gutter splint.
3. What is the recommended compression-to-breath ratio for basic life support with a
single rescuer for a 2-year-old child?

A. 10:2
B. 15:2
C. 20:2
D. 25:2
E. 30:2
Your Answer: B
Correct Answer[s]: E
Result: ncorrect
Explanation:
For a single rescuer performing CPR on a 2-year-old, the ratio is 30 compressions to 2
ventilations. The
compression rate should be approximately 100 beats/min, and the chest should be
compressed one-third
to one-half its depth with each compression. Compressions can be accomplished with
one hand, the heel
of one or both hands, or the heel of one hand with the second hand on top.

5. A 70-year-old female becomes psychotic and risperidone (Risperdal) is prescribed.
Which one of the following should be used to monitor the patient for adverse cardiac
effects of this drug?

A. Serum sodium levels
B. Echocardiography
C. Nuclear stress testing
D. Lower-extremity venous duplex ultrasonography
E. Electrocardiography
Your Answer: E
Result: ncorrect
Explanation:
Both typical and atypical antipsychotics can cause proIongation of the QTc intervaI,
resulting in torsades
de pointes, ventricular tachycardia, and sudden death. The best way of monitoring the
QTc interval is
electrocardiography

10. A 25-year-old female presents with a maculopapular rash that has progressed to
multiple areas and exhibits target lesions. A cold sore appeared on her upper lip 2 days
before the rash appeared. She is not systemically ill and is on no medications.
Which one of the following is true concerning this problem?

A. Herpes simplex virus is a likely cause
B. A skin biopsy will confirm the diagnosis
C. The lesions usually disappear within 24 hours
D. The palms of the hands and soles of the feet are not involved
E. Scarring from the lesions is often seen after resolution
Your Answer: A
Correct Answer[s]: A
Result: Correct
Explanation: Herpes simpIex virus is the most common etioIogic agent of
erythema muItiforme. Other infections, particularly Mycoplasma
pneumoniae infections and fungal infections, may also be associated with this
hypersensitivity reaction. Other causes include medications and vaccines. Skin biopsy
findings are not specific for erythema multiforme. As opposed to the lesions of urticaria,
the lesions of erythema multiforme usually are present and fixed for at least 1 week and
may evolve into target lesions. The palms of the hands and soles of the feet may be
involved. The lesions of erythema multiforme usually resolve spontaneously over 35
weeks without sequelae.

1. A 44-year-old male sees you for evaluation of an episode of pink-tinged urine last
week. He denies any flank or abdominal pain, as well as frequency, urgency, and
dysuria. He has no prior history of renal or other urologic disease, and no other
significant medical problems. He has a 24-pack-year smoking history. A urinalysis today
reveals 810 RBCs/hpf. You refer him to a urologist for cystoscopy.
Which one of the following would be the most appropriate additional evaluation?

A. KUB radiography
B. Transabdominal ultrasonography
C. Voiding cystourethrography
D. CT urography
E. Magnetic resonance urography
Your Answer: D
Correct Answer[s]: D
Result: Correct
Explanation: T urography or intravenous pyeIography is recommended by the
American oIIege of RadioIogy as the most appropriate imaging procedure for
hematuria in aII patients, with the exception of those with generalized renal
parenchymal disease, young women with hemorrhagic cystitis, children, and pregnant
females.
2. The test of choice for immediate evaIuation of an acuteIy swoIIen scrotum is:

A. a pelvic radiograph
B. radionuclide imaging
C. coIor DoppIer uItrasonography
D. CT
E. MR
Your Answer: C
Correct Answer[s]: C
Result: Correct
Explanation:
Any patient with a new scrotal mass should be evaluated immediately because of the
risk of potential emergencies, such as testicular torsion, or of life-threatening diseases
such as testicular carcinoma. Color Doppler ultrasonography is the test of choice for
immediate evaluation of scrotal masses (SOR B) because it can be done quickly and
has a high sensitivity (86%88%) and specificity (90%100%) for detecting testicular
torsion, which is a surgical emergency. Radionuclide imaging is also accurate in
diagnosing testicular torsion, but involves too much of a time delay to be useful. CT and
MR should be used only if ultrasonography is inconclusive or carcinoma is suspected,
and are particularly useful for staging testicular tumors. Pelvic radiographs are not
recommended for evaluation of scrotal masses.

4. A 58-year-old male complains of leg claudication. Subsequent tests reveal that he
has significant bilateral peripheral arterial disease. His current medications include
atenolol (Tenormin), 50 mg/day, and aspirin, 325 mg/day. His blood pressure is 128/68
mm Hg, and his pulse rate is 64 beats/min. His LDL-cholesterol level is 123 mg/dL.

The addition of which one of the following could reduce this patient's symptoms?

A. Epoetin alfa (Epogen)
B. Nifedipine (Procardia)
C. Simvastatin (Zocor)
D. Testosterone supplementation
E. Warfarin (Coumadin) titrated to an NR of 2.03.0
Your Answer: B
Result: ncorrect
Explanation: Peripheral arterial disease (PAD) is a common malady that has several
proven treatments. The outcomes of these treatments can be separated into two
primary categories: reducing PAD symptoms and preventing death due to systemic
cardiovascular events (CVEs), especially myocardial infarction. Routine exercise up to
near-maximal pain on a regular basis has been shown to be one of the most effective
treatments for symptoms of PAD. Smoking cessation and aspirin are also standard
recommendations, and can both prevent CVEs and slow the rate of progression of PAD
symptoms.

$tatin drugs (specificaIIy simvastatin and atorvastatin) have been shown to be
beneficiaI for treatment of PAD symptoms and prevention of 's through the
reduction of choIesteroI, but they aIso appear to have other properties that heIp
reduce Ieg pain in patients with PAD.Although lowering abnormally high blood
pressure is recommended in PAD patients, only ACE inhibitors have been shown to
reduce symptoms of PAD directly. Furthermore, the combination of atenoIoI and
nifedipine has actuaIIy been shown to worsen symptoms of PAD. The addition of
warfarin to aspirin has no additional benefit in either reduction of PAD symptoms or
prevention of CVEs, but it may have a role in preventing clots in patients who have
undergone revascularization.

5. A 55-year-old female sees you because of a constant leakage of small amounts of
urine. Her obstetric/gynecologic history includes two pregnancies, with vaginal
deliveries. Her current medications include hydrochlorothiazide, metformin
(Glucophage), and glyburide (DiaBeta). On examination she has mild diabetic
retinopathy, decreased sensation to monofilament testing on her feet, and suprapubic
fullness.
The most appropriate initial treatment for this problem would be:

A. tolterodine (Detrol LA)
B. duloxetine (Cymbalta)
C. estrogen replacement therapy
D. bladder neck needle suspension
E. a set schedule for urination
Your Answer: E
Result: Correct
Explanation: There are four types of urinary incontinence in women: functional
incontinence, which occurs when the patient's inability to ambulate or transfer results in
loss of urine; urinary stress incontinence, which is a result of pelvic relaxation and is
manifested as involuntary loss of urine with increases in abdominal pressure such as
that which occurs with laughing, sneezing, or coughing; detrusor instability or overactive
bladder, which is when the urge to urinate is quickly followed by loss of urine, usually a
large volume; and neurogenic bIadder, which is marked by constant Ieakage of
smaII amounts of urine.
Neurogenic bladder can be caused by diabetes mellitus, multiple sclerosis, or spinal
cord injury, and is usually initiaIIy treated with a strict voIuntary urination scheduIe,
which may be coupled with Crede's maneuver. It can be treated further by adding
bethanechoI to the regimen. Many patients have to be taught intermittent self-
catheterization of the bladder. Ultimately, the patient may require resection of the
internal sphincter of the bladder neck.

6. A 35-year-old white male presents to the emergency department with chest pain of
30 minutes duration. He describes the pain as feeling like pressure on his chest, and
says it radiates into his left arm. t is accompanied by dyspnea, diaphoresis, anxiety,
and palpitations. His past medical history is unremarkable and he has no family history
of premature heart disease. He smokes 2 packs of cigarettes per day and admits to
intranasal cocaine use 2 hours ago.
Vital signs include a blood pressure of 180/110 mm Hg, a pulse rate of 110 beats/min, a
respiratory rate of 24/min, and a temperature of 37.2C (99.0F). Other than the anxiety
and diaphoresis, the general examination is unremarkable. An EKG shows sinus
tachycardia with an early repolarization pattern. Aspirin and nitroglycerin have been
administered, as well as oxygen via nasal cannula.

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

A. Nifedipine (Procardia)
B. Enalaprilat intravenously
C. Lorazepam (Ativan) intravenously
D. Metoprolol (Toprol) intravenously
E. Thrombolytic therapy
Your Answer: A
Result: ncorrect
Explanation: Treatment of cocaine-associated chest pain is similar to that of acute
coronary syndrome, unstable angina, or acute myocardial infarction, but there are
exceptions. The hypertension, tachycardia, and chest pain wiII often respond to
intravenous benzodiazepines as early management. WhiIe -bIockers are
recommended for acute myocardiaI infarction, they can exacerbate coronary
artery spasm in cocaine associated chest pain. Fibrinolytic therapy should be given
only to patients who clearly have an ST segment elevation myocardial infarction and
cannot receive immediate direct percutaneous coronary intervention. Calcium channel
blocker use in the setting of cocaine-induced ischemia has not been studied, but may
be considered if there is no response to benzodiazepines and nitroglycerin. There are
no recommendations regarding the use of ACE inhibitors, but these agents would not
address the tachycardia.

7. According to both the Centers for Disease Control and the American College of
Sports Medicine, in order to burn fat stores obese patients should exercise:

A. a minimum of 30 minutes 3 days/week
B. a minimum of 30 minutes at least 5 days/week
C. a minimum of 20 minutes every day
D. a minimum of 10 minutes at least 3 times daily
Your Answer: A
Correct Answer[s]: B
Result: ncorrect
Explanation: Because glycogen is the primary energy source for muscles during the first
20 minutes of exercise, at least 30 minutes of exercise is necessary to begin burning fat
stores. The CDC and the American College of Sports Medicine recommend a
minimum of 30 minutes of exercise 5 days per week. Twenty minutes of exercise
daily or three 10-minute sessions daily does improve cardiovascular fitness, but does
not cause significant weight loss. Walking, on land or in water, and stationary biking are
equivalent in benefit.

9. A 50-year-old female presents with a 2-day history of four vesicIes on her upper
eyeIid, but no pain or sweIIing. She has not experienced any eye trauma, has had no
vision changes, and has no other skin changes.
Which one of the following would be the most appropriate next step in treating this
patient?

A. Referral to an ophthalmologist
B. A methylprednisolone (Medrol) dose pack
C. A topical corticosteroid
D. Topical mupirocin (Bactroban)
E. Topical metronidazole (MetroGel)
Your Answer: D
Correct Answer[s]: A
Result: ncorrect
Explanation: This patient likely has herpes zoster ophthaImicus. n addition to
treatment with a systemic antiviral agent, it is important that the patient see an
ophthalmologist to be evaluated for corneal disease and iritis, as vision can be lost. This
is a viral infection, so corticosteroids could worsen the infection. Mupirocin or
metronidazole would not resolve the infection.
10. A 70-year-old white male with hypertension has several abnormal liver function tests
on routine testing. He says he does not drink alcohol, and the prescription medications
he is taking are unlikely to cause hepatotoxicity. However, during more extensive history
taking, he tells you that he does use some over-the-counter medications.
Which one of these is most likely responsible for the abnormal laboratory findings?

A. Aspirin, used occasionally for headache
B. A fiber supplement taken to promote regular bowel habits
C. One long-acting niacin tablet per day
D. One 250-mg vitamin C tablet daily
E. Chewable simethicone after meals, almost daily
Your Answer: C
Result: Correct
Explanation: Hepatotoxicity resuIting from timed-reIease formuIations of niacin
has been reported in eIderIy individuaIs. Patients may be taking this supplement
without their physician's knowledge, feeling it is safe because it is a vitamin. Aspirin and
vitamin C can result in gastrointestinal iron loss and anemia. The other medications
listed, if used in moderation, would not be expected to alter laboratory findings

1. Which one oI the Iollowing is recommended Ior the treatment oI patients with obsessive
compulsive disorder?

A. Cognitive-behavioral therapy
B. Psychoanalytic therapy
C. Family therapy
D. Psychodynamic psychotherapy
E. Motivational interviewing
Your Answer: A
Result: Correct
Explanation: Cognitive-behavioral therapy is the recommended treatment for obsessive-
compulsive disorder (OCD).Psychoanalytic therapy has not been shown to help treat OCD.
Family therapy can help reduce Iamily tensions that result Irom the disease. Psychodynamic
psychotherapy and motivational interviewing may help patients overcome their resistance to
treatment.

2. A 73-year-old male sees you Ior evaluation oI a tremor. Based on the history and examination,
you suspect Parkinson`s disease.

Which one of the following would be most helpful for confirming the diagnosis?

A. CT oI the brain
B. MRI oI the brain
C. positive response to levodopa
D. ConIirming that the tremor occurs with movement
E. ConIirming that the tremor had a symmetric onset
Your Answer: C
Result: Correct
Explanation: Patients with Parkinson's disease should respond to an adequate therapeutic
challenge oI levodopa or a dopamine agonist. The diagnosis oI idiopathic Parkinson's disease is
clinical, not radiographic. Cardinal signs of Parkinson's disease include an asymmetric
tremor onset and a distal resting tremor of 3-6 Hz.

3. Surgical management Ior an acute midshaIt clavicle Iracture would be appropriate in which
one oI the Iollowing?

A. An 11-year-old male with a comminuted Iracture
B. A 15-year-old Iemale with a -cm displaced Iracture
C. A 30-year-old male with a -cm displaced Iracture
D. A 40-year-old male with a nondisplaced Iracture
E. A 50-year-old Iemale with a comminuted Iracture
Your Answer: B
Result: Incorrect
Explanation:
idshaft clavicle fractures are usually treated nonoperatively, but have a higher risk oI
nonunion. Risk factors for nonunion include female gender. fracture comminution or
displacement. clavicle shortening. advanced age. and greater extent of initial trauma. These
Iractures in children heal extremely well, even iI displaced or comminuted, because oI periosteal
regenerative potential.

4. A 32-year-old primipara is ready to be discharged aIter a Iull-term vaginal delivery that was
complicated by a prolonged second stage oI labor. She required a second-degree posterior
vaginal repair, but had no periurethral trauma. A transurethral catheter was removed a Iew hours
aIter delivery, but 48 hours later she complained oI abdominal pain and a persistent need to
urinate. The catheter was replaced and yielded approximately 2000 cc oI straw-colored urine.
Urinary symptoms quickly resolved, but the patient continues to be unable to void on her own. A
perineal examination is normal, as is a urinalysis.

Which one oI the Iollowing would be the most appropriate management at this time?

A. Oxybutynin (Ditropan), 10 mg daily
B. Prednisone, starting with 60 mg/day and tapering quickly over 7 days
C. Urgent vaginal ultrasonography
D. Urology consultation Ior cystoscopy
E. Discharge with a catheter in place and close Iollow-up
Your Answer: D
Result: Incorrect
Explanation: This patient suffers from postpartum urinary retention (PUR). PUR is often
defined as a post-void bladder residual of at least 150 cc that is present 6 hours or more
after delivery. This condition is more likely to occur in patients who are primiparous, have a
prolonged Iirst or second stage oI labor, have instrumented vaginal deliveries, or require a
cesarean section Ior Iailure to progress. The question oI whether epidural anesthesia promotes
the condition is still debated. Most cases oI PUR will resolve 26 days aIter delivery, but some
can take up to several weeks. The use of intermittent self-catheterization or a transurethral
catheter is recommended until the patient`s ability to spontaneously micturate returns.
Imaging studies and reIerrals to a specialist are rarely necessary, and no medication has been
proven helpIul.

5. A 5-month-old inIant has had several episodes oI wheezing, not clearly related to colds. The
pregnancy and delivery were normal; the inIant received phototherapy Ior 1 day Ior
hyperbilirubinemia. He had an episode oI otitis media 1 month ago. There is no chronic runny
nose or strong Iamily history oI asthma. He spits up small amounts oI Iormula several times a
day, but otherwise appears well. His growth curve is normal. An examination is unremarkable
except Ior mild wheezing.


A. Benign reactive airway disease oI inIancy
B. Gastroesophageal reIlux
C. Unresolved respiratory syncytial virus inIection
D. Early asthma
E. Cystic Iibrosis
Your Answer: B
Result: Correct
Explanation: Gastroesophageal reflux is a common cause of wheezing in infants. At 5 months
oI age, most inIants no longer spit up several times a day, and this is a maior clue that this child`s
wheezing may be Irom the reIlux. In addition, there is no Iamily history oI asthma and the
wheezing is not related to inIections.Cystic Iibrosis is more likely to present with recurrent
inIections and Iailure to thrive than with intermittent wheezing.

6. A patient with end-stage metastatic cancer is having continued signiIicant pain despite regular
use oI 60 mg oI long-acting morphine sulIate every 12 hours. What is the maximum 24-hour
dose oI morphine sulIate that you may saIely titrate up to in order to relieve this patient`s pain?

A. 240 mg
B. 360 mg
C. 480 mg
D. 600 mg
E. No limit
Your Answer: E
Result: Correct
Explanation:
Because there is no therapeutic ceiling for morphine. extremely large dosages can be used
safely and effectively if the drug is titrated properly.

9. A 60-year-old white Iemale with type 1 diabetes mellitus presents with early satiety, nausea,
bloating, and postprandial Iullness. Laboratory tests are normal, as are upper endoscopy and
biliary ultrasonography.

Which one oI the Iollowing would help conIirm the most likely diagnosis?

A. Pelvic ultrasonography
B. An exercise stress test
C. Psychiatric consultation
D. Gastric emptying scintigraphy
E. Colonoscopy
Your Answer: D
Result: Correct
Explanation: This patient has typical findings of gastroparesis. an autonomic neuropathy
more commonly seen in type 1 diabetics and in women. The initial evaluation should
include a patient history and examination. a CBC to rule out infection. a metabolic panel.
endoscopy. and a biliary tract evaluation. but the diagnosis is best confirmed by
scintigraphy. Pelvic ultrasonography and colonoscopy are not indicated because the patient`s
symptoms are upper intestinal. Cardiac evaluation and psychiatric consultation are not warranted
with these symptoms.

10. During a preparticipation examination oI a 5-year-old male Ior summer soccer camp, his
mother states that he Irequently awakens during the night with complaints oI cramping pain in
both legs, and that he seems to experience this aIter a day oI heavy physical activity. She says
that he appears to drag his legs at times, but she has never noticed a deIinite limp. A physical
examination oI the hips, knees, ankles, and leg musculature is entirely normal.

Which one oI the Iollowing would be the most appropriate next step in the evaluation and
management oI this patient?

A. Plain Iilms oI both hips and knees
B. Serum electrolyte levels
C. Recommending that he not participate in running sports
D. Reassurance, with no activity restrictions or treatment
E. ReIerral to a pediatric orthopedist
Your Answer: B
Result: Incorrect
Explanation: Benign nocturnal limb pains of childhood (growing pains) occur in as many as
one-third of children. most often between 4 and 6 years of age. The etiology is unknown, but
the course does not parallel pubescent growth, as would be expected iI bone growth was the
source oI pain. The pain often awakens the child within hours of falling asleep following an
active day. The pain is generally localized around the knees. most often in the shins and
calves, but also may aIIect the thighs and the upper extremities. A characteristic history coupled
with a normal physical examination will conIirm the diagnosis. Reassurance that no additional
tests or treatments are necessary and that the condition is self-limiting is the most
appropriate response.

1. A 35-year-old white male who has had diabetes mellitus Ior 20 years begins having episodes
oI hypoglycemia. He was previously stable and well controlled and has not recently changed his
diet or insulin regimen.

Which one oI the Iollowing is the most likely cause oI the hypoglycemia?

A. Spontaneous improvement oI -cell Iunction
B. Renal disease
C. Reduced physical activity
D. Insulin antibodies
Your Answer: C
Result: Incorrect
Explanation: The most common cause of hypoglycemia in a previously stable. well-
controlled diabetic patient who has not changed his or her diet or insulin dosage is diabetic
renal disease. A reduction in physical activity or the appearance oI insulin antibodies (unlikely
aIter 20 years oI therapy) would increase insulin requirements and produce hyperglycemia.
Spontaneous improvement -cell Iunction aIter 20 years would be very rare.

2. A 54-year-old male presents to the emergency department with an acute onset oI chest pain.
His cardiac risk Iactors include hypertension, hyperlipidemia, and a positive Iamily history. His
temperature is 37.0C (98.6F), pulse rate 80 beats/min, blood pressure 155/86 mm Hg, and
respiratory rate 22/min. His oxygen saturation is 95 on room air. An EKG shows rare uniIocal
PVCs and nonspeciIic ST-Twave changes. Initial cardiac markers are negative.


A. Helical (spiral) CT oI the chest
B. Echocardiography
C. PA and lateral chest Iilms
D. A ventilation-perIusion scan
E. Magnetic resonance angiography
Your Answer: A
Result: Incorrect
Explanation: P and lateral chest radiographs are still valuable in the early evaluation of
patients with chest pain. While they do not conIirm or rule out the presence oI myocardial
ischemia, other causes oI chest pain may be evident, such as pneumothorax, pneumonia, or heart
Iailure. The chest Iilm may also provide clues about other possible diagnoses, such as pulmonary
embolism, aortic disease, or neoplasia. The other tests listed oIten have a role in the evaluation oI
chest pain, but none has supplanted the plain chest Iilm as the best initial imaging study.

3. A 19-year-old college Ireshman consults you at the request oI her cross-country coach because
she has not had a period in 2 oI the last 3 months. She notes that her current training regimen is
much more intense than in high school last year. She has an appropriate body image and denies
caloric restriction. A pregnancy test at the student health center was negative. On examination
she is lean and highly trained. Her examination is otherwise normal.

Which one oI the Iollowing would be the most appropriate recommendation Ior this patient?

A. Estrogen supplementation
B. Cyclic oral contraceptive pills
C. Increased caloric intake
D. Bisphosphonate therapy
E. Discontinuation oI elite-level athletics
Your Answer: C
Result: Correct
Explanation: This patient has exercise-related oligomenorrhea, but does not have the eating
disorder that characterizes the Iemale athlete triad. Menstrual problems in athletes do correlate
with bone density loss and impaired recovery Irom exercise. Additionally, menstrual irregularity
oI varying severity is extremely common in Iemale distance runners, perhaps aIIecting as many
as 60. Hormonal manipulation has not been shown to aIIect bone density, though it may
produce withdrawal bleeding. Bisphosphonate therapy has been shown to be ineIIective, and is
not recommended in women oI child-bearing age.

The main issue in well-nourished Iemale athletes seems to be that energy intake is not increased
to match energy expenditures at high levels oI training. Unlike those with the Iemale athlete
triad, there is little evidence that athletes without eating disorders suIIer substantial harm Irom
exercise-induced menstrual problems. Ending an athletic career Ior this reason alone is not
iustiIied.

6. A 2-year-old Hispanic male with a 3-day history oI nasal congestion presents with a barking
cough and hoarseness. He is aIebrile. The examination reveals tachypnea, inspiratory and
expiratory stridor, noticeable intercostal retractions, and good color.

Which one oI the Iollowing is indicated?

A. Albuterol syrup and the use oI a humidiIier
B. Inhaled albuterol (Proventil, Ventolin)
C. Aerosolized epinephrine and intramuscular dexamethasone
D. Visualization oI the epiglottis, and ceItriaxone (Rocephin)
Your Answer: C
Result: Correct
Explanation: This child has a history and physical Iindings typical oI viral
laryngotracheobronchitis, or croup. In rare instances, this illness can be complicated by critical
upper airway obstruction. The symptoms oI cough, respiratory stridor, and distress result Irom
edema oI the subglottic portion oI the upper airway. HumidiIication oI inspired air is sometimes
beneIicial, but the child should not be sent home until improvement is demonstrated. Because
this child has stridor and intercostal retractions. aerosolized epinephrine is indicated. along
with intramuscular dexamethasone. and hospitalization may be required for observation
and continued treatment. Antibiotics do not have a role in the treatment oI viral croup, and
attempted visualization oI the epiglottis is not indicated since it will increase the child`s anxiety
and worsen the symptoms.

7. The most effective daily doses of vitamin D and calcium for hip fracture prevention in
postmenopausal women are:

A. 800 IU vitamin D and 500 mg calcium
B. 400 IU vitamin D and 500 mg calcium
C. 400 IU vitamin D and 1000 mg calcium
D. 800 IU vitamin D and 1200 mg calcium
Your Answer: D
Result: Correct
Explanation:
The most eIIective daily dose oI vitamin D Ior hip Iracture prevention in postmenopausal women
is 800 IU, and the recommended daily dose oI calcium is 1200 mg.

8. The physician counseling a 4-year-old child about the death oI a loved one should keep in
mind that children in this age group:

A. oIten Ieel no sense oI loss
B. oIten believe they are somehow responsible Ior the death
C. should not attend a Iuneral
D. should usually be told the loved one is having a long sleep
E. usually accept the Iinality oI death with little question
Your Answer: B
Result: Correct
Explanation: Children from the ages of 2 to 6 often believe they are somehow responsible
for the death of a loved one. The emotional pain may be so intense that the child may react by
denying the death, or may somehow Ieel that the death is reversible. II children wish to attend a
Iuneral, or iI their parents want them to, they should be accompanied by an adult who can
provide comIort and support. Telling a child the loved one is asleep or that he or she 'went
away usually creates Ialse hopes Ior return, or it may Ioster a sleep phobia.

1. A 46-year-old Iemale presents to your oIIice with a 2-week history oI pain in her leIt shoulder.
She does not recall any iniury, 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 oI the shoulder and almost complete loss oI external
rotation. Radiographs oI the shoulder are normal, as is her erythrocyte sedimentation rate.

A. Frozen shoulder
B. Torn rotator cuII
C. Impingement syndrome
D. Chronic posterior shoulder dislocation
E. Osteoarthritis
Your Answer: A
Result: Correct
Explanation: 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 Iilms are normal; the
diagnosis is clinical (SOR C).

Frozen shoulder is diIIerentiated Irom chronic posterior shoulder dislocation and osteoarthritis
on the basis oI radiologic Iindings. Both shoulder dislocation and osteoarthritis have
characteristic plain Iilm Iindings. 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.
2. Intravenous magnesium is used to correct which one oI the Iollowing arrhythmias?

A. Wenckebach second-degree heart block
B. Complete heart block
C. Idioventricular rhythm
D. Reentrant supraventricular tachycardia
E. Ventricular tachycardia oI torsades de pointes
Your Answer: D
Result: Incorrect
Explanation: A well-known use oI intravenous magnesium is for correcting the uncommon
ventricular tachycardia of torsades de pointes. Results oI a meta-analysis suggest that 1.2
10.0 g oI intravenous magnesium sulIate also is a saIe and eIIective strategy Ior the acute
management oI rapid atrial Iibrillation.
3. Which one oI the Iollowing is a physiologic diIIerence between males and Iemales that can
aIIect the pharmacokinetics oI medications with a narrow therapeutic index?

A. A consistently higher glomerular Iiltration rate in women
B. The typically higher BMI in women
C. Smaller Iat stores in women
D. Greater gastric acid secretion in women
E. Slower gastrointestinal transit times in women
Your Answer: B
Result: Incorrect
Explanation: There are key physiologic diIIerences between women and men that can have
important implications Ior 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 aIter eating beIore 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 BIs 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.

4. A 52-year-old Iemale with a 60-pack-year history oI cigarette smoking and known COPD
presents with a 1-week history oI increasing purulent sputum production and shortness oI breath
on exertion. Which one oI the Iollowing is true regarding the management oI this problem?

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 iI the patient is hospitalized
Your Answer: A
Result: Correct
Explanation: ntibiotic 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. BrieI courses oI systemic corticosteroids shorten hospital stays and decrease
treatment failures. Studies have not shown a diIIerence between oral and intravenous
corticosteroids. Inhaled corticosteroids are not helpful in the management of an acute
exacerbation. Levalbuterol and albuterol have similar beneIits and adverse eIIects.
Acetylcysteine, a mucolytic agent, has not been shown to be helpIul Ior routine treatment oI
COPD exacerbations.
5. During rounds, you notice a new rash on a Iull-term 2-day-old white Iemale. It consists oI 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.

A. Erythema toxicum neonatorum
B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. $taphvlococcus aureus sepsis
Your Answer: C
Result: Incorrect
Explanation: This infant has the typical ~flea-bitten rash of erythema toxicum neonatorum
(ETN). Transient neonatal
pustular melanosis is most common in frican-merican newborns. and the lesions lack
the surrounding
erythema typical of ETN. Acne neonatorum is associated with closed comedones, mostly on
the Iace. As
the inIant described is not ill, inIectious etiologies are unlikely.
6. Which one oI the Iollowing is true concerning anterior cruciate ligament (ACL) tears?

A. The incidence oI ACL tears is higher in males than in Iemales
B. ACL tears are not associated with early-onset osteoarthritis
C. The maiority oI ACL tears are caused by physical contact
D. Strength training can prevent ACL tears
Your Answer: A
Result: Incorrect
Explanation: Three trials have shown that neuromuscular training with plyometrics and
strengthening reduces anterior cruciate ligament (CL) tears. Females have a higher rate
of CL tears than males. Early-onset osteoarthritis occurs in the aIIected knee in an estimated
50 oI patients with ACL tears. The ACL typically pops audibly when it is torn, usually with no
physical contact.

8. A critically ill adult male is admitted to the intensive-care unit because oI sepsis. He has no
history oI diabetes mellitus, but his glucose level on admission is 215 mg/dL and insulin therapy
is ordered.
Which one oI the Iollowing is the most appropriate target glucose range Ior this patient?

A. 80120 mg/dL
B. 100140 mg/dL
C. 120160 mg/dL
D. 140180 mg/dL
E. 160200 mg/dL
Your Answer: C
Result: Incorrect
Explanation: The 2009 consensus guidelines on inpatient glycemic control issued by the
American Association oI Clinical Endocrinologists and the American Diabetes Association
recommend insulin inIusion 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 Irom intensive treatment targeting near-euglycemic
glucose levels compared to conventional management with a target glucose level oI 180 mg/dL.
There also were reports oI harm resulting Irom intensive glycemic control, including higher rates
oI severe hypoglycemia and even increased mortality.

10. A 21-year-old primigravida at 28 weeks gestation complains oI the recent onset oI itching.
On examination she has no obvious rash. The pruritus started on her palms and soles and spread
to the rest oI her body. Laboratory evaluation reveals elevated serum bile acids and mildly
elevated bilirubin and liver enzymes.
The most eIIective treatment Ior this condition is:

A. triamcinolone (Kenalog) cream
B. cholestyramine (Questran)
C. diphenhydramine (Benadryl)
D. doxylamine succinate
E. ursodiol (Actigall)
Your Answer: E
Result: Correct
Explanation: 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 saIe Ior mother and
Ietus. Topical antipruritics and oral antihistamines are not very eIIective. Cholestyramine may be
eIIective in mild or moderate intrahepatic cholestasis, but is less eIIective and saIe than ursodiol.

1. Which one oI the Iollowing is an appropriate rationale Ior antibiotic treatment oI Bordetella
pertussis inIections?

A. It delays progression Irom the catarrhal stage to the paroxysmal stage
B. It reduces the severity oI symptoms
C. It reduces the duration oI illness
D. It reduces the risk oI transmission to others
E. It reduces the need Ior hospitalization
Your Answer: E
Result: Incorrect
Explanation: ntibiotic 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 eIIective iI started early in the course oI the illness, characterized as the catarrhal phase.
The paroxysmal stage Iollows the catarrhal phase. The CDC recommends macrolides Ior primary
treatment oI pertussis. The preIerred antimicrobial regimen is azithromycin Ior 35 days or
clarithromycin Ior 7 days. These regimens are as eIIective as longer therapy with erythromycin
and have Iewer side eIIects. Children under 1 month oI age should be treated with azithromycin.
There is an association between erythromycin and hypertrophic pyloric stenosis in young inIants.
Trimethoprim/sulIamethoxazole 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 oI
2 months. Fluoroquinolones have been shown to reduce pertussis in vitro but have not been
shown to be
clinically eIIective (SOR A).
2. A 16-year-old Iemale cross-country runner has pain around both ankles. On examination, pain
is elicited on Ioot inversion and there is decreased motion oI the hind Ioot and peroneal tightness.
A rigid Ilat Ioot also is observed.

A. Non-ossiIication oI the os trigonum
B. Sever`s apophysitis
C. Plantar Iasciitis
D. Navicular stress Iracture
E. Tarsal coalition
Your Answer: E
Result: Correct
Explanation: 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.
3. Which one oI the Iollowing is true concerning breast cancer screening?

A. It is useIul Ior detecting premalignant conditions
B. It can predict which oI the discovered cancers are indolent, with a low potential Ior harm
C. The decrease in mortality Irom breast cancer can be attributed almost entirely to early
detection
D. It has resulted in an increase in the diagnosis oI localized disease
E. It has resulted in a signiIicant decrease in the incidence oI regional and metastatic disease
Your Answer: D
Result: Correct
Explanation: 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.
UnIortunately, it cannot predict which oI the discovered cancers are more aggressive, and cannot
accurately detect premalignant lesions. The decrease in the mortality rate oI breast cancer is due
both to earlier detection and better Iollow-up medical care.
4. You make a diagnosis oI depression in a 26-year-old Iemale. Her BMI is 32 kg/m and she has
been trying to lose weight. Which one oI the Iollowing antidepressants would be LEAST likely
to cause her to gain weight?

A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)
Your Answer: C
Result: Correct
Explanation: Bupropion is the antidepressant least likely to cause weight gain, and may
induce modest weight loss. All oI the other choices are more likely to cause weight gain. Among
SSRIs, paroxetine is associated with the most weight gain and Iluoxetine with the least.
Mirtazapine has been associated with more weight gain than the SSRIs.

7. A 70-year-old male complains oI lower-extremity pain. Increased pain with which one oI the
Iollowing would be most consistent with lumbar spinal stenosis?

A. Lumbar spine extension
B. Lumbar spine Ilexion
C. Internal hip rotation
D. Pressure against the lateral hip and trochanter
E. Walking uphill
Your Answer: C
Result: Incorrect
Explanation: Extension that increases lumbar lordosis decreases the cross-sectional area oI the
spinal canal, thereby compressing the spinal cord Iurther. Walking downhill can cause this.
Spinal Ilexion that decreases lordosis has the opposite eIIect, and will usually improve the pain,
as will sitting.

Pain with internal hip rotation is characteristic oI hip arthritis and is oIten Ielt in the groin. Pain
in the lateral hip is more typical oI trochanteric bursitis. Increased pain walking uphill is more
typical oI vascular claudication.
8. Which one oI the Iollowing is true concerning the use oI short-acting inhaled -agonists Ior
asthma?

A. They should be given beIore any inhaled corticosteroid to Iacilitate lung delivery
B. They are ineIIective in patients taking -blockers
C. They are less eIIective than oral -agonists
D. They are less eIIective than anticholinergic bronchodilators when given with inhaled
corticosteroids
E. Their eIIects begin within 5 minutes and last 46 hours
Your Answer: D
Result: Incorrect
Explanation: The effects of short-acting inhaled -agonists begin within 5 minutes and last
4-6 hours. In the past, giving inhaled -agonists iust beIore inhaled corticosteroids was Ielt to
improve the delivery and eIIectiveness oI the corticosteroids. However, this has been proven to
be ineIIective and is no longer recommended. -Blockers do diminish the eIIectiveness oI
inhaled -agonists, but this eIIect is not severe enough to contraindicate using these drugs
together. Oral -agonists are less potent than inhaled Iorms. Similarly, anticholinergic drugs
cause less bronchodilation than inhaled -agonists and are not recommended as
Iirst-line therapy.
9. Which one of the following is true regarding NSIDs?

A. They are cardioprotective
B. They should be avoided in persons with cirrhotic liver disease
C. They are not saIe in pregnancy
D. They are not saIe in lactating women
Your Answer: B
Result: Correct
Explanation: NSAIDs are prescribed commonly and many are available over the counter. It is
important Ior clinicians to understand when they are not appropriate Ior clinical use. They should
be avoided, iI 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 Iurther
impair platelet Iunction. In addition, NSAIDs decrease blood Ilow to the kidneys and can
increase the risk oI renal Iailure in patients with cirrhosis.

NSAIDs diIIer Irom aspirin in terms oI their cardiovascular eIIects. They have the potential to
increase cardiovascular morbidity, worsen heart Iailure, increase blood pressure, and increase
events such as ischemia and acute myocardial inIarction.

There are no known teratogenic eIIects oI NSAIDs in humans. This drug class is considered to
be saIe in pregnancy in low, intermittent doses, although discontinuation oI NSAID use within
68 weeks oI term is recommended. IbuproIen, indomethacin, and naproxen are considered saIe
Ior lactating women, according to the American Academy oI Pediatrics.
10. A 5-year-old Iemale is seen Ior a kindergarten physical and is noted to be below the 3rd
percentile Ior height. A review oI her chart shows that her height curve has progressively Iallen
Iurther below the 3rd percentile over the past year. She was previously at the 50th percentile Ior
height. The physical examination is otherwise normal, but your workup shows that her bone age
is delayed.
OI the Iollowing conditions, which one is the most likely cause oI her short stature?

A. Constitutional growth delay
B. Growth hormone deIiciency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia
Your Answer: A
Result: Incorrect
Explanation: 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. lthough 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
Ieatures, and bone age would be normal.

2. A 4-year-old white male is brought to your oIIice because he has had a low-grade Iever and
decreased oral intake over the past Iew days. On examination you note shallow oral ulcerations
conIined to the posterior pharynx. Which one oI the Iollowing is the most likely diagnosis?

A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola inIantum
E. Rubella
Your Answer: E
Result: Incorrect
Explanation: Herpangina is a febrile disease caused by coxsackieviruses and echoviruses.
'esicles and subsequent ulcers develop in the posterior pharyngeal area (SOR C). Herpes
inIection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be
associated with petechiae oI the soIt palate, but does not usually cause pharyngeal lesions. The
exanthem in roseola usually coincides with deIervescence. Mucosal involvement is not noted.
Rubella may cause an enanthem oI pinpoint petechiae involving the soIt palate (Forschheimer
spots), but not the pharynx.

3. A 45-year-old Iemale presents with a rash on the central portion oI her Iace. She states that she
has intermittent Ilushing and intense erythema that Ieels as iI her Iace is stinging. She has
noticed that her symptoms can be worsened by sun exposure, emotional stress, alcohol, or eating
spicy Ioods. She has been in good health and has taken coniugated estrogens (Premarin), 0.625
mg daily, since a hysterectomy Ior benign reasons. A general examination is normal except Ior
erythema oI the cheeks and chin. No pustules or comedone Iormation is noted around her eyes,
but telangiectasias are present.
Which one oI the Iollowing would be appropriate in the management oI this problem?

A. Increasing her estrogen dosage
B. ReIerral to a rheumatologist
C. Low-potency non-Iluorinated topical corticosteroids
D. Oral prednisone
E. Metronidazole gel (MetroGel)
Your Answer: E
Result: Correct
Explanation: Rosacea is a relatively common condition seen most oIten in women between the
ages oI 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 oI the
subcutaneous glands oI the nose. The usual presenting symptoms are central facial erythema
and flushing that many patients find socially embarrassing. Flushing can be triggered by
Iood, 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.

anagement 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 -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.

4. Which one oI the Iollowing conIirmed Iindings in a 3-year-old Iemale is diagnostic oI sexual
abuse?

A. Bacterial vaginosis
B. Genital herpes
C. Gonorrhea
D. Anogenital warts
E. Hepatitis
Your Answer: C
Result: Correct
Explanation:
The diagnosis oI any sexually transmitted or associated inIection in a postnatal prepubescent
child should raise immediate suspicion oI sexual abuse and prompt a thorough physical
evaluation, detailed historical inquiry, and testing Ior other common sexually transmitted
diseases. Gonorrhea. syphilis. and postnatally acquired Chlamvdia or HI' are virtually
diagnostic of sexual abuse, although it is possible Ior perinatal transmission oI Chlamvdia to
result in inIection that can go unnoticed Ior as long as 23 years. Although a diagnosis oI genital
herpes, genital warts, or hepatitis B should raise a strong suspicion oI possible inappropriate
contact and should be reported to the appropriate authorities, other Iorms oI transmission are
common. Genital warts or herpes may result Irom autoinoculation, and most cases of hepatitis B
appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only
inconclusive evidence Ior sexual contact, and is the only one oI the options listed Ior which
reporting is neither required nor strongly recommended.
5. A 63-year-old male with type 2 diabetes mellitus is seen in the emergency department Ior an
acute, superIicial, previously untreated inIected great toe. Along with $taphvlococcus aureus,
which one oI the Iollowing is the most common pathogen in this situation?

A. Pseudomonas
B. $treptococcus
C. Clostridium
D. scherichia coli
E. Adenovirus
Your Answer: B
Result: Correct
Explanation:
The most common pathogens in previously untreated acute superIicial Ioot inIections in diabetic
patients are aerobic gram-positive $taphvlococcus aureus and -hemolytic streptococci (groups
A, B, and others). Previously treated and deep inIections are oIten polymicrobial.

6. An obese, hypertensive 53-year-old physician suIIers a cardiac arrest while making rounds. He
is resuscitated aIter 15 minutes oI CPR, but remains comatose.
Which one oI the Iollowing is associated with the lowest likelihood oI neurologic recovery in
this situation?

A. Duration oI CPR ~10 minutes
B. No pupillary light reIlex at 30 minutes
C. No corneal reIlex at 2 hours
D. No motor response to pain at 6 hours
E. Myoclonic status epilepticus at 24 hours
Your Answer: A
Result: Incorrect
Explanation: It is diIIicult to establish a prognosis in a comatose patient after a cardiac arrest.
The duration oI CPR is not a Iactor, and the absence oI pupillary and corneal reIlexes, as well as
motor responses to pain, are not reliable predictors beIore 72 hours. yoclonic status
epilepticus at 24 hours suggests no possibility of a recovery.

8. A 40-year-old male who recently immigrated Irom central AIrica presents to a public health
clinic where you are working. He was reIerred by a physician in the local emergency department,
who made a diagnosis oI type 2 diabetes mellitus. The patient has no history oI Iever or night
sweats, weight loss, or cough. He does have a history oI receiving bacille Calmette-Guerin
(BCG) vaccine in the past. Screening tests Ior HIV and hepatitis perIormed in the emergency
department were negative.

Which one oI the Iollowing is true regarding screening Ior latent tuberculosis inIection by in
vitro interIeron-gamma release assay (IGRA) compared to screening by the traditional targeted
tuberculin skin test (TST) in this patient?

A. Both tests require subiective interpretation
B. BCG interIeres with IGRA results
C. IGR differentiates Mvcobacterium tuberculo8i8 from nontuberculous mycobacteria
D. IGRA results are valid iI the sample is analyzed within 24 hours
E. IGRA should be done in tandem with TST
Your Answer: C
Result: Correct
Explanation: In vitro interIeron-gamma release assays (IGRAs) are a new way oI screening Ior
latent tuberculosis inIection. One oI the advantages oI IGRA is that it targets antigens speciIic to
Mvcobacterium tuberculosis. These proteins are absent Irom the BCG vaccine strains and Irom
commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results oI IGRA
are obiective. It is unnecessary Ior IGRA to be done in tandem with skin testing, and it
eliminates the need Ior two-step testing in high-risk patients. IGRAs are labor intensive,
however, and the blood sample must be received by a qualiIied laboratory and incubated with the
test antigens within 8-16 hours oI the time it was drawn,depending upon the brand oI cuurently
available IGRAs

9. An 11-year-old Iemale has been diagnosed with 'Iunctional abdominal pain by a pediatric
gastroenterologist. Her mother brings her to see you because oI concerns that another diagnosis
may have been overlooked despite a very thorough and completely normal evaluation Ior organic
causes.

Which one oI the Iollowing would you recommend?

A. A trial oI inpatient hospital admission
B. Increased testing and levels oI reIerral until a true diagnosis is reached
C. Removing the child Irom school and activities whenever symptoms occur
D. Medications to eradicate symptoms
E. Stress reduction and participation in usual activities as much as possible
Your Answer: E
Result: Correct
Explanation: 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 oI
medications may be helpIul in reducing (but rarely eradicating) Iunctional symptoms, and
remaining open to the possibility oI a previously unrecognized organic disorder is appropriate.
However, continuing to Iocus on organic causes, invasive tests, or physician visits can actually
perpetuate a child`s complaints and distress.

It is estimated that approximately 3050 oI children with Iunctional abdominal pain will
have resolution oI their symptoms within 2 weeks oI 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.

10. Amiodarone (Cordarone) is most useIul Ior which one oI the Iollowing?

A. Prophylactic perioperative use Ior emergency surgery
B. Primary prevention oI nonischemic cardiomyopathy
C. Treatment oI atrial Ilutter
D. Treatment oI multi-Iocal premature ventricular contractions Iollowing acute myocardial
inIarction
E. Treatment oI sustained ventricular tachyarrhythmias in patients with poor hemodynamic
stability
Your Answer: E
Result: Correct
Explanation: miodarone is one oI the most Irequently prescribed antiarrhythmic medications
in the U.S. It is useIul in the acute management oI sustained ventricular tachyarrhythmias,
regardless oI hemodynamic stability. miodarone 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 oI atrial Ilutter. The only role Ior prophylactic
amiodarone is in the perioperative period oI cardiac surgery. The use oI prophylactic
antiarrhythmic agents in the Iace oI 'warning dysrhythmias or aIter myocardial inIarction is no
longer recommended. Prophylactic amiodarone is not indicated Ior primary prevention in
patients with nonischemic cardiomyopathy. ReI: Vassallo P, Trohman RG: Prescribing
amiodarone: An evidence-based review oI clinical indications. JAMA 2007;298(11):1312-1322.

1. 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 Iracture.


A. Complete bed rest Ior 2 weeks
B. arkedly decreased activity until the pain lessens. and follow-up in 1 week
C. ReIerral Ior vertebroplasty as soon as possible
D. NSAIDs and reIerral Ior physical therapy
Your Answer: D
Result: Incorrect
Explanation: This patient has suIIered a thoracic vertebral compression fracture. Most can be
managed conservatively with decreased activity until the pain is tolerable, possibly Iollowed 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.

2. On his Iirst screening colonoscopy, a 67-year-old male is Iound to have a 0.5-cm adenomatous
polyp with low-grade dysplasia.

According to current guidelines, when should this patient have his next colonoscopy?

A. 6 months
B. 1 year
C. 3 years
D. 5 years
E. Screening is no longer necessary
Your Answer: B
Result: Incorrect
1. Explanation: Overuse oI colonoscopy has signiIicant 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 oI 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).

Patients with small rectal hyperplastic polyps should be considered to have normal
colonoscopies, and thereIore the interval beIore the subsequent colonoscopy should be 10
years. An exception is patients with a hyperplastic polyposis syndrome. They are at
increased risk Ior adenomas and colorectal cancer and need to be identiIied Ior more
intensive Iollow up.
2. Patients with only one or two small (<1 cm) tubular adenomas with only low-grade
dysplasia should have their next Iollow-up colonoscopy in 5 to 10 years. The precise
timing within this interval should be based on other clinical Iactors (such as prior
colonoscopy Iindings, Iamily history, and the preIerences oI the patient and iudgment oI
the physician).
3. Patients with 3 to 10 adenomas. or any adenoma >1 cm. or any adenoma with villous
features. or high-grade dysplasia should have their next Iollow-up colonoscopy in 3
years providing that piecemeal removal has not been done and the adenoma(s) are
completely removed. II the Iollow-up colonoscopy is normal or shows only one or two
small tubular adenomas with low-grade dysplasia, then the interval Ior the subsequent
examination should be 5 years.
4. Patients who have more than 10 adenomas at one examination should be examined at
a shorter (<3 years) interval established by clinical iudgment, and the clinician should
consider the possibility oI an underlying Iamilial syndrome.
5. Patients with sessile adenomas that are removed piecemeal should be considered Ior
Iollow up at short intervals (2 to 6 months) to veriIy complete removal. Once complete
removal has been established, subsequent surveillance needs to be individualized based
on the endoscopist's iudgment. Completeness oI removal should be based on both
endoscopic and pathologic assessments.
6. ore intensive surveillance is indicated when the family history may indicate
hereditary nonpolyposis colorectal cancer.

4. 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 oI the Iollowing, compared to use oI
a nebulizer?

A. Higher hospitalization rates
B. Shorter stays in the emergency department
C. Higher relapse rates
D. Less improvement in peak-Ilow rates
E. Increases in the total dose oI albuterol
Your Answer: D
Result: Incorrect
Explanation: Compared to nebulizers. DIs 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 signiIicantly lower relapse rates at 2 and 3
weeks compared to nebulizers. There is no diIIerence in hospital admission rates.

7. A 24-year-old Iemale presents with pelvic pain. She says that the pain is present on most days,
but is worse during her menses. IbuproIen has helped in the past but is no longer eIIective. Her
menses are normal and she has only one sexual partner. A physical examination is normal.

Which one oI the Iollowing should be the next step in the workup oI this patient?

A. Transvaginal ultrasonography
B. CT oI the abdomen and pelvis
C. MRI oI the pelvis
D. A CA-125 level
E. Colonoscopy
Your Answer: A
Result: Correct
Explanation: The initial evaluation for chronic pelvic pain should include a urinalysis and
culture. cervical swabs for gonorrhea and Chlamvdia. a CBC. an erythrocyte sedimentation
rate. a -hCG level. and pelvic ultrasonography. CT and MRI are not part oI the
recommended initial diagnostic workup, but may be helpIul in Iurther assessing any
abnormalities Iound on pelvic ultrasonography. ReIerral Ior diagnostic laparoscopy is
appropriate iI the initial workup does not reveal a source oI the pain, or iI endometriosis or
adhesions are suspected. Colonoscopy would be indicated iI the history or examination suggests
a gastrointestinal source Ior the pain aIter the initial evaluation.

9. A 24-year-old Iemale with a 2-year history oI dyspnea on exertion has been diagnosed with
exercise-induced asthma by another physician. Which one oI the Iollowing Iindings on
pulmonary Iunction testing would raise concerns that she actually has vocal cord dysIunction?

A. A good response to an inhaled -agonist
B. Flattening oI the inspiratory portion oI the Ilow-volume loop, but a normal expiratory phase
C. Flattening oI the expiratory portion oI the Ilow-volume loop, but a normal inspiratory phase
D. Flattening oI both the inspiratory and expiratory portion oI the Ilow-volume loop
E. A decreased FEV
1
and a normal FVC
Your Answer: D
Result: Incorrect
Explanation:
The diagnosis oI vocal cord dysfunction should be considered in patients diagnosed with
exercise-induced asthma who do not have a good response to -agonists before exercise.
Pulmonary function testing with a flow-volume loop typically shows a normal expiratory
portion but a flattened inspiratory phase (SOR C). A decreased FEV
1
and normal FVC would
be consistent with asthma.

10. A 45-year-old Iemale presents to your oIIice with a 1-month history oI pain and swelling
posterior to the medial malleolus. She does not recall any iniury, but reports that the pain is
worse with weight bearing and with inversion oI the Ioot. Plantar Ilexion against resistance
elicits pain, and the patient is unable to perIorm a single-leg heel raise.
Which one oI the Iollowing is true regarding this problem?

A. The patient most likely has a medial ankle sprain
B. NSAIDs will improve the long-term outcome
C. Iniecting a corticosteroid into the tendon sheath oI the involved tendon is recommended
D. A lateral heel wedge should be prescribed
E. Immobilization in a cast boot Ior 3 weeks is indicated
Your Answer: B
Result: Incorrect
Explanation: The diagnosis oI tendinopathy of the posterior tibial tendon is important, in that
the tendon`s Iunction is to perIorm plantar Ilexion oI the Ioot, invert the Ioot, and stabilize the
medial longitudinal arch. An iniury can, over time, elongate the midIoot and hindIoot ligaments,
causing a painIul IlatIoot deIormity.

The patient usually recalls no trauma, although the iniury may occur Irom twisting the Ioot by
stepping in a hole. This is most commonly seen in women over the age of 40. Without proper
treatment, progressive degeneration oI 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. 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 relieI, neither aIIects
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.

1. A 70-year-old male presents to your oIIice Ior a Iollow-up visit Ior hypertension. He was
started on lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests Irom his last
visit, including a CBC and a complete metabolic panel, were normal except Ior a serum
creatinine level oI 1.5 mg/dL (N 0.61.5). A Iollow-up renal panel obtained yesterday shows a
creatinine level oI 3.2 mg/dL and a BUN oI 34 mg/dL (N 825).

Which one oI the Iollowing is the most likely cause oI this patient`s increased creatinine level?

A. Bilateral renal artery stenosis
B. Coarctation oI the aorta
C. Essential hypertension
D. Hyperaldosteronism
E. Pheochromocytoma
Your Answer: A
Result: Correct
Explanation: 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 (deIined as blood pressure
above the goal despite treatment with three drugs oI diIIerent classes at optimal doses). The other
conditions mentioned do not cause a signiIicant rise in serum creatinine aIter treatment with an
ACE inhibitor.

2. A 58-year-old male presents with a several-day history oI shortness oI breath with exertion,
along with pleuritic chest pain. His symptoms started soon aIter he returned Irom a vacation in
South America. He has a history oI deep-vein thrombosis (DVT) in his right leg aIter surgery
several years ago, and also has a previous history oI prostate cancer. You suspect pulmonary
embolism (PE.).

Which one oI the Iollowing is true regarding the evaluation oI this patient?

A. CT angiography would reliably either conIirm or rule out PE
B. Compression ultrasonography oI the lower extremities will reveal a DVT in the maiority oI
patients with PE
C. No Iurther testing is needed iI a ventilation-perIusion lung scan shows a low probability oI PE
D. No Iurther testing is needed iI a D-dimer level is normal
E. An elevated D-dimer level would conIirm the diagnosis oI PE
Your Answer: B
Result: Incorrect
Explanation: This patient has a high clinical probability Ior pulmonary embolism (PE). bout
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 oI venous thromboembolism in patients at low or
moderate risk oI pulmonary embolism, but the negative predictive value oI this test is low Ior
high-probability patients. A positive D-dimer test does not conIirm the diagnosis; it indicates the
need Ior Iurther testing, and is thus not necessary Ior this patient. A multidetector CT angiogram
or ventilation-perIusion lung scan should be the next test, as these are reliable to conIirm or rule
out PE.

.

4. A 43-year-old Iemale complains oI a several-month history oI 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 oIten awaken her, and she Ieels very tired. She has no other
medical problems and takes no medication. Laboratory tests reveal a serum calcium level oI 8.9
mg/dL (N 8.510.5), a serum potassium level oI 4.1 mmol/L (N 3.55.0), a serum Ierritin level
oI 15 ng/mL (N 10200), and a serum magnesium level oI 1.5 mEq/L (N 1.42.0).

Which one oI the Iollowing may improve her symptoms?

A. Iron supplementation
B. Magnesium supplementation
C. Antihistamines
D. Stopping calcium supplementation
E. Amitriptyline
Your Answer: A
Result: Correct
Explanation: 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 Ior 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 iI nonpharmacologic therapies are
ineIIective.

5. A 56-year-old Iemale with well-controlled diabetes mellitus and hypertension presents with an
18-hour history oI progressive leIt lower quadrant abdominal pain, low-grade Iever, and nausea.
She has not been able to tolerate oral intake over the last 6 hours. An abdominal examination
reveals signiIicant tenderness in the leIt lower quadrant with slight guarding but no rebound
tenderness. Bowel sounds are hypoactive. Rectal and pelvic examinations are unremarkable.

Which one oI the Iollowing is recommended as the initial diagnostic procedure in this situation?

A. CT oI the abdomen and pelvis
B. Abdominal and pelvic ultrasonography
C. A barium enema
D. Colonoscopy
E. Laparoscopy
Your Answer: A
Result: Correct
Explanation: 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 helpIul in suggesting other diagnoses, but it is not as speciIic or as
sensitive Ior diverticulitis as CT.

Limited-contrast studies oI the distal colon and rectum may occasionally be useIul in
distinguishing between diverticulitis and carcinoma, but would not be the initial procedure oI
choice. Water-soluble contrast material is used in this situation instead oI barium. Colonoscopy
to detect other diseases, such as cancer or inIlammatory bowel disease, is deIerred until the acute
process has resolved, usually Ior 6 weeks. The risk oI perIoration or exacerbation oI the disease
is greater iI colonoscopy is perIormed acutely. Diagnostic laparoscopy is rarely needed in this
situation. Laparoscopic or open surgery to drain an abscess or resect diseased tissue is reserved
Ior patients who do not respond to medical therapy. Elective sigmoid resection may be
considered aIter recovery in cases oI recurrent episodes.

6. Which one oI the Iollowing is true concerning Norwalk virus?

A. Outbreaks occur mostly in settings with large numbers oI children, such as schools and day-
care centers
B. Viral shedding continues long aIter the acute illness
C. The virus does not survive long on most environmental surIaces
D. An episode oI Norwalk gastroenteritis leads to long-lasting immunity
E. It is a less common cause oI diarrhea in adults than Shigella
Your Answer: B
Result: Correct
Explanation: Outbreaks oI Norwalk gastroenteritis occur in a wide variety oI 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 oI the virus, so a single inIection does not conIer immunity, and repeated inIections occur
throughout liIe. It is the most common cause of diarrhea in adults.

7. Patient-centered medical home is a term used to describe which one oI the Iollowing
developments in medical care?

A. A Iederally imposed restriction on Iamily medicine`s role in providing care
B. A physician-led team oI care providers taking responsibility Ior the quality and saIety oI an
individual`s health
C. A 'practice without walls that provides primary care services in the homes oI patients
D. A small group oI patients paying an annual Iee to have a physician be available to them at all
times
E. Improving the dignity oI care Ior nursing-home residents
Your Answer: B
Result: Correct
Explanation: The patient-centered medical home (PCH) 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 saIety are hallmarks oI the
PCMH, which stresses outcome-based and evidence-supported practices. This concept was
originated by organizations in the Iield oI pediatrics and was Iurther developed by a
collaboration oI the maior academies oI primary care. There are institutions that accredit
individual and group practices as IulIilling the role oI a PCMH, which are now being
compensated at a higher level by third-party payers, including Medicare.

8. Which one oI the Iollowing Mantoux tuberculin skin test results should be read as
NEGATIVE Ior latent tuberculosis inIection?

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
Your Answer: E
Result: Correct
Explanation: Three diIIerent cutoII levels deIining a positive reaction on a tuberculin skin test
are recommended by the CDC, each based on the level oI risk and consideration oI
immunocompetence. For those who are at highest risk and/or immunocompromised.
including HI'-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 oI a recent
inIection with Mvcobacterium tuberculosis. A nurse with a 9-mm induration would be
considered to have a negative PPD.

9. The Health Insurance Portability and ccountability ct (HIP)

. sets a federal minimum on the protection of privacy
B. requires that privacy notices be acknowledged and signed at each oIIice visit
C. allows the patient to inspect and obtain a copy oI his/her record without exception
D. requires privacy notices prior to giving emergency care
Your Answer: C
Result: Incorrect
Explanation: HIPAA regulations set a minimum standard Ior privacy protection. Privacy notices
must be provided at the Iirst delivery oI 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 iudgment oI a licensed health proIessional. Although it is not necessary to provide patients
with a privacy notice beIore rendering emergency care, it is required that patients be provided
with a privacy notice aIter the emergency has ended.

1. A 53-year-old male presents to your oIIice with a several-day history oI hiccups. They are not
severe, but have been interrupting his sleep, and he is becoming exasperated.

What should be the primary Iocus oI treatment in this individual?

A. Drug treatment to prevent recurrent episodes
B. Decreasing the intensity oI the muscle contractions in the diaphragm
C. Finding the underlying pathology causing the hiccups
D. Improving the patient`s quality oI sleep
E. Suppressing the current hiccup symptoms
Your Answer: D
Result: Incorrect
Explanation: Hiccups are caused by a respiratory reIlex that originates Irom the phrenic and
vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter oI hours are
usually benign and selI-limited, and may be caused by gastric distention. Treatments usually
Iocus on interrupting the reIlex loop oI 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 Ior this indication.

II the hiccups have lasted more than a couple oI days, and especially iI they are waking the
patient up at night, there may be an underlying pathology causing the hiccups. In one study, 66
oI patients who experienced hiccups Ior longer than 2 days had an underlying physical cause.
Identifying and treating the underlying disorder should be the focus of management for
intractable hiccups.

2. 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 oI multi-inIarct dementia, hypertension,
and hyperlipidemia. On examination he is aIebrile, and a nasogastric aspirate is negative Ior
evidence oI bleeding.

Which one oI the Iollowing is the most likely cause oI this patient`s bleeding?

A. Peptic ulcer disease
B. Ischemic colitis
C. Diverticular bleeding
D. Angiodysplasia
E. InIectious colitis
Your Answer: C
Result: Incorrect
Explanation: 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.

3. A 62-year-old Iemale 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/mm
3
(N 150,000300,000) Irom 350,000 /mm
3
a week ago. She received
prophylactic heparin postoperatively during her Iirst hospitalization.
The patient is started on intravenous antibiotics Ior the pneumonia and subcutaneous heparin Ior
deep-vein thrombosis prophylaxis. On hospital day 2, she has an acute onset oI severe dyspnea
and hypoxia; CT oI the chest reveals bilateral pulmonary emboli. Her platelet count is now
80,000/mm
3
.

A. Continue subcutaneous heparin
B. Discontinue subcutaneous heparin and start a continuous intravenous heparin drip
C. Discontinue heparin and give a platelet transIusion
D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or
desirudin (Iprivask)
E. Discontinue unIractionated heparin and start a low molecular weight heparin such as
enoxaparin (Lovenox)
Your Answer: D
Result: Correct
Explanation: This patient needs prompt evaluation and treatment Ior probable heparin-induced
thrombocytopenia (HIT). HIT is a potentially liIe-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 unIractionated heparin prophylaxis are at highest
risk Ior HIT. Because oI this patient`s high-risk scenario and the presence oI acute thrombosis, it
is advisable to begin immediate empiric treatment Ior HIT pending laboratory conIirmation.
anagement should include discontinuation of heparin and treatment with a non-heparin
anticoagulant.

4. A 64-year-old male presents with a 3-month history oI diIIiculty sleeping. A history and
physical examination, Iollowed by appropriate ancillary testing, leads to a diagnosis oI chronic
primary insomnia.
Which one oI the Iollowing would be most appropriate Ior managing this patient`s problem?

A. An SSRI
B. A small glass oI wine 1 hour beIore bedtime
C. Cognitive-behavioral therapy
D. Watching television at bedtime, with the timer set to turn oII in 60 minutes
E. Reading in bed with a soIt light
Your Answer: C
Result: Correct
Explanation: Chronic insomnia is deIined as diIIiculty with initiating or maintaining sleep, or
experiencing nonrestorative sleep, Ior at least 1 month, leading to signiIicant 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 aIter treatment is
begun. One eIIective 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 beneIits. SSRIs can cause insomnia, as can
alcohol.

5. Which one oI the Iollowing would be most appropriate Ior stroke prevention in a patient with
hypertension, diabetes mellitus, and atrial Iibrillation?

A. Clopidogrel (Plavix)
B. Aspirin
C. Dipyridamole (Persantine)
D. WarIarin (Coumadin)
E. Enoxaparin (Lovenox)
Your Answer: D
Result: Correct
Explanation: The CHDS
2
score is a validated clinical prediction rule Ior determining the risk
oI stroke and who should be anticoagulated. Points are assigned based on the patient`s
comorbidities. One point is given Ior each oI the Iollowing: history oI congestive heart failure
(C). hypertension (H). age 75 (). and diabetes mellitus (D). Two points are assigned for a
previous stroke or TI (S
2
).

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 oI stroke is higher than the risks
associated with taking warIarin. Enoxaparin is an expensive iniectable anticoagulant and is not
indicated Ior the long-term prevention oI stroke.

7. According to the guidelines oI the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment oI High Blood Pressure, Ior hypertensive patients who also have
diabetes mellitus, the blood pressure goal is below a threshold oI:

A. 140/95 mm Hg
B. 135/90 mm Hg
C. 130/80 mm Hg
D. 120/75 mm Hg
Your Answer: C
Result: Correct
Explanation: 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 Iound no
signiIicant cardiovascular beneIit Irom targeting systolic blood pressure at 120 mm Hg rather
than 140 mm Hg in patients with type 2 diabetes. This Iinding may aIIect the JNC 8 guidelines,
which are currently being developed.

8. A hospitalized patient is being treated with vancomycin Ior an inIection due to methicillin-
resistant $taphvlococcus aureus (MRSA). Which one oI the Iollowing is most important to
monitor?

A. Hepatic Iunction
B. Trough serum levels
C. Peak serum levels
D. Audiograms
Your Answer: D
Result: Incorrect
Explanation: 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 oI eIIicacy or toxicity. onitoring for ototoxicity is not
currently recommended. Older vancomycin products had impurities. which apparently
caused the ototoxicity seen with these early formulations of the drug.

9. A 35-year-old male amateur rugby player seeks your advice because right hip pain oI several
months` duration has progressed to the point oI interIering with his athletic perIormance. The
pain is accentuated when he transitions Irom a seated to a standing position, and especially when
he pivots on the hip while running, but he cannot recall any signiIicant trauma to the area and
Iinds no relieI with over-the-counter analgesics. On examination his gait is stable. The aIIected
hip appears normal and is neither tender to palpation nor excessively warm to touch. Although he
has a Iull range oI passive motion, obvious discomIort is evident with internal rotation oI the
Ilexed and adducted right hip.

Which one oI the Iollowing is most strongly suggested by this clinical picture?

A. Osteoarthritis
B. Avascular necrosis
C. Bursitis
D. Impingement
E. Pathologic Iracture
Your Answer: D
Result: Correct
Explanation: 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 (FDIR test) is the most sensitive physical finding. Special radiographic
imaging oI the Ilexed 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 (FBER test) of the affected hip. Bursitis manifests as soreness after
exercise and tenderness over the affected bursa.

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

OI the Iollowing, the most appropriate therapy at this time would be:

A. oral trimethoprim/sulIamethoxazole (Bactrim, Septra)
B. oral nitroIurantoin (Macrodantin)
C. oral levoIloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceItriaxone (Rocephin)
Your Answer: B
Result: Incorrect
Explanation: Pyelonephritis is the most common medical complication oI pregnancy. The
diagnosis is usually straightIorward, 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. mpicillin plus gentamicin or a cephalosporin is typically used.

SulIonamides are contraindicated late in pregnancy because they may increase the incidence oI
kernicterus. Tetracyclines are contraindicated because administration late in pregnancy may lead
to discoloration oI the child`s deciduous teeth. Nitrofurantoin may induce hemolysis in
patients who are deficient in G-6-PD. which includes approximately 2 of frican-
merican women. The saIety oI levoIloxacin in pregnancy has not been established, and it
should not be used unless the potential beneIit outweighs the risk.

1. A 45-year-old Iemale with no Iamily history oI breast cancer presents Ior a routine
examination. She has no constitutional symptoms or obvious breast abnormalities, and a clinical
breast examination is negative.
U.S. Preventive Services Task Force recommendations advise that until 50 years oI age the
patient should:

A. perIorm monthly breast selI-examinations
B. have mammography every 12 years
C. have scintimammography every 12 years
D. have breast ultrasonography annually
E. have a breast MRI every 12 years
Your Answer: A
Result: Incorrect
Explanation: Previous recommendations Ior breast cancer screening included selI-examination
and clinical examination on a regular basis. However, selI-examination has been shown to be
potentially harmIul because it leads to an increase in biopsies but does not decrease mortality; it
is thereIore no longer recommended. ammography is recommended every 1-2 years in
women 40-50 years old. with digital mammography being more sensitive. Ultrasonography
and scintimammography are not recommended Ior screening, but may be used in the evaluation
oI a palpable breast lesion. MRI is also not recommended as a routine screening tool, but may be
appropriate in high-risk women.

3. A previously healthy 18-month-old male is brought to your oIIice with a 2-day history oI
cough and Iever. On examination the child has a temperature oI 38.3C (100.9F), a respiratory
rate oI 30/min, and mild retractions and mild wheezes bilaterally. Oxygen saturation is 90.

The most appropriate initial management would be:

A. azithromycin (Zithromax)
B. a short course oI corticosteroids
C. aerosolized racemic epinephrine every 4 hours
D. postural drainage
E. a single treatment with aerosolized albuterol, continued only iI there is a positive response
Your Answer: C
Result: Incorrect
Explanation: For patients with bronchiolitis. evidence supports a trial of an inhaled
bronchodilator. albuterol. or epinephrine. with treatment continued only if the initial dose
proves beneficial. There is no evidence to support the use oI antibiotics unless another
associated inIection is present (e.g., otitis media). Neither corticosteroids nor postural drainage
has been Iound to be helpIul.

4. A 2-year-old Iemale is brought to the emergency department with a 2-day history oI Iever and
increasing redness on the leIt Iorearm. She is otherwise healthy. On examination her temperature
is 39.9C (103.8F), pulse rate 140 beats/min, and respiratory rate 42/min. She is irritable, and
the leIt Iorearm has a 4-cm erythematous, warm, tender area, with a Iluctuant area centrally. Her
WBC count is 21,000/mm
3
(N 43001 3 0,800), with 14 immature bands.
In addition to incision and drainage, which one oI the Iollowing is the best initial treatment in
this patient?

A. Intravenous vancomycin
B. Intravenous ampicillin/sulbactam (Unasyn)
C. Intravenous naIcillin
D. Intravenous clindamycin (Cleocin)
E. No antibiotics
Your Answer: A
Result: Correct
Explanation: This patient has systemic symptoms that suggest a severe underlying infection.
Community-acquired methicillin-resistant $taphvlococcus aureus (C-RS) should be
considered the cause of this type of infection until definitive cultures are obtained. CA-
MRSA can cause aggressive inIections in children, especially in the skin and soIt tissue. Incision
and drainage of the abscess is necessary for treatment. In a severe infection. vancomycin
should be started initially until culture and sensitivities are available (SORB).

7. You see a 30-year-old white male Ior the Iirst time Ior a routine evaluation. He says that he
has been bothered by multiple skin lesions on the neck and axillae. On examination you note
numerous skin tags.

The presence oI these lesions indicates an increased risk Ior:

A. diabetes mellitus
B. squamous cell skin cancer
C. melanoma
D. glioblastoma multiIorme
E. AIDS
Your Answer: B
Result: Incorrect
Explanation: Skin tags. or acrochordons. are associated with diabetes mellitus and obesity.
The onset oIten occurs in early adulthood, and the most common locations are the neck and
axillae. These skin lesions are not associated with any signiIicant cancer risk, and have not been
associated with HIV inIection.

8. Which one oI the Iollowing is considered Iirst-line therapy Ior migraine prophylaxis in adults?

A. Gabapentin (Neurontin)
B. Propranolol (Inderal)
C. Fluoxetine (Prozac)
D. Vitamin B
2
(riboIlavin)
E. Naproxen (Naprosyn)
Your Answer: B
Result: Correct
Explanation:
Propranolol is a first-line therapy for migraine prophylaxis in adults (SOR A). In a review
oI 26 placebocontrolled trials using data pooled Irom nine studies, the calculated responder ratio
(comparable to relative risk) was 1.9 (95 conIidence interval 1.62.35). Other Iirst-line agents
include timolol, amitriptyline, divalproex sodium, sodium valproate, and topiramate.
Gabapentin, Iluoxetine, vitamin B , and naproxen are considered second-line therapies Ior
migraine prophylaxis in adults (SOR B), and should be used when no Iirst-line agent or
combination is eIIective or tolerable.
9. A 52-year-old white male is being considered Ior pharmacologic treatment oI hyperlipidemia
because oI an LDL-cholesterol level oI 180 mg/dL. BeIore beginning medication Ior his
hyperlipidemia, he should be screened Ior:

A. hyperthyroidism
B. hypothyroidism
C. Addison`s disease
D. Cushing`s disease
E. pernicious anemia
Your Answer: B
Result: Correct
Explanation:
According to the National Cholesterol Education Program Adult Treatment Panel III Report oI
2001, any person with elevated LDL cholesterol or any other Iorm oI 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.

1. A patient who takes Iluoxetine (Prozac), 40 mg twice daily, develops shivering, tremors, and
diarrhea aIter taking an over-the-counter cough and cold medication. On examination he has
dilated pupils and a heart rate oI 110 beats/min. His temperature is normal.
Which one oI the Iollowing medications in combination with Iluoxetine could contribute to this
patient`s symptoms?

A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. GuaiIenesin
E. Diphenhydramine (Benadryl)
Your Answer: B
Result: Incorrect
Explanation: Dextromethorphan is commonly found in cough and cold remedies. and is
associated with serotonin syndrome. SSRIs such as Iluoxetine are also associated with
serotonin syndrome, and there are many other medications that increase the risk Ior serotonin
syndrome when combined with SSRIs. The other medications listed here are not associated with
serotonin syndrome, however.

3. An 82-year-old male presents to your oIIice because his blood pressure has been 'high when
taken by a Iriend on several occasions. His blood pressure in your oIIice is 173/94 mm Hg,
which is similar to the levels his Iriend recorded. The history and physical examination are
otherwise unremarkable, and a CBC, metabolic panel, and urinalysis are normal.

Which one oI the Iollowing is most consistent with current evidence?

A. This patient`s mortality will not be aIIected by treatment oI his hypertension
B. Treating this patient with an ARB Ior hypertension would be ineIIective and dangerous
C. Treatment with a thiazide diuretic will lower this patient`s risk oI death
D. In this age group, treatment oI hypertension in males does not reduce stroke and heart Iailure
as it does in Iemales
Your Answer: D
Result: Incorrect
Explanation: Studies have shown that the treatment of systolic and diastolic hypertension.
especially with thiazide diuretics. with or without an CE inhibitor. reduces stroke. heart
failure. and death from all causes. Such treatment is eIIective in both sexes.

ReI: Beckett NS, Peters R, Fletcher AE, et al: Treatment of hypertension in patients 80 years
of age or older. N ngl J Med 2008;358(18):1887-1898.
4. A 68-year-old Iemale presents with a several-month history oI weight loss, Iatigue, decreased
appetite, and vague abdominal pain. The most appropriate initial test to rule out adrenal
insuIIiciency is:

A. morning serum cortisol
B. a cosyntropin (ACTH) stimulation test
C. MRI
D. an insulin tolerance test
E. a metyrapone test
Your Answer: B
Result: Incorrect
Explanation: single morning serum cortisol level >13g/dL reliably excludes adrenal
insufficiency. If the morning cortisol level is lower than this. further evaluation with a 1g
CTH stimulation test is necessary, although the test is somewhat diIIicult. It requires dilution
oI 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 inIormation about adrenal
Iunction.

5. A healthy 48-year-old Iemale consults you about continuing the use oI 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?

A. She should stop the oral contraceptives
B. She should switch to a progestin-only pill
C. She should discontinue the contraceptive Ior 1 month, and iI FSH is then elevated to
postmenopausal levels, the pills should be stopped
D. She can saIely continue to take the contraceptive iI screening Ior thrombophilic conditions is
negative
E. It is saIe to continue the oral contraceptives
Your Answer: E
Result: Correct
Explanation: 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 speciIic enough to evaluate the eIIect oI
stopping the contraceptive.

6. Which one oI the Iollowing is necessary to make a diagnosis oI polymyalgia rheumatica?

A. Joint swelling
B. Early morning stiIIness
C. Reduction oI symptoms with high-dose NSAID therapy
D. An erythrocyte sedimentation rate >60 mm/hr
E. Bilateral shoulder or hip stiIIness and aching

Your Answer: D
Result: Incorrect
Explanation: 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 stiIIness is necessary to make the diagnosis.
Polymyalgia rheumatica does not respond to NSIDs. The erythrocyte sedimentation rate
should be >40 mm/hr.

7. The Centers Ior Disease Control and Prevention currently recommends that all patients
between the ages of 13 and 64 years be screened for:

A. tuberculosis
B. hepatitis B
C. human papillomavirus inIection
D. elevated serum cholesterol levels
E. HI' infection
Your Answer: D
Result: Incorrect
Explanation: The focus of screening for HI' 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 oI
adults have had an HIV test. Screening Ior hepatitis B and Ior tuberculosis is recommended only
Ior certain at-risk populations. There is no generally used test Ior human papillomavirus. The
CDC has not made any recommendations regarding screening Ior high cholesterol.

8. A 71-year-old Iemale with end-stage lung cancer was recently extubated and is awaiting
transIer to hospice. She is awake and conIused and has signiIicant respiratory secretions.

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

A. Atropine
B. Transdermal scopolamine (Transderm Scop)
C. Hyoscyamine (Levsin)
D. Glycopyrrolate (Robinul)
Your Answer: C
Result: Incorrect
Explanation: 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.

10. A 78-year-old male presents Ior a routine Iollow-up visit Ior 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 (P'Cs), but no
other abnormalities.
Current guidelines recommend which one oI the Iollowing?

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

Strong evidence Irom randomized, controlled trials suggests that PVCs should not be suppressed
with antiarrhythmic agents. The CAST I trial showed that using encainide or Ilecainide to
suppress PVCs increases mortality (SOR A).

1. While playing tennis, a 55-year-old male tripped and Iell, landing on his outstretched hand
with his elbow in slight Ilexion at impact. Pronation and supination oI the Iorearm are painIul on
examination, as are attempts to Ilex the elbow. There is tenderness oI the radial head without
signiIicant swelling. radiograph of the elbow shows no fracture. but a positive fat pad sign
is noted.
Appropriate management would include:

A. a long arm cast Ior 2 weeks, Iollowed by use oI a brace
B. mobilization oI the elbow beginning 3 weeks aIter the iniury
C. a posterior splint Ior 6 weeks
D. a posterior splint and a repeat radiograph in 12 weeks
Your Answer: D
Result: Correct
Explanation: 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 ioint eIIusion may be aspirated Ior pain relieI and to increase mobility. One study
compared immediate mobilization with mobilization beginning in 5 days and Iound no
diIIerences at 1 and 3 months, but early mobilization was associated with better Iunction and less
pain 1 week aIter the iniury. Radiographs should be repeated in 1-2 weeks to make sure that
alignment is appropriate.

2. The best available evidence supports which one oI the Iollowing statements regarding the
cardiovascular eIIects oI hypoglycemic agents?

A. SulIonylureas increase cardiovascular events
B. MetIormin (Glucophage) reduces cardiovascular mortality rates
C. Incretin mimetics reduce the risk oI cardiovascular events
D. u-Glucosidase inhibitors have no eIIect on cardiovascular events
Your Answer: B
Result: Correct
Explanation: etformin 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 oI sulIonylureas. The
eIIect oI incretin mimetics and incretin enhancers on cardiovascular events has not been
determined. The STOP-NIDDM study suggests that u-glucosidase inhibitors reduce the risk oI
cardiovascular events in patients with impaired glucose tolerance.

3. A 46-year-old Iemale presents to your oIIice Ior Iollow-up oI elevated blood pressure on a
pre-employment examination. She is asymptomatic, and her physical examination is normal with
the exception oI a blood pressure oI 160/100 mm Hg. Screening blood work reveals a potassium
level oI 3.1 mEq/L (N 3.75.2). You consider screening Ior primary hyperaldosteronism.

A. 24-hour urine aldosterone levels
B. An ACTH inIusion test
C. Adrenal venous sampling
D. CT oI the abdomen
E. A serum aldosterone-to-renin ratio
Your Answer: A
Result: Incorrect
Explanation: 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 oI patients reIerred to a hypertension specialist suIIer Irom this condition.
Experts recommend screening Ior this condition using a ratio of morning plasma aldosterone
to plasma renin. ratio >20:1 with an aldosterone level >15 ng/dL suggests the diagnosis.
The level oI these two values is aIIected by several Iactors, including medications (especially
most blood pressure medicines), time oI day, position oI the patient, and age.
Patients who are identiIied as possibly having this condition should be reIerred to an
endocrinologist Ior Iurther conIirmatory testing.

5. A 45-year-old male presents with a 4-month history oI low back pain that he says is not
alleviated with either ibuproIen or acetaminophen. On examination he has no evidence oI
weakness or Iocal tenderness. Laboratory studies, including a CBC, erythrocyte sedimentation
rate, C-reactive protein, and complete metabolic proIile, are all normal. MRI oI the lumbosacral
region shows mild bulging oI the L4-L5 disc without impingement on the thecal sac.
Which one oI the Iollowing has been shown to be beneIicial in this situation?

A. Traction
B. Ultrasound
C. Epidural corticosteroid iniection
D. A back brace
E. Acupuncture
Your Answer: D
Result: Incorrect
Explanation: ost 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. NSIDs). multidisciplinary rehabilitation. and acupuncture (all
SOR A).

Other treatments likely to be beneIicial include herbal medications, tricyclics, antidepressants,
exercise therapy, behavior therapy, massage, spinal therapy, opioids, and short-term muscle
relaxants (all SOR B). There is conIlicting data regarding the eIIectiveness oI back school, low-
level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy, short-
wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural
corticosteroid iniections (all SOR C).

6. A 45-year-old white Iemale with elevated cholesterol and coronary artery disease comes in Ior
a periodic Iasting 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 oI 70 mg/dL,
an HDL-cholesterol level oI 55 mg/dL, an alanine aminotransIerase (ALT) level oI 69 U/L (N 7
30), and an aspartate aminotransIerase (AST) level oI 60 U/L (N 925).

A. Continue the current therapy with routine monitoring
B. Decrease the dosage oI 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
Your Answer: C
Result: Incorrect
Explanation: 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 oIten, slight elevations in liver enzymes lead to unnecessary dosage
decreases, discontinuation oI statin therapy, or additional testing.

8. In a patient with chronic hepatitis B, which one oI the Iollowing Iindings suggests that the
inIection is in the active phase?

A. A normal liver biopsy
B. Detectable levels oI HBeAb
C. Detectable levels oI HBsAb
D. Elevated levels oI ALT
E. Undetectable levels oI HBV DNA
Your Answer: B
Result: Incorrect
Explanation: Chronic hepatitis B develops in a small percentage of adults who Iail to recover
Irom an acute inIection, 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
Irom one phase to the next, but reactivation Irom immune-carrier phase to immune-active phase
also can be seen.

ctive 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 HBeg. indicating high levels of HB' DN). ost patients with
chronic hepatitis B eventually transition to the inactive-carrier phase. which is
characterized by the clearance of HBeg and the development of anti-HBeg.
accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B
virus in the bloodstream.

9. 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 113) and his WBC count is 11,500/mm
3
(N
430010,800). His Iree T
4
is elevated, TSH is suppressed, and radioactive iodine uptake is
abnormally low.

Which one oI the Iollowing treatment options would be most helpIul at this time?

A. Levothyroxine (Synthroid) and NSAIDs
B. Propylthiouracil
C. Prednisone
D. NaIcillin
E. Thyroidectomy
Your Answer: C
Result: Correct
Explanation: This patient has signs and symptoms oI painIul 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 selI-limited disorder. Thyroid function
returns to normal in most patients after several weeks, and may be Iollowed by a temporary
hypothyroid state. Treatment is symptomatic. lthough NSIDs 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 Ior this problem.

10. A 60-year-old Iemale with moderate COPD presents with ongoing dyspnea in spite oI
treatment with both an inhaled long-acting -agonist and a long-acting anticholinergic agent.
Your evaluation reveals an oxygen saturation oI 88 and a PaO
2
oI 55. Echocardiography
reveals a normal eiection Iraction but moderate pulmonary hypertension.

A. No changes in the current medical regimen
B. Supplemental oxygen
C. Low-dose sildenaIil (Revatio)
D. NiIedipine (Procardia)
E. Low-dose prednisone
Your Answer: B
Result: Correct
Explanation: 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). SildenaIil and niIedipine are utilized in pulmonary arterial
hypertension, but evidence is lacking Ior their use in pulmonary hypertension associated with
chronic lung disease and/or hypoxemia. Low-dose prednisone may be a Iuture option.

1. A 48-year-old Iemale with type 2 diabetes has been hospitalized Ior 4 days with persistent
Iever. Her diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw
her 2 weeks ago in the oIIice with urinary Irequency, urgency, and dysuria. At that time a
urinalysis showed 25 WBCs/hpI, and a urine culture subsequently grew scherichia coli
sensitive to all antibiotics. She was placed on trimethoprim/sulIamethoxazole (Bactrim, Septra)
empirically, and this was continued aIter the culture results were reported.
She improved over the next week, but then developed Ilank pain, Iever to 39.5C (103.1F), and
nausea and vomiting. She was hospitalized and intravenous ceIazolin (KeIzol) and gentamicin
were started while blood and urine cultures were perIormed. This urine culture also grew coli
sensitive to the current antibiotics. Her temperature has continued to spike to 39.5C since
admission, without any change in her symptoms.

A. Add vancomycin (Vancocin) to the regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture Ior tuberculosis
E. Order CT oI the abdomen
Your Answer: C
Result: Incorrect
Explanation: Perinephric abscess is an elusive diagnostic problem that is deIined as a collection
oI pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota`s Iascia.
Mortality rates as high as 50 have been reported, usually Irom Iailure to diagnose the problem
in a timely Iashion. The diIIiculty in making the diagnosis can be attributed to the variable
constellation oI symptoms and the sometimes indolent course oI this disease. The diagnosis
should be considered when a patient has fever and persistence of flank pain.

Most perinephric inIections occur as an extension oI an ascending urinary tract inIection,
commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic
urinary tract abnormalities or diabetes mellitus have an increased risk. Clinical Ieatures may be
quite variable, and the most useIul predictive Iactor in distinguishing uncomplicated
pyelonephritis Irom 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
Iluid, enlargement oI the psoas muscle (both are highly suggestive oI the diagnosis), and
perirenal gas (which is diagnostic). The sensitivity and speciIicity oI CT is signiIicantly greater
than that oI either ultrasonography or intravenous pyelography.

Drainage, either percutaneously or surgically, along with appropriate antibiotic coverage reduces
both morbidity and mortality Irom this condition.

2. A 72-year-old Iemale sees you Ior 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 oI the Iollowing is recommended prior to surgery in this patient?

A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
Your Answer: C
Result: Incorrect
Explanation: 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.

3. You see a 9-year-old Iemale Ior evaluation oI her asthma. She and her mother report that she
has shortness oI breath and wheezing 34 times per week, which improves with use oI 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 Ieel her activities are limited by her symptoms. About
once per year she requires prednisone Ior an exacerbation, oIten triggered by a viral inIection.
Based on this inIormation you classiIy her asthma severity as:

A. intermittent
B. mild persistent
C. moderate persistent
D. severe persistent
Your Answer: A
Result: Incorrect
Explanation: The 2007 update to the guidelines Ior the diagnosis and management oI asthma
published by the National Heart, Lung, and Blood Institute outlines clear deIinitions oI asthma
severity. Severity is determined by the most severe category in which any Ieature 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.

4. Which one oI the Iollowing is Iound most consistently in patients diagnosed with irritable
bowel syndrome?

A. Passage oI blood per rectum
B. Passage oI mucus per rectum
C. Abdominal pain
D. Constipation
E. Diarrhea
Your Answer: E
Result: Incorrect
Explanation: A large review oI multiple studies identiIied abdominal pain as the most
consistent feature found in irritable bowel syndrome (IBS), and its absence makes the
diagnosis less likely. OI the symptoms listed, passage oI blood is least likely with IBS, and
passage oI mucus, constipation, and diarrhea are less consistent than abdominal pain (SOR A).

5. Which one oI the Iollowing is diagnostic Ior type 2 diabetes mellitus?

A. A Iasting 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
Your Answer: A
Result: Correct
Explanation: The American Diabetes Association (ADA) Iirst published guidelines Ior the
diagnosis oI diabetes mellitus in 1997 and updated its diagnostic criteria in 2010. With the
increasing incidence oI obesity, it is estimated that over 5 million Americans have undiagnosed
type 2 diabetes mellitus. Given the long-term risks oI microvascular (renal, ocular) and
macrovascular (cardiac) complications, clear guidelines Ior screening are critical. The ADA
recommends screening for all asymptomatic adults with a BI >25.0 kg/m who have 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 1c 6.5. a
fasting plasma glucose level 126 mg/dL. a 2-hour plasma glucose level 200 mg/dL. or. in a
symptomatic patient. a random blood glucose level 200 mg/dL. In the absence oI
unequivocal hyperglycemia, results require conIirmation by repeat testing.

6. A 62-year-old male is admitted to the hospital Ior urosepsis. His medical history is signiIicant
only Ior hypertension. On examination he has a temperature oI 36.5C (97.7F), a TSH level oI
0.2 U/mL (N 0.45.0), and a Iree T
4
level oI 0.4 ng/dL (N 0.61.5).

A. Pituitary adenoma
B. Graves` disease
C. Subacute thyroiditis
D. Subclinical hypothyroidism
E. Euthyroid sick syndrome
Your Answer: D
Result: Incorrect
Explanation: The euthyroid sick syndrome refers to alterations in thyroid function tests seen
frequently in hospitalized patients, and decreased thyroid Iunction tests may be seen early in
sepsis. These changes are statistically much more likely to be secondary to the euthyroid sick
syndrome than to unrecognized pituitary or hypothalamic disease (SOR C). Graves` disease
generally is a hyperthyroid condition associated with low TSH and elevated Iree T
4
. Subclinical
hypothyroidism is diagnosed by high TSH and normal Iree T
4
levels.
Subacute thyroiditis most oIten is a hyperthyroid condition.

7. An 8-year-old Iemale is brought to your oIIice because she has begun to limp. She has had a
Iever oI 38.8C (101.8F) and says that it hurts to bear weight on her right leg. She has no
history oI trauma.

On examination, she walks with an antalgic gait and hesitates to bear weight on the leg. Range oI
motion oI the right hip is limited in all directions and is painIul. Her sacroiliac ioint is not tender,
and the psoas sign is negative. Laboratory testing reveals an erythrocyte sedimentation rate oI 55
mm/hr (N 010), a WBC count oI 15,500/mm
3
(N 450013,500), and a C-reactiveprotein level
oI 2.5 mg/dL (N 0.51.0).

Which one oI the Iollowing will provide the most useIul diagnostic inIormation to Iurther
evaluate this patient`s problem?

A. MRI
B. CT
C. A bone scan
D. Ultrasonography
E. Plain-Iilm radiography
Your Answer: A
Result: Incorrect
Explanation: 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 Ior evaluating a limping child
when the history, physical examination, and radiographic and sonographic Iindings Iail to
localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides
excellent visualization oI ioints, soIt tissues, cartilage, and medullary bone. It is especially useIul
Ior conIirming osteomyelitis, delineating the extent oI malignancies, identiIying stress Iractures,
and diagnosing early Legg-Calve-Perthes disease. Plain Iilm radiography is oIten obtained as an
initial imaging modality in any child with a limp. However, Iilms may be normal in patients with
septic arthritis, providing a Ialse-negative result.

9. Which one oI the Iollowing is the most common cause oI recurrent and persistent acute otitis
media in children?

A. aemophilus influenzae
B. Moraxella catarrhalis
C. Penicillin-resistant $treptococcus pneumoniae
D. Pseudomonas aeruginosa
E. $taphvlococcus aureus
Your Answer: C
Result: Correct
Explanation: Streptococcu8 pneumoniae. Haemophilu8 influenzae. and Moraxella catarrhali8
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.

10. A 65-year-old asymptomatic Iemale is Iound to have extensive sigmoid diverticulosis on
screening colonoscopy. She asks whether there are any dietary changes she should make.
In addition to increasing Iiber intake, which one oI the Iollowing would you recommend?

A. Limiting intake oI dairy products
B. Limiting intake oI spicy Ioods
C. Limiting intake oI wheat Ilour
D. Limiting intake oI nuts
E. No limitations on other intake
Your Answer: E
Result: Correct
Explanation: Patients with diverticulosis should increase dietary fiber intake or take fiber
supplements to reduce progression of the diverticular disease. voidance of nuts. corn.
popcorn. and small seeds has not been shown to prevent complications of diverticular
disease.

1. Which one oI the Iollowing should be used Iirst Ior ventricular Iibrillation when an initial
deIibrillation attempt Iails?

A. Amiodarone (Cordarone)
B. Lidocaine (Xylocaine)
C. Adenosine (Adenocard)
D. Vasopressin (Pitressin)
E. Magnesium
Your Answer: A
Result: Incorrect
Explanation: For persistent ventricular fibrillation ('F). in addition to electrical
defibrillation and CPR. patients should be given a vasopressor. which can be either
epinephrine or vasopressin. Vasopressin may be substituted Ior the Iirst or second dose oI
epinephrine.

miodarone should be considered for treatment of 'F 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 Ior
the treatment oI narrow complex, regular tachycardias and is not used in the treatment oI
ventricular Iibrillation.

2. Which one oI the Iollowing is the best radiographic test Ior conIirming the diagnosis oI renal
colic?

A. A KUB radiograph
B. Ultrasonography
C. CT
D. Intravenous pyelography
E. MRI
Your Answer: D
Result: Incorrect
Explanation: CT is the gold standard for the diagnosis of renal colic. Its sensitivity and
speciIicity are superior to those oI ultrasonography and intravenous pyelography. Noncalcium
stones may be missed by plain radiography but visualized by CT. MRI is a poor tool Ior
visualizing stones.

3. A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule.
There are no previous studies available.

Which one oI the Iollowing would raise the most suspicion that this is a malignant lesion iI
Iound on the radiograph? .

A. The absence oI calciIication
B. Location above the midline oI the lung
C. A diameter oI 4 mm
D. A solid appearance
Your Answer: B
Result: Incorrect
Explanation: Pulmonary nodules are a common Iinding on routine studies, including plain chest
radiographs, and require evaluation. Radiographic Ieatures oI 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 oI 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).

4. A previously healthy 67-year-old male sees you Ior 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 oI
dyspnea, angina, syncope, or decreased exertional tolerance. An echocardiogram shows severe
aortic stenosis, with an aortic valve area oI 1 cm
2
, a mean gradiant ~40 mm Hg, and an
eiection Iraction oI 60.


A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. ReIerral Ior aortic valve replacement
E. WatchIul waiting
Your Answer: E
Result: Correct
Explanation: Watchful waiting is recommended for most patients with asymptomatic aortic
stenosis. including those with severe disease (SOR B). This is because the surgical risk oI
aortic valve replacement outweighs the approximately 1 annual risk oI sudden death in
asymptomatic patients with aortic stenosis. Peripheral o-blockers. such as prazosin. should be
avoided because of the risk of hypotension or syncope. Coronary angiography should be
reserved Ior symptomatic patients who do not have evidence oI severe aortic stenosis on
echocardiography perIormed to evaluate their symptoms, or Ior 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.

5. A 43-year-old Iemale presents to your oIIice Ior evaluation oI a chronic cough that has been
present Ior the past 6 months. She is not a smoker, and is not aware oI any exposure to
environmental irritants. She does not have any systemic complaints such as Iever or weight loss,
and does not have any symptoms oI heartburn or regurgitation. She is not on any regular
medications.

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


A. A methacholine inhalation challenge test
B. Pulmonary Iunction testing
C. CT oI the chest
D. A trial oI a proton pump inhibitor
E. 24-hour pH monitoring
Your Answer: D
Result: Correct
Explanation: Gastroesophageal reIlux disease (GERD) is one oI the most common causes oI
chronic cough. Patients with chronic cough have a high likelihood oI having GERD, even in the
absence oI gastrointestinal symptoms (level oI evidence 3). In Iact, 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 oI acidic gastric contents into the larynx and upper bronchial tree.

The American College oI Chest Physicians states that patients with a chronic cough should be
given a trial of antisecretory therapy (SOR B). ggressive 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 oI response to bronchodilator therapy. Chest CT and pulmonary
Iunction tests are not indicated given the lack oI Iindings Irom the history, physical examination,
and chest Iilm to suggest underlying pulmonary disease. An initial therapeutic trial oI proton
pump inhibitors is Iavored over 24-hour pH monitoring because it is less uncomIortable to the
patient and has a better clinical correlation.

6. A 27-year-old white male construction worker suIIers Irom severe plaque-type psoriasis that
has required systemic therapy. Which one oI the Iollowing is associated with this condition?

A. A reduced overall risk oI cardiovascular mortality
B. A decreased risk oI skin cancer with successIul treatment
C. A low likelihood oI recurrence with successIul treatment
D. An increased risk Ior the condition in the children oI aIIected individuals
E. Low body mass index and diIIiculty maintaining weight
Your Answer: D
Result: Correct
Explanation: Psoriasis is a genetic inIlammatory condition that has been associated with a
significant risk of cardiovascular morbidity and mortality. Children oI patients with the
disorder are at increased risk. This is especially true iI both parents have the disorder. LiIe
expectancy is somewhat reduced in patients with severe psoriasis, particularly iI 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.

7. A 29-year-old gravida 2 para 1 presents Ior pregnancy conIirmation. Her last menstrual period
began 6 weeks ago. Her medical history is signiIicant Ior hypothyroidism, which has been well-
controlled on levothyroxine (Synthroid), 150 g daily, Ior the past 2 years.

Which one oI the Iollowing would be the most appropriate next step in the treatment oI this
patient`s hypothyroidism during her pregnancy?

A. Add liothyronine (Cytomel) to her current regimen
B. Decrease the levothyroxine dosage
C. Increase the levothyroxine dosage
D. Continue her current regimen
Your Answer: C
Result: Correct
Explanation: Maternal hypothyroidism can have serious eIIects on the Ietus, so thyroid
dysIunction should be treated during pregnancy. Because oI 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.

8. A 37-year-old recreational skier is unable to liIt his right arm aIter Ialling on his right side
with his arm elevated. Radiographs oI the right shoulder are negative, but diagnostic
ultrasonography shows a complete rotator cuII tear.
Which one oI the Iollowing is most accurate with regard to treatment?

A. Surgery is most likely to be beneIicial iI perIormed less than 6 weeks aIter the iniury
B. Treatment with NSAIDs Ior 3 months is recommended beIore Iurther intervention
C. Subacromial corticosteroid iniections will provide Iunctional and symptomatic relieI in the
maiority oI patients
D. Surgical repair oI rotator cuII tears to restore Iunction is necessary only in geriatric patients
E. Therapeutic ultrasound oI the shoulder will make the condition tolerable during spontaneous
healing
Your Answer: B
Result: Incorrect
Explanation: 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 beneIit.

NSAIDs are used Ior analgesia. Their beneIit has not been shown to exceed that oI other simple
analgesics, and the side-eIIect proIile 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 beneIit Irom range-oI-motion
exercises and exercises to strengthen the involved muscle groups.

9. A 69-year-old Iemale presents with postmenopausal bleeding. You consider whether to begin
your evaluation with vaginal probe ultrasonography to assess the thickness oI her endometrium.
In evaluating the useIulness oI this test to either support or exclude a diagnosis oI endometrial
cancer, which one oI the Iollowing statistics is most useIul?

A. Likelihood ratio
B. Number needed to treat
C. Prevalence
D. Incidence
E. Relative risk
Your Answer: A
Result: Correct
Explanation: There has been a large increase in the number oI 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 Ior harm. In addition, the characteristics oI a particular test and
how the results will aIIect management and outcomes must be considered. The statistics that are
clinically useIul Ior 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, iI the patient`s endometrial stripe is ~25
mm, the likelihood ratio is 15.2 and her post-test probability oI endometrial cancer is 63.
However, iI it is < 4 mm, the likelihood ratio is 0.02 and her post-test probability oI endometrial
cancer is 0.2.

The number needed to treat is useIul Ior evaluating data regarding treatments, not diagnosis.
Prevalence is the existence oI a disease in the current population, and incidence describes the
occurrence oI new cases oI disease in a population over a deIined time period. The relative risk is
the risk oI an event in the experimental group versus the control group in a clinical trial.

10. A 72-year-old male with a history oI hypertension and a previous myocardial inIarction is
diagnosed with heart Iailure. Echocardiography reveals systolic dysIunction, and recent
laboratory tests indicated normal renal Iunction, with a serum creatinine level oI 1.1 mg/dL (N
1.5), a sodium level oI 139 mEq/L (N 136145), and a potassium level oI 3.5 mEq/L (N 3.5
5.0). He is currently asymptomatic.
Which one oI the Iollowing medications would be the best choice Ior initial management in this
patient?

A. Furosemide (Lasix)
B. Isosorbide dinitrate (Isordil)
C. Spironolactone (Aldactone)
D. Digoxin
E. Lisinopril (Prinivil, Zestril)
Your Answer: E
Result: Correct
Explanation: CE 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 Iailure patients. No ACE inhibitor has been shown to be superior to another, and no
study has Iailed to show beneIit Irom an ACE inhibitor (SOR A).

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

diuretic such as furosemide may be indicated to relieve congestion in symptomatic
patients. ldosterone 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
inIarction who develop symptomatic systolic dysIunction 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.

2. A 55-year-old Iemale with diabetes mellitus, hypertension, and hyperlipidemia presents to
your oIIice Ior routine Iollow-up. Her serum creatinine level is 1.5 mg/dL (estimated creatinine
clearance 50 mL/min).
Which one oI the Iollowing diabetes medications would be contraindicated in this patient?

A. MetIormin (Glucophage)
B. Exenatide (Byetta)
C. Acarbose (Precose)
D. Insulin glargine (Lantus)
E. Pioglitazone (Actos)
Your Answer: A
Result: Correct
Explanation: etformin is contraindicated in patients with chronic kidney disease. It should
be stopped in Iemales 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. carbose
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.

3. A 54-year-old Iemale presents with a 2-month history oI intense vulvar itching that has not
improved with topical antiIungal treatment. On examination you note areas oI white, thickened,
excoriated skin. Concerned about malignancy you perIorm punch biopsies, which reveal lichen
sclerosus.

The treatment oI choice Ior this condition is topical application oI:

A. coniugated estrogens
B. Iluorinated corticosteroids
C. petrolatum
D. 2 testosterone
E. Iluorouracil (EIudex)
Your Answer: A
Result: Incorrect
Explanation: 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 Iound to be no more eIIective
than petrolatum. Fluorouracil is an antineoplastic agent most Irequently used to treat actinic skin
changes or superIicial basal cell carcinomas.

4. StaII members oI an assisted-living Iacility ask Ior your advice regarding aerobic exercise
programs Ior their older residents. The evidence is greatest Ior which one oI the Iollowing
beneIits oI physical activity in the elderly?

A. Maintaining weight aIter weight loss
B. Improving quality oI sleep
C. Increasing bone density
D. Reducing the risk oI Ialls
Your Answer: C
Result: Incorrect
Explanation: 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.

5. The U.S. Preventive Services Task Force (USPSTF) has stated that the potential
cardiovascular beneIits oI daily aspirin use outweigh the potential harms oI gastrointestinal
hemorrhage in certain populations. The USPSTF currently recommends daily aspirin use Ior
which one oI the Iollowing populations?

A. Males 2544 years oI age
B. Males over 80 years oI age
C. Females 2544 years oI age
D. Females over 45 years oI age
E. Females 5579 years oI age
Your Answer: E
Result: Correct
Explanation: The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin
use for males 45-79 years oI age when the potential beneIit oI a reduction in myocardial
inIarction outweighs the potential harm oI an increase in gastrointestinal hemorrhage, and for
females 55-79 years of age when the potential beneIit oI a reduction in ischemic strokes
outweighs the potential harm oI an increase in gastrointestinal hemorrhage (SOR A, USPSTF A
Recomendation).

The USPSTF has concluded that the current evidence is insuIIicient to assess the balance oI
beneIits and harms oI aspirin Ior cardiovascular disease prevention in men and women 80 years
oI age or older (USPSTF I Recommendation). It recommends against the use oI aspirin Ior stroke
prevention in women younger than 55, and Ior myocardial inIarction prevention in men younger
than 45 (USPSTF D Recommendation).

6. You see a newly adopted 5-month-old Ior his Iirst well child visit. The parents ask when the
child can sit in a saIety seat in the car Iacing Iorward.

You would advise that the child should Iace rearward until he is at least:

A. 12 months oI age AND weighs 20 lb
B. 15 months oI age AND weighs 25 lb
C. 15 months oI age OR weighs 25 lb
D. 18 months oI age AND weighs 30 lb
E. 18 months oI age OR weighs 30 lb
Your Answer: D
Result: Incorrect
Explanation: II a child Iaces Iorward in a crash, the Iorce is distributed via the harness system
across the shoulders, torso, and hips, but the head and neck have no support. Without support,
the inIant`s head moves rapidly Iorward in Ilexion while the body stays restrained, causing
potential iniury to the neck, spinal cord, and brain. In a rear-Iacing position, the Iorce oI the
crash is distributed evenly across the baby`s torso, and the back oI the child saIety 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 Iace rearward, and a 6-month-old child who
weighs 21 lb should also Iace rearward.

7. Which one oI the Iollowing is most appropriate Ior the treatment oI Iibromyalgia syndrome?

A. Metaxalone (Skelaxin)
B. Hydrocodone
C. Naproxen
D. Tizanidine (ZanaIlex)
E. Amitriptyline
Your Answer: E
Result: Correct
Explanation: A meta-analysis oI antidepressant medications Ior the treatment oI Iibromyalgia
syndrome concluded that short-term use oI 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 Ior the management oI Iibromyalgia syndrome perIormed Ior the
European League Against Rheumatism recommends heated pool treatment with or without
exercise, tramadol Ior the management oI pain, and certain antidepressants, including
amitriptyline. Evidence Ior long-term eIIectiveness oI antidepressants in Iibromyalgia syndrome
is lacking, however.

8. In the secondary prevention oI ischemic cardiac events, which one oI the Iollowing is most
likely to be beneIicial in a 68-year-old Iemale with known coronary artery disease and preserved
leIt ventricular Iunction?

A. ACE inhibitors
B. Hormone therapy
C. Calcium channel blockers
D. Vitamin E
E. Oral glycoprotein IIb/IIIa receptor inhibitors
Your Answer: A
Result: Correct
Explanation: Secondary prevention oI cardiac events consists oI long-term treatment to prevent
recurrent cardiac morbidity and mortality in patients who have either already had an acute
myocardial inIarction or are at high risk because oI severe coronary artery stenosis, angina, or
prior coronary surgical procedures. Effective treatments include aspirin. -blockers after
myocardial infarction. CE 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 oI 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
inIarction. Contrary to decades oI large observational studies, multiple randomized, controlled
trials show no cardiac beneIit Irom hormone therapy in postmenopausal women.

9. A chest radiograph oI the driver oI an automobile involved in a head-on collision shows a
widened mediastinum. This suggests:

A. myocardial contusion
B. spontaneous rupture oI the esophagus
C. rupture oI a bronchus
D. partial rupture oI the thoracic aorta
E. acute heart Iailure
Your Answer: D
Result: Correct
Explanation: Deceleration-type blows to the chest can produce partial or complete
transection of the aorta. 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 Iailure, myocardial contusion).

10. The most common initial symptom oI Hodgkin lymphoma is:

A. unexplained Iever
B. night sweats
C. weight loss
D. painless lymphadenopathy
E. cough
Your Answer: D
Result: Correct
Explanation: The most common presenting symptom of Hodgkin lymphoma is painless
lymphadenopathy. Approximately one-third oI patients with Hodgkin lymphoma present with
unexplained Iever, 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.

1. Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be
problematic in elderly patients because they can:

A. decrease blood pressure
B. cause bradycardia
C. worsen existing urinary obstruction
D. enhance the anticholinergic eIIects oI other medications
E. enhance the sedative eIIects oI other medications
Your Answer: D
Result: Incorrect
Explanation:
Sympathomimetic agents can elevate blood pressure and intraocular pressure. may worsen
existing urinary obstruction, and adversely interact with -blockers, methyldopa, tricyclic
antidepressants, and oral hypoglycemic agents and MAOIs. They also speed up the heart rate.
First-generation nonprescription antihistamines can enhance the anticholinergic and sedative
eIIects oI other medications.

3. A 70-year-old white male presents with Iatigue, weakness, and Ioot paresthesias. His
hemoglobin level is 10.5 g/dL (N 12.617.4). His peripheral smear is shown in Figure 2.


A. Iron deIiciency anemia
B. Vitamin B
12
deIiciency anemia
C. Hemolytic anemia
D. Acute myelogenous leukemia
E. Chronic myelogenous leukemia
Your Answer: B
Result: Correct
Explanation:
The blood smear shows a hypersegmented polymorphonuclear (PMN) white blood cell,
typical oI vitamin B
12
deficiency with pernicious anemia. The anemia is oI the macrocytic type
(MCV ~100 m ). There is no evidence oI hemolysis or leukemia. While iron deIiciency anemia
can be a coexisting problem, the hypersegmented PMN is classic Ior vitamin B
12
deIiciencyIt is
important to note that elderly patients with vitamin B
12
deIiciency may have neurologic signs and
symptoms beIore developing hematologic abnormalities.

4. A 3-year-old Iemale is brought to your oIIice with a 3-hour history oI skin lesions that are
prominent, warm, papular, and serpiginous (see Figure 3). Which one oI the Iollowing is the
most likely cause oI these lesions?

A. Heredity
B. Physical abuse
C. InIection
D. A topical agent
E. An oral medication
Your Answer: B
Result: Incorrect
Explanation:
cute urticaria occurs when an allergen activates mast cells in the skin, and is commonly
caused by oral and parenteral drugs, Iood, and, less Irequently, inIections. Topical agents and
physical abuse are unlikely to present in this manner, and hereditary angioedema is more a
systemic illness than a skin disorder.
5. An 84-year-old male is walking across the street and has to hurry to avoid oncoming traIIic.
He suddenly develops extreme pain in his knee and Ialls to the street, and has to be carried to the
sidewalk.

The Iollowing day he comes to the emergency department. He is comIortable when placed in a
knee immobilizer, but is very tender iust above the patella. He can bend his knee, but when he
tries to straighten his leg it is so weak that he cannot move it at all. Radiographs oI the knee are
shown in Figure 4.

What is the most likely diagnosis?

A. Patellar tendon rupture
B. Quadriceps tendon rupture
C. Tibial plateau Iracture
D. Patellar subluxation
E. Lumbar radiculopathy
Your Answer: A
Result: Incorrect
Explanation:
Quadriceps tendon rupture can be partial or complete. When complete. as in this case. the
patient has no ability to straighten the leg actively. similar pattern is seen with patellar
tendon rupture. but in this situation the patella is retracted superiorly by the quadriceps.
Quadriceps rupture often produces a sulcus sign. a painful indentation just above the
patella. II the patient is not seen until some time has passed since the iniury, the gap in the
quadriceps can Iill with blood, so that it is no longer palpable. The clinical examination is usually
diagnostic Ior this condition, but this patient`s radiograph shows some interesting Iindings,
especially on the lateral view. A small shard oI the patella has been pulled oII and has migrated
superiorly with the quadriceps. The hematoma Iilling the gap in the quadriceps is the same
density as the muscle, but wrinkling oI the Iascia over the distal quadriceps provides a clue that it
is no longer attached to the superior margin oI the patella.
Tibial plateau Iractures are intra-articular, so they produce a large hemarthrosis. They are evident
on a radiograph in almost all cases. Pain inhibits movement oI the knee, but the extreme
weakness evident in this case would not be seen. Patellar subluxation is obvious acutely. when
the patella is displaced laterally. ore often. the patient comes in after the patella has
relocated. Findings then include tenderness along the medial retinaculum. sometimes a
joint effusion. and a positive apprehension sign when the patella is pushed gently laterally.
Lumbar radiculopathy can cause weakness oI the quadriceps iI it involves the third lumbar root,
but complete paralysis would not occur. Other Iindings would include lumbar pain radiating to
the leg, possibly with paresthesias and Iasciculations iI there were signiIicant neurologic
impairment.

6. A 25-year-old Iemale is in active labor at term and is dilated to 7 cm. An electronic Ietal
monitoring tracing is shown in Figure 5.

Which one oI the Iollowing is a possible etiology Ior this Ietal heart rate pattern?

A. Normal progress oI labor
B. Maternal Iever
C. EIIects oI epidural anesthesia
D. Post-dates pregnancy
E. Umbilical cord prolapse
Your Answer: B
Result: Correct
Explanation: This tracing shows fetal tachycardia. defined as a baseline fetal heart rate
>160 beats/min for at least 15 minutes. This is considered a nonreassuring pattern. Causes of
fetal tachycardia include maternal fever. fetal hypoxia. hyperthyroidism. maternal or fetal
anemia. medication effects of parasympatholytic or sympathomimetic drugs.
chorioamnionitis. fetal tachyarrhythmia. and prematurity. Fetal tachycardia is not a sign oI
normal progression oI labor. Epidural anesthesia, post-dates pregnancy, and umbilical cord
prolapse would all be causes oI Ietal bradycardia.

7. A hospitalized 55-year-old male has developed the tachyarrhythmia shown in Figure 6. He is
alert and denies chest pain, although he complains oI palpitations and is mildly dyspneic since
the onset oI this sustained dysrhythmia. His blood pressure is 116/76 mm Hg and pulse oximetry
shows 93 saturation on 2L oI oxygen.

Which one oI the Iollowing would be the best treatment Ior this patient?

A. Synchronized DC cardioversion
B. Metoprolol (Lopressor)
C. Amiodarone (Cordarone)
D. Adenosine (Adenocard)
E. Atropine
Your Answer: A
Result: Incorrect
Explanation: The patient has paroxysmal supraventricular tachycardia (PSVT) with a heart
rate oI approximately 170 beats/min. Intravenous adenosine is the treatment of choice for
PS'T. Because the patient is hemodynamically stable, DC cardioversion is not indicated.
Metoprolol may slow the heart rate but likely will not convert it to sinus rhythm. Amiodarone is
indicated Ior hemodynamically stable ventricular tachycardia. Atropine is contraindicated in this
or any other tachyarrhythmia.

9. A 90-year-old Iemale nursing-home patient has a 1.52.0-cm lesion on her Iace (shown in
Figure 8). She states that the 'spot has been present Ior years and that it doesn`t bother her.
Closer examination reveals a Ilat maculopapular lesion with varying colors and an irregular
border.


A. Actinic keratosis
B. Metastatic breast carcinoma
C. Seborrheic keratosis
D. Lentigo maligna melanoma
E. Basal cell carcinoma
Your Answer: D
Result: Correct
Explanation: This patient has a malignant melanoma, oIten called lentigo maligna melanoma.
These lesions typically appear during the seventh or eighth decade oI liIe, and are most oIten
located on the Iace. This patient's age, health status, and wishes must be considered in any
treatment plans. The other skin lesions listed can be seen in this age group, but they are easily
distinguished Irom this malignant lesion.

10. A 5-year-old male Iell while playing and complained that his wrist hurt. The next day he is
brought to your oIIice because he reIuses to use his arm.

Which one oI the Iollowing best describes the condition seen in the radiographs shown in Figure
9?

A. A normal appearance
B. A radial Iracture
C. An ulnar Iracture
D. A radioulnar Iracture
E. Indeterminate result
Your Answer: A
Result: Incorrect
Explanation: Even though they are the most common Iracture in this age group, radial fractures
can be missed by clinicians. The bend in the cortex of the distal radius indicates the fracture.
Sometimes reIerred to as a buckle or torus Iracture, it will heal with almost any choice oI
treatment. Most clinicians opt Ior casting to reduce the chance oI reiniury during the Iirst Iew
weeks oI healing, but the parents` preIerences in this regard are important. Some pediatric long-
bone Iractures involve growth plates, and the results can be indeterminate, requiring either more
advanced imaging or comparison views oI the opposite limb.

1. A 91-year-old white male presents with a 6-month history oI a painless ulcer on the dorsum oI
the proximal interphalangeal ioint oI the second toe. Examination reveals a hallux valgus and a
rigid hammer toe oI the second digit. His Ioot has mild to moderate atrophic skin changes, and
the dorsal and posterior tibial pulses are absent.

Appropriate treatment includes which one oI the Iollowing?

A. Surgical correction oI the hammer toe
B. Custom-made shoes to protect the hammer toe
C. Bunionectomy
D. A metatarsal pad
Your Answer: B
Result: Correct
Explanation: 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 oI 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 oI Ioam
rubber placed over the hammer toe. Metatarsal pads are not useIul in the treatment oI hallux
valgus and a rigid hammer toe.

2. Hantavirus pulmonary syndrome results Irom exposure to the excreta oI:

A. migratory Iowl
B. bats
C. parrots
D. mice
E. turtles
Your Answer: B
Result: Incorrect
Explanation: Hantavirus pulmonary syndrome results from exposure to rodent droppings.
mainly the deer mouse in the southwestern U.S. About 10 oI deer mice are estimated to be
inIected with hantavirus. In other parts oI the country the virus is carried by the white-Iooted
mouse. While other rodents are carriers oI the virus, they are less likely to live near dwellings,
and populations are less dense.

3.
A 28-year-old white Iemale consults you with a complaint oI 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 proIile are also normal.

The next step in her workup should be:

A. endometrial aspiration
B. dilatation and curettage
C. LH and FSH assays
D. administration oI estrogen
E. cyclic administration oI progesterone Ior 3 months
Your Answer: A
Result: Incorrect
Explanation: bnormal uterine bleeding is a relatively common disorder that may be due to
Iunctional disorders oI the hypothalamus, pituitary, or ovary, as well as uterine lesions. However,
the patient who is younger than 30 years oI age will rarely be Iound to have a structural uterine
deIect. 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.

6. A 10-week-old term male inIant is brought to your oIIice with a 2-day history oI diIIiculty
breathing. He has been healthy since birth, with the exception oI a 3-day episode oI wheezing
and rhinorrhea 3 weeks ago. Your initial examination shows an alert inIant with increased work
of breathing. rhinorrhea. and wheezing. His oxygen saturation is 93 and his temperature is
38.4C (101.1F).


A. Antigen testing or another rapid assay
B. A baseline chest radiograph
C. A trial oI nebulized albuterol (AccuNeb)
D. Advising the parents that the child can saIely be returned to day care tomorrow
Your Answer: B
Result: Incorrect
Explanation: The American Academy oI Pediatrics guideline on the diagnosis and management
oI bronchiolitis recommends against the use of laboratory or radiographic studies to make
the diagnosis, although additional testing may be appropriate iI there is no improvement.
Bronchiolitis can be caused by a number oI diIIerent viruses, alone or in combination, and the
knowledge gained Irom virologic testing rarely inIluences management decisions or outcomes
Ior the vast maiority oI children.

While the guideline does not support routine use oI bronchodilators in the management oI
bronchiolitis, it does allow Ior 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 aIIect the course oI bronchiolitis with respect to
outcomes.

The guideline places considerable emphasis on hygienic practices, including the use oI alcohol-
based hand sanitizers beIore and aIter contact with the patient or inanimate obiects in the
immediate vicinity. Education oI the Iamily about hygienic practices is recommended as well.
Returning the child to day care the next day is potentially harmIul.

8. The FDA recommends that over-the-counter cough and cold products not be used in children
below the age oI:

A. 1 year
B. 2 years
C. 3 years
D. 4 years
E. 5 years
Your Answer: B
Result: Correct
Explanation: In 2008 the FDA issued a public health advisory Ior 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 liIe-threatening side
eIIects can occur Irom such use. These products include decongestants, expectorants,
antihistamines, and antitussives.

9. In a patient with hyperuricemia who has experienced an attack oI gout, which one oI the
Iollowing is LEAST likely to precipitate another gout attack?

A. Red meat
B. Milk
C. SeaIood
D. Nuts
E. Beans
Your Answer: B
Result: Correct
Explanation: Reducing consumption oI red meat, seaIood, and alcohol may help reduce the risk
oI a gout attack. Dairy products. in contrast to other foods high in protein. decrease the risk
of another attack. Nuts and beans are high in purines and will worsen gout.

A A shave blopsv
8 Lxclslon wlLh a 1mm maraln
C Wlde exclslon wlLh a 1cm maraln
u Wlde exclslon wlLh a 1cm maraln
L Lxclslon wlLh senLlnel node dlssecLlon
Your Answer: C
Result: Incorrect
Explanation: The diagnosis of melanoma should be made by simple excision with clear
margins. A shave biopsy should be avoided because determining the thickness oI the lesion is
critical Ior staging. Wide excision with or without node dissection is indicated for confirmed
melanoma. depending on the findings from the initial excisional biopsy.

Whlch one of Lhe followlna ls Lrue reaardlna Lhe LreaLmenL of aenerallzed anxleLv dlsorder?

A CoanlLlvebehavloral Lherapv has been shown Lo be aL leasL as effecLlve as pharmacoloalc Lherapv
8 8usplrone (8uSpar) ls as effecLlve as SS8l Lherapv for paLlenLs wlLh comorbld depresslon
C 8enzodlazeplnes are no more effecLlve Lhan placebo
u uuloxeLlne (CvmbalLa) ls no more effecLlve Lhan placebo
L LsclLalopram (Lexapro) ls no more effecLlve Lhan placebo
Your Answer: A
Result: Correct
Explanation: Cognitive-behavioral therapy has been shown to be at least as effective as
medication for treatment of generalized anxiety disorder (GD). but with less attrition and
more durable effects. Many SSRIs and SNRIs have proven eIIective Ior GAD in clinical trials,
but only paroxetine, escitalopram, duloxetine, and venlaIaxine are approved by the FDA Ior this
indication. Benzodiazepines have been widely used because oI their rapid onset oI action and
proven eIIectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneIicial
than benzodiazepine or buspirone therapy Ior patients with GAD and comorbid depression.

A monLhold male presenLs wlLh a hlsLorv of a fever up Lo 3C (11l) pulllna aL boLh ears
dralnaae from hls rlahL ear and a poor appeLlLe followlna several davs of nasal conaesLlon 1hls ls hls
flrsL eplsode of acuLe lllness and he has no hlsLorv of drua allerales

1he fever ls conflrmed on examlnaLlon and Lhe chlld ls found Lo be fussv buL can be dlsLracLed Pe ls
eaLlna adequaLelv and shows no slans of dehvdraLlon oslLlve flndlnas lnclude mlld nasal conaesLlon a
purulenL dlscharae from Lhe rlahL audlLorv canal and a red bulalna lmmoblle Lvmpanlc membrane ln
Lhe lefL audlLorv canal

Whlch one of Lhe followlna would be flrsLllne LreaLmenL for Lhls paLlenL?

A CefLrlaxone (8ocephln)
8 Amoxlclllln/clavulanaLe (AuamenLln)
C Amoxlclllln
u AzlLhromvcln (ZlLhromax)
L enlclllln vk
Your Answer: C
Result: Correct
Explanation: This patient has acute bilateral otitis media, with presumed tympanic membrane
perIoration, and qualiIies by any criterion Ior treatment with antibiotics. moxicillin. 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 ineIIective because oI 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.

3 An asvmpLomaLlc 6vearold male sees vou for a healLh malnLenance vlslL Pe ls a former claareLLe
smoker buL qulL vears aao

Accordlna Lo Lhe uS revenLlve Servlces 1ask lorce evldence shows LhaL Lhe poLenLlal beneflL exceeds
Lhe rlsk for whlch one of Lhe followlna screenlna LesLs ln Lhls paLlenL?

A A chesL radloaraph
8 Abdomlnal ulLrasonoaraphv
C CphLhalmlc LonomeLrv
u A prosLaLespeclflc anLlaen level
L An LkC
Your Answer: A
Result: Incorrect
Explanation: The U.S. Preventive Services Task Force (USPSTF) recommends one-time
screening for abdominal aortic aneurysm () by ultrasonography in men aged 65-75
who have ever smoked (SOR B, USPSTF B Recommendation). The USPSTF Iound good
evidence that screening these patients Ior AAA and surgical repair oI large AAAs (>5.5 cm)
leads to decreased AAA-speciIic mortality. There is good evidence that abdominal
ultrasonography, perIormed in a setting with adequate quality assurance (i.e., in an accredited
Iacility with credentialed technologists), is an accurate screening test Ior AAA. There is also
good evidence oI important harms Irom screening and early treatment, including an increased
number oI operations, with associated clinically signiIicant morbidity and mortality, and short-
term psychological harms. Based on the moderate magnitude oI net beneIit, the USPSTF
concluded that the beneIits oI screening Ior AAA in men aged 6575 who have ever smoked
outweighs the potential harm.

While they may be considered Ior making the diagnosis in patients who have symptoms, none oI
the other tests listed have evidence to support a net beneIit Irom their use as routine screening
tools in patients like the one described here.

6 A 3vearold hvperLenslve male has had Lwo prevlous mvocardlal lnfarcLlons ln splLe of hls besL
efforLs he has noL achleved slanlflcanL welahL loss and he flnds lL dlfflculL Lo follow a hearLhealLhv dleL
Pe Lakes rosuvasLaLln (CresLor) ma/dav and hls lasL llpld proflle showed a LoLal cholesLerol level of
1 ma/dL a Lrlalvcerlde level of 19 ma/dL an PuLcholesLerol level of 43 ma/dL and an LuL
cholesLerol level of 11 ma/dL

Whlch one of Lhe followlna would be Lhe mosL approprlaLe chanae ln manaaemenL?

A lncrease Lhe rosuvasLaLln dosaae
8 Add aLorvasLaLln (LlplLor)
C Add nlacln
u Add fenoflbraLe (Llpofen 1rlcor)
L Add ezeLlmlbe (ZeLla)
Your Answer: E
Result: Incorrect
Explanation: This patient`s goal LDL-cholesterol level is 70 mg/dL, and he is not at the
maximum dosage oI a potent statin. There is no data that shows that adding a diIIerent statin will
be beneIicial, and outcomes data Ior 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.

Screenlna for colon cancer would be recommended for whlch one of Lhe followlna paLlenLs?

A A 3vearold male whose moLher was dlaanosed wlLh colon cancer aL aae 3
8 A 4vearold female whose moLher was dlaanosed wlLh colon cancer aL aae 34
C A 44vearold female whose faLher had a Lubular adenoma 1 cm ln slze removed durlna colonoscopv
aL aae 3
u A 46vearold male whose paLernal uncle was dlaanosed wlLh colon cancer aL aae 31
L A 4vearold female whose faLher was dlaanosed wlLh colon cancer aL aae 4
Your Answer: B
Result: Correct
Explanation: 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 Ior these persons is three to Iour times
that oI 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 oI the guidelines on screening Ior CRC published by the American College oI
Gastroenterology no longer recommends earlier screening Ior patients who have a single Iirst
degree relative with CRC diagnosed at 60 years oI age or aIter. Another change in this guideline
is that an increased level oI screening is no longer recommended Ior a simple Iamily history oI
adenomas in a Iirst degree relative.

A hemoalobln A
1c
of would correspond Lo whlch one of Lhe followlna mean (averaae) plasma
alucose levels?

A 16 ma/dL
8 134 ma/dL
C 1 ma/dL
u 1 ma/dL
L 4 ma/dL
Your Answer: D
Result: Incorrect
Explanation: A hemoglobin A
1c
(HbA
1c
) oI 6.0 correlates with a mean plasma glucose level oI
126 mg/dL or 7.0 1c 1c mmol/dL.
rough guide for estimating average plasma glucose levels assumes that an
1c
of 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 HbA
1c
oI 7.0 is thereIore roughly
equivalent to an average glucose level oI 150 mg/dL, and an HbA
1c
oI 8.0 translates to an
average glucose level oI 180 mg/dL.

9 A 3vearold male ls brouahL Lo Lhe emeraencv deparLmenL wlLh shorLness of breaLh chesL
LlahLness Lremulousness and dlaphoresls Aslde from Lachvpnea Lhe phvslcal examlnaLlon ls normal
ArLerlal blood aases on room alr show a pC
of 9 mm Pa (n 1) a pCC
of 4 mm Pa (n 343)
and a pP of 3 (n 44)
1he mosL llkelv cause of Lhe paLlenL's blood aas abnormallLles ls

A carbon monoxlde polsonlna
8 anxleLv dlsorder wlLh hvpervenLllaLlon
C an acuLe exacerbaLlon of asLhma
u pulmonarv embolus
L pneumoLhorax
Your Answer: D
Result: Incorrect
Explanation: The elevated pH. normal oxygen saturation. and low pCO
2
are characteristic
of acute respiratory alkalosis. as seen with acute hyperventilation states. In patients with a
pulmonary embolism. pO
2
and pCO
2
are decreased. while the pH is elevated. indicating the
acute nature of the disorder. With the other diagnoses, Iindings on the physical examination
would be diIIerent 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 signiIicant physical Iindings including tachycardia, hypotension, and
decreased mental activity.

1. A 60-year-old Iemale receiving home hospice care was taking oral morphine, 15 mg every 2
hours, to control pain. When this was no longer eIIective, she was transIerred to an inpatient
Iacility Ior pain control. She required 105 mg oI morphine in a 24-hour period, so she was started
on intravenous morphine, 2 mg/hr with a bolus oI 2 mg, and was well controlled Ior 5 days.
However, her pain has worsened over the past 2 days.

Which one oI the Iollowing is the most likely cause oI this patient`s increased pain?

A. An inadequate initial morphine dose
B. Addiction to morphine
C. Pseudoaddiction to morphine
D. Physical dependence on morphine
E. Tolerance to morphine
Your Answer: A
Result: Incorrect
Explanation: 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 oI unrelieved pain. Physical dependence is seen with abrupt narcotic withdrawal.

3. The mother oI an 8-year-old Iemale is concerned about purple 'warts on her daughter`s
hands. The mother explains that the lesions started a Iew months ago on the right hand along the
top oI most oI the knuckles and interphalangeal ioints, and she has recently noticed them on the
leIt hand. The child has no other complaints and the mother denies any unusual behaviors. A
physical examination is unremarkable except Ior the slightly violaceous, Ilat-topped lesions the
mother described.

What is the most likely cause Ior this patient`s Iinger lesions?

A. Dermatomyositis
B. Aggressive warts
C. Rubbing/wringing oI the hands
D. Bulimia nervosa
E. Child abuse
Your Answer: C
Result: Incorrect
Explanation: One oI the most characteristic Iindings 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.

4. A 20-year-old patient comes to the emergency department complaining oI shortness oI 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 oI the Iollowing would be the most appropriate initial treatment?

A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion
Your Answer: C
Result: Correct
Explanation: fter 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. II conversion does not occur, a 12-mg dose should be given. This dose may be repeated
once. II the patient is unstable, immediate synchronized cardioversion should be administered.

5. Which one oI the Iollowing is true regarding the risk oI inducing cancer with CT scanning?

A. CT oI the chest is associated with a greater risk than CT oI the head
B. The risk increases with age at the time oI the scan
C. Males have a greater risk oI ultimately developing CT-induced lung cancer than Iemales
D. Current techniques with rapid scanners make the risk comparable to that associated with
standard radiographs oI the same area
E. The risk in neonates is markedly reduced because oI the eIIiciency oI DNA repair processes at
this age
Your Answer: B
Result: Incorrect
Explanation: 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 liIetime
risk oI developing cancer aIter radiation exposure, and CT imaging carries substantially more
risk than plain radiographs oI the same area. Women are at greater risk Ior developing lung
cancer aIter a chest CT than men, and CT also increases their risk oI developing breast cancer.

8. A patient is sent to you by his employer aIter Ialling down some steps and twisting his ankle
and Ioot. Which one oI the Iollowing would be the most appropriate reason to obtain Ioot or
ankle radiographs?

A. Notable swelling and discoloration over the anterior taloIibular ligament
B. A complaint oI marked pain with weight bearing as he walks into the examining room
C. Pain in the maleolar zone and bone tenderness oI the posterior medial malleolus
D. The absence oI passive plantar Ioot Ilexion when the calI is squeezed (Thompson test)
Your Answer: C
Result: Correct
Explanation: The Ottawa ankle and Ioot rules are prospectively validated decision rules that help
clinicians decrease the use oI radiographs Ior Ioot and ankle iniuries without increasing the rate
oI missed Iracture. The rules apply in the case oI blunt trauma, including twisting iniuries, Ialls,
and direct blows.

ccording 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.

positive Thompson sign. seen with chilles tendon rupture. is the absence of passive
plantar foot flexion when the calf is squeezed.

9. A 77-year-old white male complains oI urinary incontinence oI 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 oI Iever or dysuria. He underwent transurethral
resection oI the prostate (TURP) Ior 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 Iound with post-void catheterization.

Which one oI the Iollowing is the most likely cause oI this patient`s incontinence?

A. Detrusor instability
B. Urinary tract inIection
C. OverIlow
D. Fecal impaction
E. Recurrent bladder outlet obstruction
Your Answer: C
Result: Incorrect
Explanation: 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.

InIection is unlikely as the cause oI persistent incontinence in this patient in the absence oI Iever
or symptoms oI urinary tract inIection. OverIlow is unlikely in the absence oI residual urine.
Impaction is a relatively rare cause oI urinary incontinence, and associated Iindings would be
present on rectal examination. Normalization oI the urinary stream and the absence oI residual
urine reduce the likelihood oI recurrent obstruction. The prostate would be expected to remain
enlarged on rectal examination aIter transurethral resection oI the prostate (TURP).

10. A 47-year-old male is preparing Ior a 3-day trip to central Mexico to present the keynote
address Ior an international law symposium. He asks you Ior an antibiotic to be taken
prophylactically to prevent bacterial diarrhea.
Which one oI the Iollowing would you recommend?

A. Trimethoprim/sulIamethoxazole (Bactrim, Septra)
B. RiIaximin (XiIaxan)
C. Doxycycline
D. NitroIurantoin (Macrobid)
Your Answer: B
Result: Correct
Explanation: While prophylactic antibiotics are not generally recommended Ior prevention oI
traveler`s diarrhea, they may be useIul under special circumstances Ior certain high-risk hosts,
such as the immunocompromised, or Ior those embarking on critical short trips Ior which even a
short period oI diarrhea might cause undue hardship. Rifaximin. a nonabsorbable antibiotic.
has been shown to reduce the risk for traveler`s diarrhea by 77.
Trimethoprim/sulIamethoxazole and doxycycline are no longer considered eIIective
antimicrobial agents against enteric bacterial pathogens. Increasing resistance to the
Iluoroquinolones, especially among Campvlobacter species, is limiting their use as prophylactic
agents.
1. An asymptomatic 3-year-old male presents Ior 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 oI the examination is normal. Which one oI the
Iollowing is the most likely diagnosis?
A. Eisenmenger`s syndrome
B. Mitral stenosis
C. Peripheral pulmonic stenosis
D. Still`s murmur
E. Venous hum
Your Answer: D
Correct Answer: D
Result: Correct
Explanation of correct answer:
There are several benign murmurs oI childhood that have no association with physiologic or
anatomic abnormalities. OI these, Still`s murmur best Iits the murmur described. The cause oI
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 oI a continuous low-pitched murmur caused
by the collapse oI the iugular veins and their subsequent Iluttering, 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 oI the heart that cause signiIicant signs and symptoms, including shortness oI
breath, cyanosis, and organomegaly, which should become apparent Irom a routine history and
examination.

2. A 57-year-old male with severe renal disease presents with acute coronary syndrome. Which
one oI the Iollowing would most likely require a signiIicant dosage adiustment Irom the standard
protocol?
A. Enoxaparin (Lovenox)
B. Metoprolol (Lopressor, Toprol)
C. Carvedilol (Coreg)
D. Clopidogrel (Plavix)
E. Tissue plasminogen activator (tPA)
Your Answer: A
Correct Answer: A
Result: Correct
Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal
impairment the dosage must be signiIicantly reduced. For some indications the dose normally
given every 12 hours is given only every 24 hours. lthough some -blockers require a
dosage adjustment. metoprolol and carvedilol are metabolized by the liver and do not
require dosage adjustment in patients with renal failure. Clopidogrel is currently
recommended at the standard dosage Ior patients with renal Iailure and acute coronary
syndrome. Thrombolytics like tPA are given at the standard dosage in renal Iailure, although
hemorrhagic complications are increased.

3. A 55-year-old male who has a long history oI marginally-controlled hypertension presents
with gradually increasing shortness oI breath and reduced exercise tolerance. His physical
examination is normal except Ior a blood pressure oI 140/90 mm Hg, bilateral basilar rales, and
trace pitting edema. Which one oI the Iollowing ancillary studies would be the preIerred
diagnostic tool Ior evaluating this patient?
A. 12-lead electrocardiography
B. Posteroanterior and lateral chest radiographs
C. 2-dimensional echocardiography with Doppler
D. Radionuclide ventriculography
E. Cardiac MRI
Your Answer: C
Correct Answer: C
Result: Correct
The most useful diagnostic tool for evaluating patients with heart failure is two-
dimensional echocardiography with Doppler to assess leIt ventricular eiection Iraction
(LVEF), leIt ventricular size, ventricular compliance, wall thickness, and valve Iunction. The
test should be perIormed during the initial evaluation. Radionuclide ventriculography can be
used to assess LVEF and volumes, and MRI or CT also may provide inIormation in selected
patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should
be perIormed in all patients presenting with heart Iailure, but should not be used as the primary
basis Ior determining which abnormalities are responsible Ior the heart Iailure.

4. A 23-year-old Iemale sees you with a complaint oI intermittent irregular heartbeats that occur
once every week or two, but do not cause her to Ieel lightheaded or Iatigued. They last only a
Iew seconds and resolve spontaneously. She has never passed out, had chest pain, or had
diIIiculty with exertion. She is otherwise healthy, and a physical examination is normal. Which
one oI the Iollowing cardiac studies should be ordered initially?
A. 24-hour ambulatory EKG monitoring (Holter monitor)
B. 30-day continuous closed-loop event recording
C. Echocardiography
D. An EKG
E. Electrophysiologic studies
Your Answer: D
Correct Answer: D
Result: Correct
The symptom oI an increased or abnormal sensation oI one`s heartbeat is reIerred to as
palpitations. This condition is common to primary care, but is oIten benign. Commonly, these
sensations have their basis in anxiety or panic. However, about 50 oI those who complain oI
palpitations will be Iound to have a diagnosable cardiac condition. It is recommended to start the
evaluation Ior cardiac causes with an EKG, which will assess the baseline rhythm and screen Ior
signs oI chamber enlargement, previous myocardial inIarction, conduction disturbances, and a
prolonged QT interval.

5. Which one oI the Iollowing is most appropriate Ior the initial treatment oI claudication?
A. Regular exercise
B. Chelation
C. Vasodilating agents
D. WarIarin (Coumadin)
Your Answer: A
Correct Answer: A
Result: Correct
Claudication is exercise-induced lower-extremity pain that is caused by ischemia and relieved
by rest. It aIIects 10 oI persons over 70 years oI age. However, up to 90 oI patients with
peripheral vascular disease are asymptomatic. Initial treatment should consist of vigorous risk
factor modification and exercise. Patients who Iollow an exercise regimen can increase their
walking time by 150. A supervised program may produce better results. Risk Iactors include
diabetes mellitus, hypertension, smoking, and hyperlipidemia. Unconventional treatments such
as chelation have not been shown to be eIIective. Vasodilating agents are oI no beneIit. There is
no evidence that anticoagulants such as aspirin have a role in the treatment oI claudication.

6. In a patient who presents with symptoms of acute myocardial infarction. which one of
the following would be an indication for thrombolytic therapy?
A. New-onset ST-segment depression
B. New-onset left bundle branch block
C. New-onset Iirst degree atrioventricular block
D. New-onset Wenckebach second degree heart block
E. Frequent uniIocal ventricular ectopic beats
Your Answer: B
Correct Answer: B
Result: Correct
In patients with ischemic chest pain, the EKG is important Ior determining the need Ior
Iibrinolytic therapy. Myocardial inIarction 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
leIt bundle branch block suggests occlusion oI the leIt anterior descending artery, placing a
signiIicant portion oI the leIt ventricle in ieopardy. Thrombolytic therapy could be harmIul in
patients with ischemia but not inIarction they will show ST-segment depression only. Frequent
uniIocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy.

7. A 68-year-old Iemale has an average blood pressure oI 150/70 mm Hg despite appropriate
liIestyle modiIication eIIorts. Her only other medical problems are osteoporosis and mild
depression. The most appropriate treatment at this time would be
A. lisinopril (Prinivil, Zestril)
B. clonidine (Catapres)
C. propranolol (Inderal)
D. amlodipine (Norvasc)
E. hydrochlorothiazide
Your Answer: E
Correct Answer: E
Result: Correct
Randomized. placebo-controlled trials have shown that isolated systolic hypertension in the
elderly responds best to diuretics and to a lesser extent, -blockers. Diuretics are preIerred,
although long-acting dihydropyridine calcium channel blockers may also be used. In the case
described, -blockers or clonidine may worsen the depression. Thiazide diuretics may also
improve osteoporosis, and would be the most cost-eIIective and useIul agent in this instance.

8. A 31-year-old healthy Iemale is admitted to the hospital Irom the emergency department aIter
presenting with aching in her right shoulder and swelling in the ipsilateral Iorearm 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 Ior a thrombus in the axillosubclavian vein. She has
no prior history oI clotting, takes no medications, and has no previous history oI medical or
surgical procedures involving this extremity. The most likely etiology Ior this patient's condition
is
A. a hypercoagulable state
B. a compressive anomaly in the thoracic outlet
C. use oI iniection drugs
D. Budd-Chiari syndrome
Your Answer: C
Correct Answer: B
Result: Incorrect
Thrombosis oI the upper extremity accounts Ior about 10 oI all venous thromboembolism
(VTE) cases. However, axillosubclavian vein thrombosis (ASVT) is becoming more Irequent
with the increased use oI indwelling subclavian vein catheters. Spontaneous S'T (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 oIten bilateral, and the other upper extremity at similar risk Ior thrombosis.
While a hypercoagulable state also may contribute to the thrombosis, it is much less common.
Budd-Chiari syndrome reIers to thrombosis in the intrahepatic, suprahepatic, or hepatic veins. It
is not commonly associated with spontaneous upper-extremity thrombosis.

9. A 56-year-old white male presents with a 2-week history oI intermittent pain in his leIt leg.
The pain usually occurs while he is walking and is primarily in the calI muscle or Achilles
region. Sometimes he will awaken at night with cramps in the aIIected leg. He has no known
risk Iactors Ior atherosclerosis. Which one oI the Iollowing would be the best initial test Ior
peripheral vascular occlusive disease?
A. Ankle-brachial index
B. Arterial Doppler ultrasonography
C. Arteriography
D. Magnetic resonance angiography (MRA)
E. Venous ultrasonography
Your Answer: A
Correct Answer: A
Result: Correct
The ankle-brachial index (BI) is an inexpensive. sensitive screening tool and is the most
appropriate first test for peripheral vascular occlusive disease (P'OD) in this patient. The
ABI is the ratio oI systolic blood pressure measured in the ankle to systolic pressure using the
standard brachial measurement. 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 useIul iI the ABI suggests an
abnormality. Venous ultrasonography would not detect PVOD, but it could rule out deep venous
thrombosis, which is another common etiology Ior calI pain.

10. A 69-year-old male has a 4-day history oI swelling in his leIt leg. He has no history oI
trauma, recent surgery, prolonged immobilization, weight loss, or malaise. His examination is
unremarkable except Ior a diIIusely swollen leIt leg. A CBC, chemistry proIile, prostate-speciIic
antigen level, chest radiograph, and EKG are all normal; however, compression ultrasonography
oI the extremity reveals a clot in the proximal Iemoral vein. He has no past history oI venous
thromboembolic disease. In addition to initiating therapy with low molecular weight heparin, the
American College oI Chest Physicians recommends that warIarin (Coumadin) be instituted now
and continued Ior at least
A. 1 month
B. 3 months
C. 6 months
D. 12 months
Your Answer: C
Correct Answer: B
Result: Incorrect
For patients with a first episode of unprovoked deep venous thrombosis. evidence supports
treatment with a warfarin for at least 3 months (SOR A). The American College oI Chest
Physicians recommends that patients be evaluated at that point Ior the potential risks and beneIits
oI long-term therapy (SOR C)

2. A 67-year-old Hispanic male comes to your oIIice with severe periumbilical abdominal pain,
vomiting, and diarrhea which began suddenly several hours ago. His temperature is 37.0 degrees
C (98.6 degrees F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is
slightly distended, soIt, and diIIusely tender; bowel sounds are normal. Other Iindings include
clear lungs, a rapid and irregularly irregular heartbeat, and a pale leIt Iorearm and hand with no
palpable leIt brachial pulse. Right arm and lower extremity pulses are normal. Urine and stool
are both positive Ior blood on chemical testing. His hemoglobin level is 16.4 g/dL (N 13.018.0)
and his WBC count is 25,300/mm
3
(N 430010,800). The diagnostic imaging procedure most
likely to produce a speciIic diagnosis oI his abdominal pain is:
A. Intravenous pyelography (IVP)
B. Sonography oI the abdominal aorta
C. A barium enema
D. Celiac and mesenteric arteriography
E. Contrast venography
Your Answer: B
Correct Answer: D
Result: Incorrect
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 oI a brachial artery embolus and a
cardiac rhythm indicating atrial Iibrillation suggest the diagnosis. Some patients may have a
surprisingly normal abdominal examination in spite oI severe pain. Microscopic hematuria and
blood in the stool may both occur with embolization. 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

3. A 49-year-old white Iemale comes to your oIIice complaining oI painIul, cold Iinger tips
which turn white when she is hanging out her laundry. While there is no approved treatment Ior
this condition at this time, which one oI the Iollowing drugs has been shown to be useIul?
B. NiIedipine (Procardia)
C. Ergotamine/caIIeine (CaIergot)
D. Methysergide (Sansert)
Your Answer: B
Correct Answer: B
Result: Correct
At present there is no approved treatment Ior Raynaud`s disease. However, patients with this
disorder reportedly experience subiective symptomatic improvement with calcium channel
antagonists. Nifedipine is the calcium channel blocker oI choice in patients with Raynaud`s
disease. Beta-blockers can produce arterial insuIIiciency oI the Raynaud type, so propranolol and
atenolol would be contraindicated. Drugs such as ergotamine preparations and methysergide can
produce cold sensitivity, and should thereIore be avoided in patients with Raynaud`s disease.

4. You perIorm a health maintenance examination on a 2-year-old white male. He is
asymptomatic and is meeting all developmental milestones. The only signiIicant Iinding is a
grade 3/6 diastolic murmur heard at the right upper sternal border. Which one oI the Iollowing
would be most appropriate at this time?
A. No Iurther evaluation
B. ReIerral to a pediatric cardiologist
C. Reevaluation in 6 months
D. Maintenance doses oI digoxin
Your Answer: B
Correct Answer: B
Result: Correct
Children who have a murmur that is diastolic or is greater than 2/6 should be referred for
cardiovascular evaluation, perhaps aIter an echocardiogram is obtained. Other reasons Ior
reIerral include cardiac symptoms, abnormal splitting oI S2, a murmur that increases on
standing, a holosystolic murmur, or eiection clicks. Digoxin is not indicated at this point in this
asymptomatic patient.

.
5. For long-term therapy, the most eIIective control oI heart rate in atrial Iibrillation, both at rest
and with exercise, occurs with which one oI the Iollowing?
A. Digitalis
B. Beta-adrenergic blockers
C. Calcium channel blocIkers
D. Class 1A antiarrhythmics
Your Answer: B
Correct Answer: B
Result: Correct
For long-term therapy. beta-adrenergic antagonist drugs provide the most effective control
of heart rate in atrial fibrillation, both at rest and during exercise. Although calcium channel
blockers also lower heart rate both at rest and with exercise, they are not as eIIective as beta-
blockers. Digitalis is primarily eIIective in controlling the heart rate at rest, and oIten does not
adequately control heart rate with exercise. The Class 1 antiarrhythmics are most useIul in
maintaining sinus rhythm and, in Iact, may paradoxically increase heart rate

8. A 60-year-old AIrican-American male was recently diagnosed with an abdominal aortic
aneurysm. A lipid proIile perIormed a Iew months ago revealed an LDL level oI 125 mg/dL.
You would now advise him that his goal LDL level is:
A. 100 mg/dL
B. 130 mg/dL
C. 150 mg/dL
D. 160 mg/dL
Your Answer: A
Correct Answer: A
Result: Correct
ost 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 CD-equivalent diseases. including peripheral artery disease. symptomatic carotid
artery disease. and abdominal aortic aneurysm.

9. You approach the administrator oI your small-town hospital about the possibility oI starting a
cardiac rehabilitation program. Which one oI the Iollowing is true concerning such programs?
A. Patients should have a baseline exercise stress test beIore starting cardiac rehabilitation
B. A standard exercise prescription is appropriate Ior all cardiac patients
C. Cardiac rehabilitation has no eIIect on coronary risk Iactors
D. Cardiac rehabilitation has no eIIect on exercise capacity
E. Coronary events are Irequent in rehabilitation settings
Your Answer: A
Correct Answer: A
Result: Correct
Cardiac rehabilitation programs are saIe and eIIective. Rates oI coronary events in rehabilitation
settings are very low. Cardiac rehabilitation consistently improves exercise capacity and has
Iavorable eIIects on coronary risk Iactors, even without nutritional counseling. baseline
exercise stress test prior to starting cardiac rehabilitation is necessary to screen for
exertional ischemia or arrhythmias. and serves as a basis Ior prescribing an exercise regimen.
The exercise prescription is individualized based on results oI the exercise stress test, the age oI
the patient, and the patient`s clinical status.

10. Which one oI the Iollowing is a risk Iactor Ior perioperative arrhythmias?
A. Supraventricular tachycardia
B. Congestive heart Iailure
C. Age ~60
D. Premature atrial contractions
E. Past history oI hyperthyroidism
Your Answer: A
Correct Answer: B
Result: Incorrect
Significant predictors of intraoperative and perioperative ventricular arrhythmias include
preoperative ventricular (not supraventricular) ectopy. a history of congestive heart
failure. and a history of cigarette smoking. Age and a history oI hyperthyroidism are not
signiIicant predictors oI perioperative ventricular arrhythmias

1. A 34-year-old Iemale with a history oI bilateral tubal ligation consults you because oI
excessive body and Iacial hair. She has a normal body weight, no other signs oI virilization, and
regular menses.
Which one oI the Iollowing is the most appropriate treatment Ior her mild hirsutism?
A. Spironolactone (Aldactone)
B. Leuprolide (Lupron)
C. Prednisone
D. MetIormin (Glucophage)
Your Answer: A
Correct Answer: A
Result: Correct
ntiandrogens such as spironolactone. along with oral contraceptives. are recommended
for treatment of hirsutism in premenopausal women (SOR C). In addition to having side
eIIects, prednisone is only minimally helpIul Ior reducing hirsutism by suppressing adrenal
androgens. Leuprolide, although better than placebo, has many side eIIects and is expensive.
MetIormin can be used to treat patients with polycystic ovarian syndrome, but this patient does
not meet the criteria Ior this diagnosis.

2. An 80-year-old male nursing-home resident is brought to the emergency department because
oI a severe, productive cough associated with a high Iever, hypoxia, and hypotension. The
patient is Iound to have a leIt lower lobe pneumonia, and admission to the intensive-care unit is
advised.
Which one oI the Iollowing is the most appropriate antibiotic therapy Ior this patient?
A. MoxiIloxacin (Avelox)
B. CeItriaxone (Rocephin) and azithromycin (Zithromax)
C. Doxycycline
D. CeItriaxone and metronidazole (Flagyl)
E. CeItazidime (Fortaz), imipenem/cilastatin (Primaxin), and vancomycin (Vancocin)
Your Answer: E
Correct Answer: E
Result: Correct
Empiric coverage for methicillin-resistant Staphylococcus aureus and double coverage for
pseudomonal pneumonia should be prescribed in patients with nursing home-acquired
pneumonia requiring intensive-care unit admission (SOR B).

3. A 67-year-old white Iemale has a DXA scan with a resulting T-score oI 2.7. She has a strong
Iamily history oI breast cancer.
A. A bisphosphonate
B. RaloxiIene (Evista)
C. Calcitonin nasal spray (Miacalcin)
D. Teriparatide (Forteo)
E. Coniugated estrogens (Premarin)
Your Answer: B
Correct Answer: B
Result: Correct
Raloxifene is a selective estrogen receptor modulator. While it increases the risk of venous
thromboembolism. it is indicated in this patient to decrease the risk of invasive breast
cancer (SOR A). Bisphosphonates inhibit osteoclastic activity. Zoledronic acid, alendronate, and
risedronate decrease both hip and vertebral Iractures, whereas ibandronate decreases Iracture risk
at the spine only. Calcitonin nasal spray is an antiresorptive spray that decreases the incidence oI
vertebral compression Iractures. Teriparatide is a recombinant human parathyroid hormone with
potent bone anabolic activity, eIIective against vertebral and nonvertebral Iractures. Hormone
replacement therapy is recommended Ior osteoporosis only in women with moderate or severe
vasomotor symptoms. The lowest possible dose should be used Ior the shortest amount oI time
possible (SOR C).

4. A 50-year-old white Iemale comes to you because she has Iound a breast mass. Your
examination reveals a Iirm, Iixed, nontender, 2-cm mass. No axillary nodes are palpable, nor is
there any nipple discharge. You send her Ior a mammogram, and Iine-needle aspiration is
perIormed to obtain cells Ior cytologic examination. The mammogram is read as 'suspicious
and the Iine-needle cytology report reads, 'a Iew benign ductal epithelioid cells and adipose
tissue.
A. A repeat mammogram in 3 months
B. Repeat Iine-needle aspiration in 3 months
C. An excisional biopsy oI the mass
D. ReIerral Ior breast irradiation
E. ReIerral to a surgeon Ior simple mastectomy
Your Answer: C
Correct Answer: C
Result: Correct
In the ideal setting, the accuracy oI Iine-needle aspiration may be over 90. Clinical inIormation
is critical Ior interpreting the results oI Iine-needle aspiration, especially given the Iact that the
tissue sample is more limited than with a tissue biopsy. It is crucial to determine whether the
Iindings on Iine-needle aspiration explain the clinical Iindings. Although the report Irom the
mammogram and the biopsy are not ominous in this patient, they do not explain the clinical
Iindings. Immediate repeat Iine-needle aspiration or, preIerably, a tissue biopsy is indicated.
Proceeding directly to therapy, whether surgery or irradiation, is inappropriate because the
diagnosis is not clearly established. Likewise, any delay in establishing the diagnosis is not
appropriate.

5. A 67-year-old Iemale comes to your oIIice because she noticed Ilashing lights in her leIt eye 2
hours ago, and since then has had decreased vision in the lateral aspect oI that eye. On
examination she has a blind spot in the lateral visual Iield oI her leIt eye. Her Iundus is diIIicult
to examine because oI an early cataract.
A. Posterior vitreous detachment
B. Vitreous hemorrhage
C. Macular degeneration
D. Ocular migraine
E. Retinal detachment
Your Answer: E
Correct Answer: E
Result: Correct
In a patient complaining of flashes of light and a visual field defect. retinal detachment is
the most likely diagnosis. any cases of vitreous detachment are asymptomatic. and it does
not cause sudden visual field defects in the absence of a retinal detachment. A vitreous
hemorrhage would cause more blurring oI vision in the entire Iield oI vision. Ocular migraine
causes binocular symptoms.

6. A 27-year-old white Iemale at 12 weeks gestation comes to your oIIice complaining oI a
vaginal discharge. On speculum examination you note a purulent cervical discharge with a
Iriable cervix. A gonorrhea culture is negative. You make a diagnosis oI Chlamvdia trachomatis
cervicitis.
Which one oI the Iollowing is the appropriate treatment?
A. Metronidazole (Flagyl)
B. Tetracycline
D. Miconazole (Monistat) cream
Your Answer: B
Correct Answer: C
Result: Incorrect
zithromycin is the drug of choice for Chlamvdia trachomati8 infections in pregnant
patients. Metronidazole is used to treat trichomoniasis and Gardnerella vaginitis aIter 12 weeks
gestation. The use oI tetracycline is not appropriate in pregnant women, and miconazole is used
to treat vaginal candidiasis.

7. A previously alert, otherwise healthy 74-year-old AIrican-American male has a history oI
slowly developing progressive memory loss and dementia associated with urinary incontinence
and gait disturbance resembling ataxia. This presentation is most consistent with:
A. normal pressure hydrocephalus
B. Alzheimer`s disease
C. subacute sclerosing panencephalitis
D. multiple sclerosis
Your Answer: A
Correct Answer: A
Result: Correct
In normal pressure hydrocephalus a mild impairment oI memory typically develops gradually
over weeks or months, accompanied by mental and physical slowness. The condition progresses
insidiously to severe dementia. Patients also develop an unsteady gait and urinary incontinence,
but there are no signs oI increased intracranial pressure.

In Alzheimer`s disease the brain very gradually atrophies. A disturbance in memory Ior recent
events is usually the Iirst symptom, along with some disorientation to time and place; otherwise,
there are no symptoms Ior some period oI time. Subacute sclerosing panencephalitis usually
occurs in children and young adults between the ages of 4 and 20 years and is characterized
by deterioration in behavior and work. The most characteristic neurologic sign is mild
clonus.

Multiple sclerosis is characteristically marked by recurrent attacks oI demyelinization. The
clinical picture is pleomorphic, but there are usually suIIicient typical Ieatures oI incoordination,
paresthesias, and visual complaints. Mental changes may occur in the advanced stages oI the
disease. About two-thirds oI those aIIected are between the ages oI 20 and 40.

8. You see a 1-year-old male Ior a routine well child examination. Laboratory tests reveal a
hemoglobin level oI 10 g/dL (N 914), a hematocrit oI 31 (N 2842), a mean corpuscular
volume oI 68 :m3 (N 7086), and a mean corpuscular hemoglobin concentration oI 25 g/dL (N
3036). A trial oI iron therapy results in no improvement and a serum lead level is normal.

Which one oI the Iollowing would be the most appropriate test at this time?
A. Hemoglobin electrophoresis
B. Bone marrow examination
C. Vitamin B
12
and Iolate levels
D. A TSH level
Your Answer: A
Correct Answer: A
Result: Correct
This patient has a microcytic. hypochromic anemia. which can be caused by iron
deficiency. thalassemia. sideroblastic anemia. and lead poisoning. In a child with a
microcytic anemia who does not respond to iron therapy, hemoglobin electrophoresis is
appropriate to diagnose thalassemia. Hypothyroidism, vitamin B
12
deIiciency, and Iolate
deIiciency result in macrocytic anemias.

9. Which one oI the Iollowing is most accurate regarding somatization disorder?
A. Onset beIore age 40 is atypical
B. It is a Iorm oI malingering
C. Symptoms tend to resolve spontaneously within weeks oI onset
D. Symptoms are limited to one organ system or bodily Iunction
E. The incidence is increased among Iemale Iirst degree relatives oI patients with the disorder
Your Answer: E
Correct Answer: E
Result: Correct
Somatization disorder is a psychological disorder characterized by the chronic presence oI
several unexplained symptoms beginning before the age of 30 years. It is diagnostically
grouped with conversion disorder, hypochondriasis, and body dysmorphic disorder. By
deIinition, the symptom complex must include a minimum oI two symptoms relating to the
gastrointestinal system, one neurologic complaint, one sexual complaint, and Iour pain
complaints. The condition is more common in women than in men, and the incidence is
increased as much as tenIold in Iemale Iirst degree relatives oI aIIected patients.

1. A 40-year-old white male presents with a 5-year history oI periodic episodes oI 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 oI the Iollowing?
A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia
Your Answer: A
Correct Answer: B
Result: Incorrect
Cluster headache is predominantly a male disorder. The mean age of onset is 27-30 years.
ttacks often occur in cycles and are unilateral. igraine 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 2030 seconds.

2. A 24-year-old male presents with a Iever oI 38.9C (102.0F), generalized body aches, a sore
throat, and a cough. His symptoms started 24 hours ago. He is otherwise healthy. You suspect
novel inIluenza A H1N1 inIection, as there have been numerous cases in your community
recently. A rapid inIluenza diagnostic test is positive, and you recommend over-the-counter
symptomatic treatment. You see him 2 days later aIter he is admitted to the hospital through the
emergency department with dehydration and mild respiratory distress. A specimen is sent to the
state laboratory Ior PCR testing.
A. Oseltamivir (TamiIlu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment
Your Answer: A
Correct Answer: A
Result: Correct
The currently circulating novel inIluenza 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 oI inIluenza is recommended Ior all
persons with clinical deterioration requiring hospitalization, even iI the illness started more than
48 hours beIore admission. ntiviral treatment should be started as soon as possible.
Waiting for laboratory confirmation is not recommended.

4. A 51-year-old immigrant Irom Vietnam presents with a 3-week history oI nocturnal Iever,
sweats, cough, and weight loss. A chest radiograph reveals a right upper lobe cavitary inIiltrate.
A PPD produces 17 mm oI induration, and acid-Iast bacilli are present on a smear oI induced
sputum.
While awaiting Iormal laboratory identiIication oI the bacterium, which one oI the Iollowing
would be most appropriate?
A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, riIampin (RiIadin), and pyrazinamide
Your Answer: E
Correct Answer: E
Result: Correct
Leading authorities, including experts Irom the American Thoracic Society, CDC, and InIectious
Diseases Society oI America, mandate aggressive initial four-drug treatment when
tuberculosis is suspected (before confirmation by culture). 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, riIampin, and
pyrazinamide are recommended, although one regimen does not include pyrazinamide but
extends coverage with the other antibiotics. Treatment regimens can be modiIied once culture
results are available.

5. An incidental 2-cm adrenal nodule is discovered on renal CT perIormed to evaluate hematuria
in a 57-year-old Iemale with Ilank pain. She has no past medical history oI palpitations,
headache, hirsutism, sweating, osteoporosis, diabetes mellitus, or hypertension. A physical
examination is normal, with the exception oI a blood pressure oI 144/86 mm Hg. Laboratory
evaluation reveals a serum sodium level oI 140 mmol/L (N 135145) and a serum potassium
level oI 3.8 mmol/L (N 3.55.0).
What is the most appropriate next step in the evaluation oI this patient?
A. Repeat CT in 12 months
B. Evaluation Ior adrenal hormonal secretion
C. Fine-needle aspiration oI the nodule
D. MRI oI the abdomen
E. ReIerral to a general surgeon Ior exploratory laparotomy
Your Answer: A
Correct Answer: B
Result: Incorrect
The incidental discovery of adrenal masses presents a common clinical challenge. Such masses
are Iound on abdominal CT in 4 oI cases, and the incidence oI adrenal masses increases to 7
in adults over 70 years oI age. While the maiority oI masses are benign, as many as 11 are
hypersecreting tumors and approximately 7 are malignant tumors; the size oI the mass and its
appearance on imaging are maior predictors oI malignancy. Once an adrenal mass is identified.
adrenal function must be assessed with an overnight dexamethasone suppression test.
morning cortisol level >5 ug/dL after a 1-mg dose indicates adrenal hyperfunction.
dditional 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 RI.
and/or scintigraphy to distinguish malignant masses. PET scanning is useful to verify
malignant disease. NonIunctioning benign masses can be monitored Ior changes in size and Ior
the onset oI hypersecretory states, although the appropriate interval and studies are controversial.
MRI may be preIerred over CT because oI concerns about excessive radiation exposure. Fine-
needle aspiration oI the mass can be perIormed to diIIerentiate between adrenal and non-adrenal
tissue aIter malignancy and pheochromocytoma have been excluded.

6. Which one oI the Iollowing has been shown to beneIit Irom screening Ior asymptomatic
bacteriuria?
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
Your Answer: E
Correct Answer: E
Result: Correct
Clinical guidelines published by the U.S. Preventive Services Task Force in 2008 reaIIirmed the
2004 recommendations regarding screening Ior 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).

9. A 12-year-old Iemale is brought to your oIIice with an 8-day history oI sore throat and Iever,
along with migratory aching ioint pain. She is otherwise healthy and has no history oI travel, tick
exposure, or prior systemic illness. A physical examination is notable Ior exudative pharyngitis;
a blanching, sharply demarcated macular rash over her trunk; and a III/VI systolic eiection
murmur. Joint and neurologic examinations are normal. A rapid strep test is positive and her C-
reactive protein level is elevated.
OI the Iollowing, the most likely diagnosis is:
A. iuvenile rheumatoid arthritis
B. inIective endocarditis
C. Kawasaki syndrome
D. acute rheumatic Iever
E. Lyme disease
Your Answer: D
Correct Answer: D
Result: Correct
cute 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 515 years. The
diagnosis is based on the Jones criteria. Two maior criteria, or one maior criterion and two minor
criteria, plus evidence oI a preceding streptococcal inIection, indicate a high probability oI the
disease.

ajor criteria include carditis. migratory polyarthritis. erythema marginatum. chorea.
and subcutaneous nodules. inor criteria include fever. arthralgia. an elevated erythrocyte
sedimentation rate or C-reactive protein (CRP) level. and a prolonged PR interval on
EKG. The diIIerential diagnosis is extensive and there is no single laboratory test to conIirm the
diagnosis. This patient meets one maior criterion (erythema marginatum rash) and three minor
criteria (Iever, elevated CRP levels, and arthralgia). Echocardiography should be perIormed iI
the patient has cardiac symptoms or an abnormal cardiac examination, to rule out rheumatic
carditis.

10. A 73-year-old Iemale presents with complaints oI dyspnea and decreasing exercise tolerance
over the past Iew months. She says she has to prop herselI up on two pillows in order to breathe
better. She also complains oI palpitations, even at rest. She has long-standing hypertension, but
has not taken any antihypertensive medications Ior several years. She has no history oI 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 Iibrillation,
but no changes oI acute ischemia.
Which one oI the Iollowing would be most useIul Ior determining her initial treatment?
A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level
Your Answer: C
Correct Answer: C
Result: Correct
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 Iindings and chest radiographs do not distinguish systolic Irom
diastolic heart Iailure. n echocardiogram is the study of choice. as it will assess left
ventricular function.

In diastolic dysfunction. the left ventricular ejection fraction is normal or slightly elevated.
Diastolic failure is more common in elderly females and patients with hypertension. and
less common in patients with a previous history of coronary artery disease. Diuretics and
angiotensin receptor blockers (RBs) are useful treatments. Because oI their eIIects on
diastolic Iilling times, tachycardia and atrial Iibrillation oIten cause decompensation in patients
with diastolic heart Iailure.

At this time, cardiac catheterization is not indicated, and a stress test will not provide useIul
inIormation. II the patient had systolic Iailure, a workup Ior ischemic disease would be needed,
but most cases oI diastolic dysIunction are not caused by ischemia. While hyperthyroidism can
cause tachycardia and atrial Iibrillation, the more immediate issue in this patient is the heart
Iailure, which requires diagnosis and treatment. A pulmonary embolus can cause shortness oI
breath but usually has an acute onset, so a D-dimer level would not help at this time.

1. In the elderly, the risk oI heat wave-related death is highest in those who
A. have COPD
B. have diabetes and are insulin-dependent
C. have a Iunctioning Ian, but not air conditioning
D. are homebound
Your Answer: C
Correct Answer: D
Result: Incorrect
Factors associated with a higher risk of heat-related deaths include being confined to bed.
not leaving home daily. and being unable to care for oneself. Living alone during a heat
wave is associated with an increased risk oI death, but this increase is not statistically
signiIicant. Among medical conditions, the highest risk is associated with preexisting
psychiatric illnesses, Iollowed by cardiovascular disease, use oI psychotropic medications, and
pulmonary disease. A lower risk oI heat-related deaths has been noted in those who have
working air conditioning, visit air-conditioned sites, or participate in social activities. Those who
take extra showers or baths and who use Ians have a lower risk, but this diIIerence is not
statistically signiIicant.

3. During a well child examination oI a healthy-appearing 4-week-old white male born at term,
his mother questions you about a prominence in the leIt side oI his scrotum, which she has noted
since his baths were begun. Your physical examination reveals an oblong, nontender,
nonreducible, light-transmitting mass closely adhered to or involving the testis. You should
recommend which one oI the Iollowing?
A. Further observation
B. Sterile aspiration oI the mass
C. Immediate surgery
D. Surgery in 3-4 months
Your Answer: B
Correct Answer: A
Result: Incorrect
hydrocele of the tunica vaginalis testis occurs frequently at birth but usually resolves in a
few weeks or months. No treatment is indicated during the first year of life unless there is
a clinically evident hernia. A simple scrotal hydrocele without communication with the
peritoneal cavity and no associated hernia should be excised iI it has not spontaneously resolved
by the age oI 12 months. Aspirating the mass Ior diagnostic or therapeutic reasons is not
recommended, since a loop oI bowel may be iniured. Removing the Iluid is ineIIectiveas it will
quickly reaccumulate.

5. A 56-year-old AIrican-American male has pain and tingling in the medial aspect oI his ankle
and the plantar aspect oI his Ioot. He iogs 3 miles daily and has no history oI any iniury. The
symptoms are aggravated by activity, and sometimes keep him awake at night. The only
Iindings on examination are paresthesias when a reIlex hammer is used to tap iust inIerior to the
medial malleolus. This patient probably has
A. a stress Iracture
B. a herniated nucleus pulposus at L5 or S1
C. plantar Iasciitis
D. diabetic neuropathy
E. tarsal tunnel syndrome
Your Answer: C
Correct Answer: E
Result: Incorrect
Entrapment of the posterior tibial nerve or its branches as the nerve courses behind the
medial malleolus results in a neuritis known as tarsal tunnel syndrome. Causes oI
compression within the tarsal tunnel include varices oI the posterior tibial vein, tenosynovitis oI
the Ilexor tendon, structural alteration oI the tunnel secondary to trauma, and direct compression
oI the nerve. Pronation of the foot causes pain and paresthesias in the medial aspect of the
ankle and heel. and sometimes the plantar surface of the foot.
The usual site Ior a stress Iracture is the shaIt oI the second, third, or Iourth metatarsals. A
herniated nucleus pulposus would produce reIlex and sensory changes. Plantar fasciitis is the
most common cause of heel pain in runners and often presents with pain at the beginning
of the workout. The pain decreases during running only to recur afterward. Diabetic
neuropathy is usually bilateral and often produces paresthesias and burning at night. with
absent or decreased deep tendon reflexes.

6. A 35-year-old male with a toothache presents to a local clinic Ior uninsured patients. On
examination you Iind a decayed leIt lower molar that is tender when tapped lightly, and
surrounding gingival inIlammation and tenderness. There is no obvious mandibular swelling,
but he does have a tender submandibular lymph node. The earliest available dental appointment
is in 1 week. He is allergic to penicillin. Which one oI the Iollowing would be the best antibiotic
treatment Ior this patient?
A. Doxycycline
B. Trimethoprim/sulIamethoxazole (Bactrim, Septra)
C. Clindamycin (Cleocin)
D. CiproIloxacin (Cipro)
E. Cephalexin (KeIlex)
Your Answer: E
Correct Answer: C
Result: Incorrect
This patient most likely has periodontitis of the tooth`s roots with cellulitis. complicated by
an apical abscess. This inIection is caused by anaerobic oral bacteria. Penicillin 'K.
amoxicillin or amoxicillin/clavulanate is preferred for antibiotic treatment. but this patient
is allergic to penicillin. Clindamycin is a good choice to cover the likely pathogens.
Doxycycline, trimethoprim/sulIamethoxazole, ciproIloxacin, and cephalexin have limited
eIIectiveness against anaerobes and would not be indicated.

7. A 35-year-old white male has a blood pressure oI 142/88 mm Hg, conIirmed on repeat
measurements. A complete metabolic panel and urinalysis reveal a serum creatinine level oI 1.9
mg/dL (N 0.6-1.5) and 2 protein in the urine. Which one oI the Iollowing would be the most
appropriate initial treatment?
A. ACE inhibitors
B. Aldosterone antagonists
C. -Blockers
D. Calcium channel blockers
E. Diuretics
Your Answer: D
Correct Answer: A
Result: Incorrect
Although JNC-7 guidelines recommend a diuretic as the initial pharmacologic agent for
most patients with hypertension. the presence of compelling indications may indicate the
need for treatment with antihypertensive agents that demonstrate a particular benefit in
primary or secondary prevention. JNC-7 guidelines recommend CE inhibitors (CEIs) or
angiotensin receptor blockers (RBs) for hypertensive patients with chronic kidney disease
(SOR A). First-line therapy Ior proteinuric kidney disease includes an ACEI or an ARB.
Because these drugs can cause elevations in creatinine and potassium, these levels should be
monitored. A serum creatinine level as much as 35 above baseline is acceptable in patients
taking these agents and is not a reason to withhold treatment unless hyperkalemia develops. II
an ACEI or an ARB does not control the hypertension, the addition oI a diuretic or a calcium
channel blocker may be required. The combination oI ACEIs and diuretics may be used to
control hypertension in patients with diabetes mellitus, heart Iailure, or high coronary disease
risk, as well as post myocardial inIarction. Calcium channel blockers are recommended Ior
managing hypertension in patients with diabetes or high coronary disease risk. -Blockers are
useIul as part oI combination therapy in patients with hypertension and heart Iailure, or post
myocardial inIarction.

8. A 45-year-old white male undergoes a health screening at his church. He has a carotid
Doppler study, abdominal ultrasonography, heel densitometry, and a multiphasic blood panel.
He receives a report indicating that all oI the studies are normal, but a 0.7-cm thyroid nodule was
noted. The TSH level is normal. He schedules a visit with you and brings you the report. A
neck examination and ENT examination are normal, and you do not detect a nodule. You
recommend
A. a radionuclide thyroid scan
B. T3, T4, and calcitonin levels
C. repeat ultrasonography in 6-12 months
D. a Iine-needle biopsy
E. hemithyroidectomy
Your Answer: D
Correct Answer: C
Result: Incorrect
This is a classic incidentaloma. Nodules are detected in up to 50 oI thyroid sonograms and
carry a low risk oI malignancy (5). If the TSH level is normal. nuclear scanning and
further thyroid studies are not necessary. Nodules smaller than 1 cm are difficult to biopsy
and thyroid surgery is not indicated for what is almost certainly benign disease. It is
reasonable to follow small nodules with clinical examinations and periodic sonograms.

9. An asymptomatic 40-year-old male presents Ior a routine examination and is Iound to have a
total bilirubin level oI 1.8 mg/dL (N <1.0) and an indirect bilirubin level oI 1.3 mg/dL. He
drinks 3-6 beers/week. An examination and laboratory tests, including a CBC and serum liver
enzymes, are within normal limits. Which one oI the Iollowing is true regarding the diagnosis?
A. The most likely diagnosis is alcoholic liver disease
B. The most likely diagnosis is Dubin-Johnson syndrome
C. The most likely diagnosis is Gilbert syndrome
D. Ultrasonography oI the liver and gallbladder are necessary to make a diagnosis
Your Answer: C
Correct Answer: C
Result: Correct
Gilbert syndrome is an autosomal dominant disease characterized by indirect
hyperbilirubinemia caused by impaired glucuronyl transferase activity. The workup
includes studies to exclude hemolysis (CBC. reticulocyte count. and haptoglobin) and liver
disease (ST. LT. alkaline phosphatase. and prothrombin time). Alcoholic liver disease is
associated with a greater elevation oI AST than oI ALT. Dubin-Johhnson syndrome is a benign
liver disease distinguished by direct or coniugated hyperbilirubinemia. Imaging studies are not
required to conIirm Gilbert syndrome; such studies are more useIul Ior conditions involving
coniugated hyperbilirubinemia. Other causes oI indirect hyperbilirubinemia include hematoma,
inIection, cardiac disease, rhabdomyolysis, living at high altitude, thyrotoxicosis, and some
medications
10. Which one oI the Iollowing causes oI anemia is associated with a normal red cell distribution
width?
A. Vitamin B12 deIiciency
B. Iron deIiciency
C. -Thalassemia trait
D. Sideroblastic anemia
E. MyeloIibrosis
Your Answer: C
Correct Answer: C
Result: Correct
Red cell distribution width (RDW) is a measure oI the variability oI size oI the red cells. It is
particularly useIul in distinguishing anemic disorders, especially iron deficiency anemia (high
RDW. normal to low mean corpuscular volume) and uncomplicated heterozygous
thalassemia (normal RDW. low mean corpuscular volume).

1. Which one oI the Iollowing is true regarding hospice?
A. Hospice beneIits end iI the patient lives beyond the estimated 6-month liIe expectancy
B. A do-not-resuscitate (DNR) order is required Ior a patient receiving Medicare hospice beneIits
C. Patients in hospice cannot receive chemotherapy, blood transIusions, or radiation treatments
D. Patients must be reIerred to hospice by their physician
E. Any terminal patient with a liIe expectancy 6 months is eligible
Your Answer: E
Correct Answer: E
Result: Correct
Any patient with a liIe expectancy oI less than 6 months who chooses a palliative care approach
is an appropriate candidate Ior hospice. There is no penalty iI patients do not die within 6
months, as long as the disease is allowed to run its natural course. edicare does not require a
DNR order to enroll in hospice. but it does require that patients seek only palliative. not
curative. treatment. Patients may receive chemotherapy. blood transfusions. or radiation if
the goal of the treatment is to provide symptom relief. Patients can be referred to hospice
by anyone. including nurses. social workers. family members. or friends.

2. A 62-year-old male on hemodialysis develops a pruritic rash on his arms and chest. with
erythematous. thickened plaques and edema. He had brain imaging with a gadolinium-
enhanced MRI Ior neurologic symptoms 10 days ago.
Which one oI the Iollowing is true regarding this problem?
A. A skin biopsy is diagnostic
B. The problem is limited to the skin
C. Immediate treatment is critical
D. The disease is more common in males
E. Death Irom the disease is unusual
Your Answer: E
Correct Answer: A
Result: Incorrect
This patient has gadolinium-associated nephrogenic systemic fibrosis. which is associated
with the use of gadolinium-based contrast material in patients with severe renal
dysfunction. often on dialysis. Associated proinIlammatory states, such as recent surgery,
malignancy, and ischemia, are oIten present as well. This condition occurs without regard to
gender, race, or age. Dermatologic manifestations are usually seen. but multiple organ
systems may be involved. There is no effective treatment. and mortality is approximately
30. deep biopsy of the affected skin is diagnostic.

3. A 3-year-old male is brought to the emergency department by his parents, who report seeing
him swallow a handIul oI adult ibuproIen tablets 20 minutes ago. Which one oI the Iollowing
would be the most appropriate initial management oI this patient?
A. Oral ipecac
B. Oral activated charcoal
C. Gastric lavage
D. Whole-bowel irrigation
E. Close observation
Your Answer: B
Correct Answer: B
Result: Correct
single dose of activated charcoal is the decontamination treatment of choice for most
medication ingestions. It should be used within 1 hour of ingestion of a potentially toxic
amount of medication (SOR C). Gastric lavage. cathartics. or whole bowel irrigation is best
for ingestion of medications that are poorly absorbed by activated charcoal (iron. lithium)
or medications in sustained-release or enteric-coated formulations. Ipecac has no role in
home use or in the health care setting (SOR C).

4. A 26-year-old gravida 3 para 2 was diagnosed with gestational diabetes mellitus at 24 weeks
gestation. She was prescribed appropriate nutritional therapy and an exercise program. AIter 4
weeks, her Iasting plasma glucose levels remain in the range oI 105110 mg/dL.

Which one oI the Iollowing would be the most appropriate treatment Ior this patient at this time?
A. Continuation oI the current regimen
B. Long-acting insulin glargine (Lantus) once daily
C. Pioglitazone (Actos) once daily
D. A combination oI intermediate-acting insulin (e.g., NPH) and a short-acting insulin (e.g.,
lispro) twice daily
E. Sliding-scale insulin 4 times daily using ultra-short-acting insulin
Your Answer: B
Correct Answer: D
Result: Incorrect
In addition to an appropriate diet and exercise regimen, pharmacologic therapy should be
initiated in pregnant women with gestational diabetes mellitus whose fasting plasma glucose
levels remain above 100 mg/dL despite diet and exercise. There is strong evidence that such
treatment to maintain Iasting plasma glucose levels below 95 mg/dL and 1-hour postprandial
levels below 140 mg/dL results in improved Ietal well-being and neonatal outcomes. While oral
therapy with metIormin or glyburide is considered saIe and possibly eIIective, insulin therapy is
the best option Ior the pharmacologic treatment oI gestational diabetes. Thiazolidinediones such
as pioglitazone have not been shown to be eIIective or saIe in pregnancy.

The use oI long-acting basal insulin analogues, such as glargine and detemir, has not been
suIIiciently evaluated in pregnancy. Sliding-scale coverage with ultra-short-acting insulin or
insulin analogues, such as lispro and aspart, is generally not required in most women with
gestational diabetes. While it may be eIIective, it involves Iour daily glucose checks and
iniections.

ost patients are successfully treated with a twice-daily combination of an intermediate-
acting insulin and a short-acting insulin while continuing a diet and exercise program.

5. A 45-year-old Hispanic male with schizophrenia presents with an exacerbation oI his COPD.
He currently takes only ziprasidone (Geodon). He asks Ior a prescription Ior clarithromycin
(Biaxin) because it has worked well Ior previous exacerbations.
Which one oI the Iollowing eIIects oI this drug combination should you be alert Ior?
A. Stevens-Johnson syndrome
B. Prolonged QT interval
C. Seizures
D. Diarrhea
E. Hypoglycemia
Your Answer: B
Correct Answer: B
Result: Correct
Ziprasidone is a second-generation antipsychotic used in the treatment of schizophrenia.
These drugs cause QT-interval prolongation, which can in turn lead to torsades de pointes and
sudden cardiac death. This risk is further increased when these drugs are combined with
certain antibiotics (e.g.. clarithromycin). antiarrhythmics (class I and III). and tricyclic
antidepressants. The FDA has issued a black box warning Ior both Iirst- and second-generation
antipsychotic drugs due to a 1.6- to 1.7-Iold increase in the risk oI sudden cardiac death and
cerebrovascular accidents associated with their use in the elderly population (SOR A). None oI
the other conditions listed is associated with this drug combination.

6. A 44-year-old Iemale presents with a complaint oI increasingly dry eyes over the past 34
months, and says she can no longer wear contacts due to the discomIort and itching. She also
apologizes Ior chewing gum during the visit, explaining that it helps keep her mouth moist. On
examination you note decreased tear production, decreased saliva production, and new dental
caries. She stopped taking a daily over-the-counter allergy medication about 1 month ago.
A. Sarcoidosis
B. Sigren`s syndrome
C. Ocular rosacea
D. Allergic coniunctivitis
E. Medication side eIIect
Your Answer: B
Correct Answer: B
Result: Correct
Sjgren`s syndrome is one of the three most common systemic autoimmune diseases. It
results from lymphocytic infiltration of exocrine glands and leads to acinar gland
degeneration. necrosis. atrophy. and decreased function. A positive anti-SS-A or anti-SS-B
antigen test or a positive salivary gland biopsy is a criterion Ior classiIication oI this diagnosis.
In addition to ocular and oral complaints. clinical manifestations include arthralgias.
thyroiditis. pulmonary disease. and GERD.

Most patients with sarcoidosis present with shortness oI breath or skin maniIestations, and
patients with lupus generally have Iatigue and ioint pain. Ocular rosacea causes eye symptoms
very similar to those oI Sigren`s syndrome, but oral Iindings would not be expected. Drugs
such as anticholinergics can cause a dry mouth, but this would be unlikely a month aIter the
medication was discontinued (SOR B).

7. A 14-year-old Iemale is brought to your oIIice by her mother because oI a 3-month history oI
irritability, hypersomnia, decline in school perIormance, and lack oI interest in her previous
extracurricular activities. The mother is also your patient, and you know that she has a history oI
depression and has recently separated Irom her husband. AIter an appropriate workup, you
diagnose depression in the daughter.
For initial therapy you recommend:
A. amitriptyline
B. methylphenidate (Ritalin)
C. divalproex sodium (Depakote)
D. cognitive-behavioral therapy
Your Answer: D
Correct Answer: D
Result: Correct
This patient has multiple risk Iactors Ior depression: the hormonal changes oI puberty, a Iamily
history oI depression, and psychosocial stressors. Cognitive-behavioral therapy is effective in
treating mild to moderate depression in children and adolescents (SOR A). SSRIs are an
adiunctive treatment reserved Ior treatment oI severe depression, and have limited evidence Ior
eIIectiveness in children and adolescents.
Amitriptyline should not be used because oI its limited eIIectiveness and adverse eIIects (SOR
A). Methylphenidate is used Ior treating attention deIicit disorder, not depression. Divalproex
sodium is used to treat bipolar disorder.

8. A 55-year-old hospitalized white male with a history oI rheumatic aortic and mitral valve
disease has a 3-day history oI Iever, back pain, and myalgias. No deIinite Iocus oI inIection is
Iound on your initial examination. His WBC count is 24,000/mm
3
(N 430010,800) with 40
polymorphonuclear leukocytes and 40 band Iorms. The Iollowing day, two blood cultures have
grown gram-positive cocci in clusters.
Until the speciIic organism sensitivity is known, the most appropriate antibiotic treatment would
be:
A. ciproIloxacin (Cipro)
B. naIcillin
C. streptomycin and penicillin
D. ceItriaxone (Rocephin)
E. vancomycin and gentamicin
Your Answer: B
Correct Answer: E
Result: Incorrect
This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the
organism are known. treatment should include intravenous antibiotic coverage for
nterococcu8. Streptococcu8. and methicillin-sensitive and methicillin-resistant
Staphvlococcu8. patient who does not have a prosthetic valve should be started on
vancomycin and gentamicin. with monitoring of serum levels. nterococcus and methicillin-
resistant $taphvlococcus are oIten resistant to cephalosporins. II the organism proves to be
$taphvlococcus sensitive to naIcillin, the patient can be switched to a regimen oI naIcillin and
gentamicin.

10. A mother brings her 2-month-old inIant to the emergency department because oI proIuse
vomiting and severe diarrhea. The inIant is dehydrated, has a cardiac arrhythmia, appears to have
ambiguous genitalia, and is in distress.
This presentation suggests a diagnosis oI:
A. acute gastroenteritis
B. hypertrophic pyloric stenosis
C. congenital adrenal hyperplasia
D. congenital intestinal malrotation
E. Turner`s syndrome
Your Answer: C
Correct Answer: C
Result: Correct
Congenital adrenal hyperplasia is a Iamily oI diseases caused by an inherited deIiciency oI any
oI the enzymes necessary Ior the biosynthesis oI cortisol. In patients with the salt-losing variant,
symptoms begin shortly aIter birth with Iailure to regain birth weight, progressive weight loss,
and dehydration. Vomiting is prominent, and anorexia is also present. Disturbances in cardiac
rate and rhythm may occur. along with cyanosis and dyspnea. In the male. various degrees
of hypospadias may be seen. with or without a bifid scrotum or cryptorchidism.

1. A 62-year-old AIrican-American Iemale undergoes a workup Ior pruritus. Laboratory Iindings
include a hematocrit oI 55.0 (N 36.046.0) and a hemoglobin level oI 18.5 g/dL (N 12.016.0).
Which one oI the Iollowing additional Iindings would help establish the diagnosis oI
polycythemia vera?
A. A platelet count ~400,000/mm
3

B. An O
2
saturation 90
C. A WBC count 4500/mm (N 430010,800)
3

D. An elevated uric acid level
Your Answer: B
Correct Answer: A
Result: Incorrect
Polycythemia vera should be suspected in frican-mericans or white females whose
hemoglobin level is >16 g/dL or whose hematocrit is >47. For white males. the thresholds
are 18 g/dL and 52. It should also be suspected in patients with portal vein thrombosis and
splenomegaly, with or without thrombocytosis and leukocytosis. ajor criteria include an
increased red cell mass. a normal O
2
saturation. and the presence of splenomegaly. inor
criteria include elevated vitamin B
12
levels. elevated leukocyte alkaline phosphatase. a
platelet count >400.000/mm
3
and a WBC count >12.000/mm
3
. Patients with polycythemia
vera may present with gout and an elevated uric acid level. but neither is considered a
criterion for the diagnosis.

2. Over the last 6 months a developmentally normal 12-year-old white Iemale has experienced
intermittent abdominal pain, which has made her quite irritable. She also complains oI ioint pain
and general malaise. She has lost 5 kg (11 lb) and has developed an anal Iissure.
Which one oI the Iollowing is the most likely cause oI these symptoms?
A. Celiac disease (gluten enteropathy)
B. Irritable bowel syndrome
C. Hepatitis A
D. Crohn`s disease
E. Giardiasis
Your Answer: D
Correct Answer: D
Result: Correct
The most common age oI onset Ior inIlammatory bowel disease is during adolescence and young
adulthood, with a second peak at 5080 years oI age. The maniIestations oI Crohn`s disease are
somewhat dependent on the site oI involvement, but systemic signs and symptoms are more
common than with ulcerative colitis. Perianal disease is also common in Crohn`s disease.
Irritable colon and other Iunctional bowel disorders may mimic symptoms oI Crohn`s disease,
but obiective Iindings oI weight loss and anal lesions are extremely uncommon. This is also true
Ior viral hepatitis and giardiasis. In addition, the historical and epidemiologic Iindings in this
case are not consistent with either oI these inIections. Celiac disease and giardiasis can produce
Crohn`s-like symptoms oI diarrhea and weight loss, but are not associated with anal Iissures.

4. Which one oI the Iollowing is considered Iirst-line therapy Ior nausea and vomiting oI
pregnancy?
A. Ginger
B. Blue cohosh
C. Cranberry
D. Vitamin B
6

E. Fenugreek
Your Answer: D
Correct Answer: D
Result: Correct
A number oI alternative therapies have been used Ior problems related to pregnancy, although
vigorous studies are not always possible. For nausea and vomiting. however. vitamin B
6
is
considered first-line therapy. sometimes combined with doxylamine. Other measures that
have been Iound to be somewhat useIul include ginger and acupressure.

5. A 45-year-old Iemale presents to your oIIice because she has had a lump on her neck Ior the
past 2 weeks. She has no recent or current respiratory symptoms, Iever, weight loss, or other
constitutional symptoms. She has a history oI well-controlled hypertension, but is otherwise
healthy. On examination you note a nontender, 2-cm, soIt node in the anterior cervical chain.
The remainder oI the examination is unremarkable.
A. Immediate biopsy
B. Treatment with antibiotics, then a biopsy iI the problem does not resolve
C. Monitoring clinically Ior 46 weeks, then a biopsy iI the node persists or enlarges
D. Serial ultrasonography to monitor Ior changes in the node
Your Answer: C
Correct Answer: C
Result: Correct
There is limited evidence to guide clinicians in the management oI an isolated, enlarged cervical
lymph node, even though this is a common occurrence. Evaluation and management is guided by
the presence or absence oI inIlammation, the duration and size oI the node, and associated
patient symptoms. In addition, the presence oI risk Iactors Ior malignancy should be taken into
account.

Immediate biopsy is warranted if the patient does not have inflammatory symptoms and
the lymph node is >3 cm. if the node is in the supraclavicular area. or if the patient has
coexistent constitutional symptoms such as night sweats or weight loss. Immediate evaluation
is also indicated iI the patient has risk Iactors Ior malignancy. Treatment with antibiotics is
warranted in patients who have inIlammatory symptoms such as pain, erythema, Iever, or a
recent inIection.

In a patient with no risk factors for malignancy and no concerning symptoms. monitoring
the node for 4-6 weeks is recommended. II the node continues to enlarge or persists aIter this
time, then Iurther evaluation is indicated. This may include a biopsy or imaging with CT or
ultrasonography. The utility oI serial ultrasound examinations to monitor lymph nodes has not
been demonstrated.

6. A 45-year-old male is seen in the emergency department with a 2-hour history oI substernal
chest pain. An EKG shows an ST-segment elevation oI 0.3 mV in leads V4V6.
In addition to evaluation Ior reperIusion therapy, which one oI the Iollowing would be
appropriate?
A. Enteric aspirin, 81 mg
B. Intravenous metoprolol (Lopressor)
C. Oral clopidogrel (Plavix)
D. WarIarin (Coumadin), aIter blood is drawn to establish his baseline INR
E. Delaying treatment pending results oI two sets oI cardiac enzyme measurements
Your Answer: C
Correct Answer: C
Result: Correct
This patient has an ST-segment elevation myocardial infarction (STEI). STEMI is deIined
as an ST-segment elevation oI greater than 0.1 mV in at least two contiguous precordial or
adiacent limb leads. The most important goal is to begin Iibrinolysis less than 30 minutes aIter
the Iirst contact with the health system. The patient should be given oral clopidogrel. and
should also chew 162-325 mg of aspirin.

Enteric aspirin has a delayed eIIect. Intravenous -blockers such as metoprolol should not be
routinely given, and warIarin is not indicated. Delaying treatment until cardiac enzyme results
are available in a patient with a deIinite myocardial inIarction is not appropriate.

7. A 36-year-old Iemale sees you Ior a 6-week postpartum visit. Her pregnancy was complicated
by gestational diabetes mellitus. Her BMI at this visit is 33.0 kg/m
2
and she has a Iamily
historyoI diabetes mellitus.
This patient`s greatest risk Iactor Ior developing type 2 diabetes mellitus is her:
A. age
B. obesity
C. history oI a completed pregnancy
D. history oI gestational diabetes
E. Iamily history oI diabetes
Your Answer: D
Correct Answer: D
Result: Correct
history of gestational diabetes mellitus (GD) is the greatest risk factor for future
development of diabetes mellitus. It is thought that GDM unmasks an underlying propensity to
diabetes. While a healthy pregnancy is a diabetogenic state, it is not thought to lead to Iuture
diabetes. This patient`s age is not a risk Iactor. Obesity and Iamily history are risk Iactors Ior the
development oI diabetes, but having GDM leads to a IourIold greater risk oI developing diabetes,
independent oI other risk Iactors (SOR C). It is thought that 510 oI women who have GDM
will be diagnosed with type 2 diabetes within 6 months oI delivery. About 50 oI women with a
history oI GDM will develop type 2 diabetes within 10 years oI the aIIected pregnancy.

8. You see a 68-year-old mechanic Ior a routine evaluation. He has a 2-year history oI
hypertension. His weight is normal and he adheres to his medication regimen. His current
medications are metoprolol (Lopressor), 100 mg twice daily; olmesartan (Benicar), 40 mg/day;
and hydrochlorothiazide, 25 mg/day. His serum glucose levels have always been normal, but his
lipid levels are elevated.

A physical examination is unremarkable except Ior an enlarged prostate and a blood pressure oI
150/94 mm Hg. Laboratory studies show a serum creatinine level oI 1.6 mg/dL (N 0.61.5) and a
serum potassium level oI 4.9 mmol/L (N 3.55.0).

The patient`s record shows blood pressures ranging Irom 145/80 mm Hg to 148/96 mm Hg over
the past year.
A. Continue his current management with no changes
B. Substitute Iurosemide (Lasix) Ior hydrochlorothiazide
C. Add clonidine (Catapres)
D. Add spironolactone (Aldactone)
E. Add hydralazine (Apresoline)
Your Answer: C
Correct Answer: B
Result: Incorrect
Resistant or reIractory hypertension is deIined as a blood pressure >140/90 mm Hg, or >130/80
mm Hg in patients with diabetes mellitus or renal disease (i.e., with a creatinine level ~1.5
mg/dL or urinary protein excretion ~300 mg over 24 hours), despite adherence to treatment with
Iull doses oI at least three antihypertensive medications, including a diuretic. 1NC 7 guidelines
suggest adding a loop diuretic if serum creatinine is >1.5 mg/dL in patients with resistant
hypertension.

10. A 52-year-old male presents with a small nodule in his palm iust proximal to the Iourth
metacarpophalangeal ioint. It has grown larger since it Iirst appeared, and he now has mild
Ilexion oI the Iinger, which he is unable to straighten. He reports that his Iather had similar
problems with his Iingers. On examination you note pitting oI the skin over the nodule.
The most likely diagnosis is:
A. degenerative ioint disease
B. trigger Iinger
C. Dupuytren`s contracture
D. a ganglion
E. Ilexor tenosynovitis
Your Answer: B
Correct Answer: C
Result: Incorrect
Dupuytren`s contracture is characterized by changes in the palmar fascia, with progressive
thickening and nodule formation that can progress to a contracture oI the associated Iinger. The
fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule
because oI the connection with the skin.
Degenerative ioint disease is not associated with a palmar nodule. Trigger finger is related to
the tendon. not the palmar fascia. and causes the finger to lock and release. Ganglions also
affect the tendons or joints. are not located in the fascia. and are not associated with
contractures. Flexor tenosynovitis. an inflammation. is associated with pain. which is not
usually seen with Dupuytren`s contracture.

1. Which one of the following is NOT considered a first-line treatment for head lice?
. Lindane 1
B. Malathion 0.5 (Ovide)
C. Permethrin 1 (Nix)
D. Pyrethrins 0.33/pipernyl butoxide 4 (RID)
Your Answer: C
Correct Answer: A
Result: Incorrect
Lindane`s eIIicacy has waned over the years and it is inconsistently ovicidal. Because oI its
neurotoxicity, lindane carries a black box warning and is speciIically recommended only as
second-line treatment by the FDA. Pyrethroid resistance is widespread, but permethrin is still
considered to be a Iirst-line treatment because oI its Iavorable saIety proIile. The eIIicacy oI
malathion is attributed to its triple action with isopropyl alcohol and terpineol, likely making this
a resistance-breaking Iormulation. The probability oI simultaneously developing resistance to all
three substances is small. Malathion is both ovicidal and pediculicidal.

2. Which one oI the Iollowing is a Irequent cause oI cross-reactive Iood-allergy symptoms in
latex-allergic individuals?
A. Avocadoes
B. Goat`s milk
C. Pecans
D. Pastrami
E. Peppermint
Your Answer: A
Correct Answer: A
Result: Correct
The majority of patients who are latex-allergic are believed to develop IgE antibodies that
cross-react with some proteins in plant-derived foods. These Iood antigens do not survive the
digestive process, and thus lack the capacity to sensitize aIter oral ingestion in the traditional
Iood-allergy pathway. Antigenic similarity with proteins present in latex, to which an individual
has already been sensitized, results in an indirect allergic response limited to the exposure that
occurs prior to alteration by digestion, localized primarily in and around the oral cavity. The
Irequent association with certain Iruits has been labeled the 'latex-Iruit syndrome. Although
many Iruits and vegetables have been implicated, Iruits most commonly linked to this problem
are bananas. avocadoes. and kiwi.

3. A 42-year-old Iemale is Iound to have a thyroid nodule during her annual physical
examination. Her TSH level is normal. Ultrasonography oI her thyroid gland shows a solitary
nodule measuring 1.2 cm.
A. A radionuclide thyroid scan
B. A Iine-needle aspiration biopsy oI the nodule
C. Partial thyroidectomy
D. Total thyroidectomy
E. Reassurance
Your Answer: B
Correct Answer: B
Result: Correct
ll patients who are found to have a thyroid nodule on a physical examination should have
their TSH measured. Patients with a suppressed TSH should be evaluated with a
radionuclide thyroid scan; nodules that are ~hot (show increased isotope uptake) are
almost never malignant and fine-needle aspiration biopsy is not needed. For all other
nodules. the next step in the workup is a fine-needle aspiration biopsy to determine
whether the lesion is malignant (SOR B).

4. A 19-year-old Iemale high-school student is brought to your oIIice by a Iriend who is
concerned about the patient having cut her wrists. The patient denies that she was trying to kill
herselI, and states that she did this because she 'iust got so angry at her boyIriend when she
caught him sending a text message to another woman. She denies having a depressed mood or
anhedonia, and blames her Iluctuating mood on everyone who 'keeps abandoning her, making
her Ieel like she`s 'nothing. She admits that she has diIIiculty controlling her anger. Her sleep
quality and pattern appear normal, as does her appetite. She denies hallucinations or delusions.
The wounds on her wrists appear superIicial and there is evidence oI previous cutting behavior
on her Iorearms. Her vital signs are stable.
Which one oI the Iollowing would be most beneIicial Ior this patient?
A. Clonazepam (Klonopin)
B. Fluoxetine (Prozac)
C. Quetiapine (Seroquel)
D. Inpatient psychiatric admission
E. Psychotherapy
Your Answer: E
Correct Answer: E
Result: Correct
This patient displays most oI the criteria Ior borderline personality disorder. This is a
maladaptive personality type that is present Irom a young age, with a strong genetic
predisposition. It is estimated to be present in 1 oI the general population and involves equal
numbers oI men and women; women seek care more oIten, however, leading to a
disproportionate number oI women being identiIied by medical providers.

Inpatient hospitalization may be an appropriate treatment option iI the person is experiencing
extreme diIIiculties in living and daily Iunctioning, and pharmacotherapy may oIIer a mild
degree oI symptom relieI. While these modalities have a role in certain patients. psychotherapy
is considered the mainstay of therapy, especially in a relatively stable patient such as the one
described.

5. Treatment with donepezil (Aricept) is associated with an increased risk Ior :
A. pulmonary embolism
B. liver Iailure
C. bradycardia requiring pacemaker implantation
D. cataract development requiring surgery
E. conIusion requiring institutionalization
Your Answer: C
Correct Answer: C
Result: Correct
A large population study has established a significant increased risk of bradycardia. syncope.
and pacemaker therapy with cholinesterase inhibitor therapy. Elevation of liver enzymes
with the potential for hepatic dysfunction has been seen with tacrine, but it has not been
noted with the other approved cholinesterase inhibitors. Cataract Iormation and thrombosis with
pulmonary embolism do not increase with this therapy. Although improvement in mental
Iunction is oIten marginal with cholinesterase inhibitor therapy, the therapy has not been shown
to increase the need Ior institutionalization.

6. An 8-year-old Iemale is brought to your oIIice with a 3-day history oI bilateral knee pain. She
has had no associated upper respiratory symptoms. On examination she is aIebrile. Her knees
have Iull range oI motion and no eIIusion, but she has a purpuric papular rash on both lower
extremities.
Which one oI the Iollowing is the most likely cause oI her symptoms?
A. Henoch-Schnlein purpura
B. Rocky Mountain spotted Iever
C. Juvenile rheumatoid arthritis
D. Lyme disease
E. Rheumatic Iever
Your Answer: A
Correct Answer: A
Result: Correct
The combination oI arthritis with a typical palpable purpuric rash is consistent with a diagnosis
oI Henoch-Schnlein purpura. This most oIten occurs in children Irom 2 to 8 years old.
rthritis is present in about two-thirds of those affected. Gastrointestinal and renal
involvement are also common.
Rocky Mountain spotted Iever presents with a rash, but arthralgias are not typical. These patients
are usually sick with a Iever and headache. Juvenile rheumatoid arthritis is associated with a
salmon-pink maculopapular rash, but not purpura. The rash associated with Lyme disease is
erythema migrans, which is a bull`s-eye lesion at the site oI a tick bite. The rash associated with
rheumatic Iever is erythema marginatum, which is a pink, raised, macular rash with sharply
demarcated borders.

7. Which one oI the Iollowing hospitalized patients is the most appropriate candidate Ior
thromboembolism prophylaxis with enoxaparin (Lovenox)?
A. An ambulatory 22-year-old obese male admitted Ior an appendectomy
B. A 48-year-old male with atrial Iibrillation on chronic therapeutic anticoagulation, admitted Ior
cellulitis
C. A 48-year-old male with end-stage liver disease and coagulopathy
D. A 52-year-old Iemale on chronic estrogen therapy, admitted with severe thrombocytopenia
E. A 67-year-old Iemale with hemiparesis, admitted Ior community-acquired pneumonia
Your Answer: C
Correct Answer: E
Result: Incorrect
Venous thromboembolism is a Irequent cause oI preventable death and illness in hospitalized
patients. Approximately 1015 oI high-risk patients who do not receive prophylaxis develop
venous thrombosis. Pulmonary embolism is thought to be associated with 510 oI deaths in
hospitalized patients. Anticoagulant prophylaxis signiIicantly reduces the risk oI pulmonary
embolism and should be used in all high-risk patients.
Prophylaxis is generally recommended for patients over the age of 40 who have limited
mobility for 3 days or more and have at least one of the following risk factors: acute
inIectious disease, New York Heart Association class III or IV heart Iailure, acute myocardial
inIarction, acute respiratory disease, stroke, rheumatic disease, inIlammatory bowel disease,
previous venous thromboembolism, older age (especially ~75 years), recent surgery or trauma,
immobility or paresis, obesity (BMI ~30 kg/m
2
), central venouscatheterization, inherited or
acquired thrombophilic disorders, varicose veins, or estrogen therapy.
Pharmacologic therapy with an anticoagulant such as enoxaparin is clearly indicated in the 67-
year-old who has limited mobility secondary to hemiparesis and is being admitted Ior an acute
inIectious disease. The patient on chronic anticoagulation, the patient with severe
thrombocytopenia, and the patient with coagulopathy are at high risk Ior bleeding iI given
anticoagulants, and are better candidates Ior nonpharmacologic therapies such as Ioot extension
exercises, graduated compression stockings, or pneumatic compression devices. Although the
22-year-old is obese and recently had surgery, his young age and ambulatory status make
anticoagulant prophylaxis less necessary.

9. Which one oI the Iollowing should be given intravenously in the initial treatment oI status
epilepticus?
A. PropoIol (Diprivan)
B. Phenobarbital
C. Lorazepam (Ativan)
D. Midazolam (Versed)
Your Answer: C
Correct Answer: C
Result: Correct
Status epilepticus reIers to continuous seizures or repetitive, discrete seizures with impaired
consciousness in the interictal period. It is an emergency and must be treated immediately, since
cardiopulmonary dysfunction. hyperthermia. and metabolic derangement can develop,
leading to irreversible neuronal damage. Lorazepam, 0.10.15 mg/kg intravenously, should be
given as anticonvulsant therapy aIter cardiopulmonary resuscitation. This is followed by
phenytoin. given via a dedicated peripheral intravenous line. Fosphenytoin, midazolam, or
phenobarbital can be used iI there is no response to lorazepam.
PropoIol has been used Ior reIractory status epilepticus to induce general anesthesia when the
initial drugs have Iailed, but reports oI Iatal propoIol inIusion syndrome have led to a decline in
its use.

10. According to JNC 7, the risk oI cardiovascular disease begins to increase when the systolic
blood pressure exceeds a threshold oI :
A. 150 mm Hg
B. 140 mm Hg
C. 130 mm Hg
D. 125 mm Hg
E. 115 mm Hg
Your Answer: C
Correct Answer: E
Result: Incorrect
ccording to 1NC 7. the risk of both ischemic heart disease and stroke increases
progressively when systolic blood pressure exceeds 115 mm Hg and diastolic blood pressure
exceeds 75 mm Hg.

1. A 60-year-old white Iemale presents with pain in her leIt calI on walking. The pain does not
go away with continued walking, and is relieved by rest. She smokes one pack oI cigarettes daily
and has type 2 diabetes mellitus which is only moderately controlled with oral agents. She has
been Iairly noncompliant with dietary measures, and has not been interested in Iollowing your
recommendations regarding medication Ior her hyperlipidemia. She is unable to do many oI the
things that she previously enioyed doing, such as playing golI. Her ankle-brachial index at rest
on the leIt is 0.60 and on the right is 1.10. Which one oI the Iollowing is true regarding
management oI this patient`s peripheral vascular disease?
A. In order to improve Iunctional capacity, exercise training should be encouraged
B. Her goal LDL-cholesterol level is 130 mg/dL
C. Improved control oI her diabetes with insulin will slow the progression oI her disease
D. II she requires Iemoropopliteal bypass surgery, estrogen should be given postoperatively Ior
secondary prevention
Your Answer: C
Correct Answer: A
Result: Incorrect
Exercise therapy for peripheral vascular disease (P'D) improves maximal treadmill
walking distance and functional capacity. A rigorous exercise-training program may be as
beneIicial as bypass surgery and more beneIicial than angioplasty. The goal LDL-cholesterol
level in patients with established atherosclerotic vascular disease, including those with PVD (and
all patients with diabetes mellitus) should be 100 mg/dL. Tight control of diabetes mellitus
has not been shown to favorably affect P'D.

3. A 35-year-old AIrican-American Iemale has iust returned home Irom a vacation in Hawaii.
She presents to your oIIice with a swollen leIt lower extremity. She has no previous history oI
similar problems. Homan`s sign is positive, and ultrasonography reveals a noncompressible vein
in the leIt popliteal Iossa extending distally. Which one oI the Iollowing is true in this situation?
A. Monotherapy with an initial 10-mg loading dose oI warIarin (Coumadin) would be
appropriate
B. Enoxaparin (Lovenox) should be administered at a dosage oI 1 mg/kg subcutaneously twice a
day
C. The incidence oI thrombocytopenia is the same with lowmolecular-weight heparin as with
unIractionated heparin
D. The dosage oI warIarin should be adiusted to maintain the INR at 2.53.5
E. Anticoagulant therapy should be started as soon as possible and maintained Ior 1 year to
prevent deep vein thrombosis (DVT) recurrence
Your Answer: C
Correct Answer: B
Result: Incorrect
The use oI 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
Ior outpatient care should have good cardiopulmonary reserve, normal renal Iunction, and no risk
Ior excessive bleeding. Oral anticoagulation with warIarin can be initiated on the Iirst day oI
treatment aIter heparin loading is completed. Monotherapy with warIarin is inappropriate. The
incidence of thrombocytopenia with low-molecular-weight heparin is lower than with
conventional heparin. The INR should be maintained at 2.03.0 in this patient. The 2.53.5
range is used Ior patients with mechanical heart valves. The therapeutic INR should be
maintained Ior 36 months in a patient with a Iirst DVT related to travel.

4. Which one oI the Iollowing historical Ieatures is most suggestive oI congestive heart Iailure in
a 6-month-old white male presenting with tachypnea?
A. Diaphoresis with Ieeding
B. Fever
C. Nasal congestion
D. Noisy respiration or wheezing
E. Staccato cough
Your Answer: D
Correct Answer: A
Result: Incorrect
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 inIant`s greatest exertion is related to Ieeding. Fever
and nasal congestion are more suggestive oI inIectious problems. Noisy respiration or wheezing
does not distinguish between congestive heart Iailure, asthma, and inIectious processes. A
staccato cough is more suggestive oI an inIectious process, including pertussis.

5. In which one of the following clinical situations would it be most appropriate to use a
beta-blocker that has intrinsic sympathomimetic activity. such as acebutolol (Sectral) or
pindolol (Visken)?
A. As a cardioprotective agent post myocardial inIarction
B. In a hypertensive patient with symptomatic bradycardia while taking metoprolol
(Lopressor)
C. In a hypertensive patient with diabetes mellitus
D. In a hypertensive patient with asthma
E. To maintain sinus rhythm in a patient with chronic atrial Iibrillation
Your Answer: D
Correct Answer: B
Result: Incorrect
Beta-blockers with intrinsic sympathomimetic activity (ISA) are less beneIicial in reducing
mortality post myocardial inIarction, and Ior this reason are not recommended Ior ischemic heart
disease. They have a potential advantage in only one clinical situation. Since they tend to lower
heart rates less, they may be beneIicial in patients with symptomatic bradycardia while taking
other beta-blockers. All beta-blockers should be used cautiously in patients with diabetes or
asthma. Only sotalol, which delays ventricular depolarization, has been shown to be eIIective Ior
maintenance oI sinus rhythm in patients with chronic atrial Iibrillation.

6. You are treating a 50-year-old white male Ior diabetes mellitus and hyperlipidemia. At the
time oI his initial presentation 1 year ago, his hemoglobin A1c was 8.0 (N 3.86.4), LDL 130
mg/dL, HDL 28 mg/dL, and triglycerides 450 mg/dL. AIter treatment with metIormin
(Glucophage) and high-dose simvastatin (Zocor), his most recent laboratory evaluation revealed
a hemoglobin A1c oI 6.2, LDL 95 mg/dL, HDL 32 mg/dL, and triglycerides 300 mg/dL. The
patient has not had any documented coronary or peripheral vascular disease. His Iamily history is
positive Ior a myocardial inIarction in his Iather at age 55. He is a nonsmoker. He has a body
mass index (BMI) oI 28 and has been unable to lose weight. His blood pressure is well controlled
on enalapril (Vasotec). What is the most appropriate management oI his elevated triglycerides?
A. No speciIic treatment
B. Switch Irom metIormin to a sulIonylurea such as glyburide (Micronase, DiaBeta) or glipizide
(Glucotrol)
C. Addition oI a Iibrate such as gemIibrozil (Lopid) or IenoIibrate (Tricor)
D. Addition oI cholestyramine (Questran)
Your Answer: C
Correct Answer: C
Result: Correct
lthough the significance of elevated triglycerides and a low HDL in low-risk patients is
somewhat uncertain. in a high-risk patient such as a diabetic. improvement in these results
will lower the risk of subsequent cardiac events. In diabetics, metIormin and
thiazolidinediones (e.g., rosiglitazone) are more likely to improve lipid levels than are
sulIonylureas. Nicotinic acid is problematic in diabetics. as it tends to cause deterioration in
glucose control. Fibrates are good choices for this patient because they will lower the
triglyceride level and raise the HDL level. Exercise and weight loss are likely to be helpIul as
well. Cholestyramine will raise triglyceride levels.

7. Which one oI the Iollowing procedures carries the highest risk Ior postoperative deep venous
thrombosis?
A. Abdominal hysterectomy
B. Coronary artery bypass graIt
C. Transurethral prostatectomy
D. Lumbar laminectomy
E. Total knee replacement
Your Answer: E
Correct Answer: E
Result: Correct
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 iniury
and stasis, and impairment oI natural anticoagulants. For total knee replacement, hip Iracture
surgery, and total hip replacement, the prevalence oI DVT is 40-80, and the prevalence oI
pulmonary embolism is 2-30. Other orthopedic procedures, such as elective spine
procedures, have a much lower rate, approximately 5. The prevalence oI DVT aIter a coronary
artery bypass graIt is approximately 5, aIter transurethral prostatectomy 5, and aIter
abdominal hysterectomy approximately 16.

9. A 13-year-old male is Iound to have hypertrophic cardiomyopathy. His Iather also had
hypertrophic cardiomyopathy, and died suddenly at age 38 Iollowing a game oI tennis. The boy`s
mother asks you Ior advice regarding his condition. What advice should you give her?
A. He may participate in noncontact sports
B. He should receive liIelong treatment with beta-blockers
C. His condition usually decreases liIespan
D. His hypertrophy will regress with age
E. His siblings should undergo echocardiography
Your Answer: E
Correct Answer: E
Result: Correct
Hypertrophic cardiomyopathy is an autosomal dominant condition and close relatives oI
aIIected 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.
10. A 70-year-old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm.
You should usually recommend surgical intervention when the diameter oI the aneurysm
approaches:
A. 3.5 cm
B. 4.5 cm
C. 5.5 cm
D. 6.5 cm
E. 7.5 cm
Your Answer: C
Correct Answer: C
Result: Correct
Based on recent clinical trials. the most common recommendation for surgical repair is when
the aortic aneurysm approaches 5.5 cm in diameter. Two large studies, the Aneurysm
Detection and Management (ADAM) Veteran AIIairs Cooperative Study, and the United
Kingdom Small Aneurysm Trial, Iailed to show any beneIit Irom early surgery Ior men with
aneurysms less than 5.5 cm in diameter. The risks oI aneurysm rupture were 1 or less in both
studies, with 6-year cumulative survivals oI 74 and 64, respectively. Interestingly, the risk
Ior aneurysm rupture was Iour times greater in women, indicating that 5.5 cm may be too high,
but a new evidence-based threshold has not yet been deIined.

4. 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 Iairly active until the shortness
oI breath slowed him down recently. You hear a grade 3/6 systolic eiection murmur at the right
upper sternal border which radiates into the neck. Echocardiography reveals aortic stenosis, with
a mean transvalvular gradient oI 55 mm Hg and a calculated valve area oI 0.6 cm
2
. LeIt
ventricular Iunction is normal. Which one oI the Iollowing is appropriate management Ior this
patient?
A. Aortic valve replacement
B. Aortic balloon valvotomy
C. Medical management with beta-blockers and nitrates
D. WatchIul waiting until the gradient is severe enough Ior treatment
E. DeIerring the decision pending results oI an exercise stress test
Your Answer: A
Correct Answer: A
Result: Correct
Since this patient`s mean aortic-valve gradient exceeds 50 mm Hg and the aortic-valve area is
not larger than 1 cm
2
, it is likely that his symptoms are due to aortic stenosis. s 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 eIIective, and balloon valvotomy only temporarily relieves the symptoms and
does not prolong survival. Patients who present with dyspnea have only a 50 chance oI being
alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and
dangerous in patients with symptomatic aortic stenosis

5. A 73-year-old white male nursing-home resident has Alzheimer`s dementia and hypertension.
He has been weaker and less responsive over the last week and has gained 8 lb. On physical
examination he has normal vital signs with a heart rate oI 110 beats/min, but is noted to have
marked lower extremity edema and presacral edema. Laboratory evaluation shows a serum
sodium level oI 122 mmol/L (N 135145). Which one oI the Iollowing is the most likely cause
oI his hyponatremia?
A. Diuretic use
B. Syndrome oI inappropriate secretion oI antidiuretic hormone (SIADH)
C. Addison`s disease
D. Congestive heart Iailure
E. Psychogenic polydipsia
Your Answer: E
Correct Answer: D
Result: Incorrect
ost decision trees for the evaluation of hyponatremia begin with an assessment of volume
status; edema reflects volume overload and increased total body sodium caused by
congestive heart failure. cirrhosis. or renal failure. If edema is absent. plasma osmolality
should be determined. SIDH. ddison`s disease (hypoadrenalism). diuretic use. and renal
artery stenosis all lower serum osmolality. Urine electrolytes help distinguish the other
conditions: psychogenic polydipsia causes low urine sodium, while SIADH and hypoadrenalism
cause inappropriately elevated urine sodium. Diuretic use, a very common cause oI
hyponatremia in the geriatric population, causes hypovolemic hyponatremia and can be
associated with either high or low urine sodium, but there is oIten concomitant hypokalemia.

7. Which one of the following is considered a contraindication to the use of beta-blockers
for congestive heart failure?
A. Mild asthma
B. Symptomatic heart block
C. New York Heart Association (NYHA) Class III heart Iailure
D. NYHA Class I heart Iailure in a patient with a history oI a previous myocardial inIarction
E. An eiection Iraction 30
Your Answer: E
Correct Answer: B
Result: Incorrect
According to several randomized, controlled trials, mortality rates are improved in patients with
heart Iailure 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 Ior potential exacerbations. Beta-blocker use has been
shown to be eIIective in patients with NYHA Class II or III heart Iailure. There is no absolute
threshold eiection Iraction. Beta-blockers have also been shown to decrease mortality in patients
with a previous history oI myocardial inIarction, regardless oI their NYHA classiIication

10. A 72-year-old AIrican-American male comes to your oIIice Ior surgical clearance to undergo
elective hemicolectomy Ior recurrent diverticulitis. The patient suIIered an uncomplicated acute
anterior-wall myocardial inIarction approximately 18 months ago. A stress test was normal 2
months aIter he was discharged Irom the hospital. Currently, the patient Ieels well, walks while
playing nine holes oI golI three times per week, and is able to walk up a Ilight oI stairs without
chest pain or signiIicant dyspnea. Findings are normal on a physical examination. Which one oI
the Iollowing would be most appropriate Ior this patient prior to surgery?
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
Your Answer: C
Correct Answer: A
Result: Incorrect
The current recommendations Irom the American College oI 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 Ior most surgery primarily on the basis oI their Iunctional status. II these
patients are capable oI moderate activity (greater than 4 METs) without cardiac symptoms, they
can be cleared with no stress testing or coronary angiography Ior an elective minor or
intermediate-risk operation such as the one this patient is to undergo. 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.

2. An anxious and agitated 18-year-old white male presents to your oIIice with a 2-hour history
oI severe muscle spasms in the neck and back. He was seen 2 days ago in a local emergency
department with symptoms oI gastroenteritis, treated with intravenous Iluids, and sent home with
a prescription Ior prochlorperazine (Compazine) suppositories. The best therapy Ior this problem
is intravenous administration oI:
A. atropine
B. diphenhydramine (Benadryl)
C. haloperidol
D. succinylcholine (Anectine)
E. carbamazepine (Tegretol)
Your Answer: B
Correct Answer: B
Result: Correct
While rarely liIe threatening, an acute dystonic reaction can be Irightening and painIul to the
patient and conIusing to the treating physician who may be unaware oI what medications the
patient is taking. Dystonia can be caused by any agent that blocks dopamine, including
prochlorperazine. metoclopramide. and typical neuroleptic agents such as haloperidol. The
acute treatment of choice is diphenhydramine or benztropine.

3. In a patient with a severe anaphylactic reaction to peanuts, the most appropriate route Ior
epinephrine is:
A. intramuscular
B. intravenous
C. oral
D. subcutaneous
E. sublingual
Your Answer: A
Correct Answer: A
Result: Correct
Intramuscular epinephrine is the recommended drug for anaphylactic reactions (SOR A).
Epinephrine is absorbed more rapidly intramuscularly than subcutaneously.

4. A 19-year-old college student comes to your oIIice with signiIicant pain in his right great toe
that is making it diIIicult Ior him to walk. He has never had this problem beIore.
When you examine him you Iind increased swelling with marked erythema and seropurulent
drainage and ulceration oI the medial nail Iold. The toe is very tender to touch, particularly when
pressure is applied to the tip oI the toe. The most appropriate initial management would be:

A. oral antibiotics that cover common skin Ilora, Ior 57 days
B. soaking the toe in warm, soapy water Ior 1020 minutes twice daily, Iollowed by application
oI a topical antibiotic, with a return visit in 35 days
C. elevation oI the nail with a wisp oI cotton
D. partial avulsion oI the medial nail plate and phenolization oI the matrix at this visit
E. partial avulsion oI both the medial and lateral nail plates at this visit
Your Answer: B
Correct Answer: D
Result: Incorrect
This ingrown nail meets the criteria Ior moderate severity: increased swelling. seropurulent
drainage. infection. and ulceration of the nail fold. In these cases, antibiotics beIore or aIter
phenolization oI the matrix do not decrease healing time, postoperative morbidity, or recurrence
rates (SOR B). A conservative approach, elevating the nail edge with a wisp of cotton or a
gutter splint. is reasonable in patients with a mild to moderate ingrown toenail who do not
have significant pain. substantial erythema. or purulent drainage.
Either immediate partial nail avulsion followed by phenolization. or direct surgical excision
of the nail matrix is effective for the treatment of ingrown nails (SOR B). Pretreatment with
soaking and antibiotics has not been demonstrated to add therapeutic beneIit or to speed
resolution. Several studies demonstrate that once the ingrown portion oI the nail is removed and
matricectomy is perIormed, the localized inIection will resolve without the need Ior antibiotic
therapy. Bilateral partial matricectomy maintains the Iunctional role oI the nail plate (although it
narrows the nail plate) and should be considered in patients with a severe ingrown toenail or to
manage recurrences.

5. A 59-year-old male who is morbidly obese suIIers a cardiac arrest. Intravenous access cannot
be obtained. Which one oI the Iollowing is true regarding intraosseous drug administration in
this patient?
A. The patient`s age and size are a contraindication to intraosseous administration
B. The time needed to establish intraosseous access is too great
C. Many drugs cannot be administered intraosseously
D. Endotracheal administration is preIerred
E. There are no contraindications to intraosseous administration in this patient
Your Answer: E
Correct Answer: E
Result: Correct
The current American Heart Association ACLS guidelines state that intraosseous access can be
obtained in almost all age groups rapidly. and is preferred over the endotracheal route.
ny drug that can be administered intravenously can be administered intraosseously.
Many drugs administered via an endotracheal tube are poorly absorbed, and drug levels vary
widely.

8. A 30-year-old male presents with a 3-week history oI severe, burning pain in his right
shoulder. He recalls no mechanism oI iniury. An examination reveals weakness to resistance oI
the biceps and triceps, and with external rotation oI the shoulder. Full range oI motion oI the
neck and shoulder does not worsen the pain.
Which one oI the Iollowing would be most likely to identiIy the cause oI this patient`s problem?
A. Electromyography and nerve conduction studies
B. MRI oI the neck
C. MR arthrography (MRA) oI the shoulder
D. CT oI the brain
E. Ultrasonography oI the upper extremity
Your Answer: B
Correct Answer: A
Result: Incorrect
This patient has brachial neuritis. which can be difficult to differentiate from cervical
radiculopathy. shoulder pathology. and cerebrovascular accident. The pain preceded the
weakness. no trauma was involved. and the weakness is in a nondermatomal distribution.
making brachial neuritis the most likely diagnosis. Electromyography is most likely to
show this lesion. but only after 3 weeks of symptoms. MRI oI the neck may show
abnormalities, but not the cause oI the current problem. Symptoms are not consistent with
shoulder pathology, deep-vein thrombosis oI the upper extremity, or cerebrovascular accident.

9. A 30-year-old AIrican-American Iemale is being evaluated because oI absent menses Ior the
last 6 months. Menarche was at age 12. Her menstrual periods have Irequently been irregular,
and are accompanied only occasionally by dysmenorrhea. She had her Iirst child 4 years ago, but
has not been able to become pregnant since. A physical examination and pelvic examination are
unremarkable. A serum pregnancy test is negative, prolactin levels are normal, and LH and FSH
levels are both three times normal on two occasions.
These Iindings are consistent with:
A. hypothalamic amenorrhea
B. ovarian Iailure
C. pituitary microadenoma
D. polycystic ovary syndrome
Your Answer: D
Correct Answer: B
Result: Incorrect
The history and physical Iindings in this patient are consistent with all oI the conditions listed.
However. the elevated FSH and LH indicate an ovarian problem. and this case is consistent
with ovarian failure or premature menopause. Most pituitary tumors associated with
amenorrhea produce hyperprolactinemia. Polycystic ovary syndrome usually results in normal
to slightly elevated LH levels and tonically low FSH levels. Hypothalamic amenorrhea is a
diagnosis oI exclusion, and can be induced by weight loss, excessive physical exercise (running,
ballet), or systemic illness. It is associated with tonically low levels oI LH and FSH.

1. A 26-month-old child presents with a 2-day history oI 68 loose stools per day and a low-
grade Iever. When evaluating the child to determine whether he is dehydrated, which one oI the
Iollowing would NOT be useIul?
A. Skin turgor
B. Capillary reIill time
C. Respiratory rate and pattern
D. The BUN/creatinine ratio
E. The serum bicarbonate level
Your Answer: D
Correct Answer: D
Result: Correct
The most useful findings for identifying dehydration are prolonged capillary refill time.
abnormal skin turgor. and abnormal respiratory pattern (SOR C). Capillary reIill time is not
aIIected by Iever and should be less than 2 seconds. Skin recoil is normally instantaneous, but
recoil time increases linearly with the degree oI dehydration. The respiratory pattern should be
compared with age-speciIic normal values, but will be increased and sometimes labored,
depending on the degree oI dehydration.
Unlike in adults. calculation of the BUN/creatinine ratio is not useful in children. lthough
the normal BUN level is the same for children and adults. the normal serum creatinine
level changes with age in children. In combination with other clinical indicators, a low serum
bicarbonate level (17 mmol/L) is helpIul in identiIying children who are dehydrated, and a level
13 mmol/L is associated with an increased risk oI Iailure oI outpatient rehydration eIIorts.

2. A 70-year-old Asian male presents with hematochezia. He has stable vital signs. Lower
endoscopy is perIormed, but is unsuccessIul due to active bleeding.

A. Abdominal CT
B. A barium enema
C. A technetium-99m blood pool scan
D. Exploratory laparotomy
E. A small-bowel radiograph
Your Answer: A
Correct Answer: C
Result: Incorrect
In most patients with heavy gastrointestinal bleeding. localizing the bleeding site. rather
than diagnosing the cause of the bleeding. is the most important task. A lower GI series is
usually nondiagnostic during heavy, active bleeding. A small-bowel radiograph may be helpIul
aIter the active bleeding has stopped, but not during the acute phase oI the bleeding. blood
pool scan allows repeated scanning over a prolonged period of time. with the goal of
permitting enough accumulation of the isotope to direct the arteriographer to the most
likely source of the bleeding. II the scan is negative, arteriography would be unlikely to reveal
the active source oI bleeding, and is also a more invasive procedure. Exploratory laparotomy
may be indicated iI a blood pool scan or an arteriogram is nondiagnostic and the patient
continues to bleed heavily.

3. A patient presenting with severe carbon monoxide poisoning should be treated with:
A. inhaled helium
B. supplemental oxygen
C. intravenous calcium gluconate
D. intravenous iron
E. intravenous magnesium
Your Answer: B
Correct Answer: B
Result: Correct
Patients with carbon monoxide poisoning should be treated immediately with normobaric
oxygen, which speeds up the excretion oI carbon monoxide.

6. A 40-year-old nurse presents with a 1-year history oI rhinitis, and a more recent onset oI
episodic wheezing and dyspnea. Her symptoms seem to improve when she is on vacation. She
does not smoke, although she says that her husband does. Her FEV
1
improves 20 with
inhaled -agonists.
A. Occupational asthma
B. Sarcoidosis
C. COPD
D. Anxiety
E. Vocal cord dysIunction
Your Answer: A
Correct Answer: A
Result: Correct
Occupational asthma merits special consideration in all cases of new adult asthma or
recurrence of childhood asthma after a significant asymptomatic period (SOR C).
Occupational asthma is oIten preceded by the development oI rhinitis in the workplace and
should be considered in patients whose symptoms improve away Irom work. Reversibility with
-agonist use makes COPD less likely, in addition to the Iact that the patient is a nonsmoker.
Cystic Iibrosis is not a likely diagnosis in a patient this age with a long history oI being
asymptomatic. Sarcoidosis would be less likely to cause reversible airway obstruction and
intermittent symptoms. Vocal cord dysIunction would not be expected to respond to
bronchodilators.

7. A previously healthy 60-year-old male is diagnosed with multiple myeloma aIter a workup Ior
an incidental Iinding on routine laboratory work. He has no identiIied organ or tissue damage
and is asymptomatic.
Which one oI the Iollowing would be appropriate treatment oI this patient`s condition?
A. No treatment
B. Chemotherapy
C. Autologous stem cell transplantation
D. Radiation
Your Answer: A
Correct Answer: A
Result: Correct
This patient has smoldering (asymptomatic) multiple myeloma. He does not have any organ or
tissue damage related to this disease and has no symptoms. Early treatment oI these patients does
not improve mortality (SOR A) and may increase the likelihood oI developing acute leukemia.
The standard treatment Ior symptomatic patients under age 65 is autologous stem cell
transplantation. Patients over 65 who are healthy enough to undergo transplantation would also
be appropriate candidates. Patients who are not candidates Ior autologous stem cell
transplantation generally receive melphalan and prednisolone with or without thalidomide.
Radiotherapy can be used to relieve metastatic bone pain or spinal cord compression.

8. A 35-year-old male presents with a 4-month history oI pain in the lower lumbar region
without radiation. He works in retail sales, and the pain and stiIIness prevent him Irom working.
He estimates the pain to be 7 on a 10-point scale. He has been under the care oI a chiropractor
and has experienced some relieI with spinal manipulation. His history is negative Ior red Ilags
indicating a serious cause Ior his pain.
The only positive Iindings on a physical examination are diIIuse mild tenderness over the lumbar
region and mild limitation oI lumbar mobility on Iorward and lateral Ilexion/extension
maneuvers. Appropriate laboratory tests and imaging studies are all within normal limits.
In addition to appropriate analgesics, which one oI the Iollowing modalities has the best
evidence oI long-term beneIit in this situation?
A. Transdermal electric nerve stimulation (TENS)
B. Epidural corticosteroid iniections
C. SSRIs
D. Multidisciplinary rehabilitation
Your Answer: D
Correct Answer: D
Result: Correct
This patient has nonspecific chronic back pain. most likely a lumbar strain or sprain. In
addition to analgesics (e.g.. acetaminophen or NSIDs) (SOR ) and spinal manipulation
(SOR B). a multidisciplinary rehabilitation program is the best choice for management
(SOR A). This program includes a physician and at least one additional intervention
(psychological, social, or vocational). Such programs alleviate subiective disability, reduce pain,
return the person to work earlier, and reduce the amount oI sick time taken in the Iirst year by 7
days. BeneIits persist Ior up to 5 years. Back school, TENS, and SSRIs have been Iound to have
negative or conIlicting evidence oI eIIectiveness (SOR C). There is no evidence to support the
use oI epidural corticosteroid iniections in patients without radicular signs or symptoms (SOR
C).
.
9. A 55-year-old male presents to your oIIice Ior evaluation oI increasing dyspnea with exertion
over the past 2 weeks. He has smoked 2 packs oI cigarettes per day since the age oI 20. He has
had a chronic cough Ior years, along with daily sputum production. He was given an albuterol
inhaler Ior wheezing in the past, which he uses intermittently. On examination he has a severe
decrease in breath sounds, no evidence oI iugular venous distention, no cardiac murmur, and no
peripheral edema. A chest Iilm shows hyperinIlation, but no inIiltrates or pleural eIIusion. OIIice
spirometry shows that his FEV
1
is only 55 oI the predicted value.
You consider using inhaled corticosteroids as part oI the treatment regimen Ior this patient. This
has been shown to:
A. increase cataract Iormation
B. increase the incidence oI Iracture
C. increase the risk oI pneumonia
D. slow the progression oI the disease
E. improve overall mortality Irom the disease
Your Answer: C
Correct Answer: C
Result: Correct
COPD has several symptoms, including poor exercise tolerance, chronic cough, sputum
production, dyspnea, and signs oI right-sided heart Iailure. The most common etiology is
cigarette smoking. A patient with any combination oI two oI these Iindings, such as a 70-pack-
year history oI smoking, decreased breath sounds, or a history oI COPD, likely has airflow
obstruction. defined as an FE'
1
<60 of the predicted value. In stable COPD. treatment is
reserved for patients who have symptoms and airflow obstruction. Treatment options Ior
monotherapy are all similar in eIIectiveness and include long-acting inhaled anticholinergics,
long-acting -agonists, and inhaled corticosteroids.
Inhaled corticosteroids will not reduce mortality or affect long-term progression of COPD.
However. they do reduce the number of exacerbations and the rate of decline in the quality
of life. There appears to be no increase in cataract Iormation or rate oI Iracture. These agents do
have side effects. including candidal infection of the oropharynx. hoarseness. and an
increased risk of developing pneumonia.

1he flndlna of a normal paraLhvrold hormone (1P) level ln a paLlenL wlLh hvpercalcemla ls dlaanosLlc
for hvperparaLhvroldlsm slnce 1P should be suppressed ln Lhe presence of elevaLed calclum
SvmpLomaLlc hvpercalcemla causes dehvdraLlon because of boLh lnLesLlnal svmpLoms and dluresls
8everslble renal lnsufflclencv can resulL and can become permanenL lf lL ls lonasLandlna and severe

LffecLlve oral anLlvlral druas are now avallable for chronlc hepaLlLls 8 (aL a cosL of abouL $ per dav)
and can be added Lo hlahlv acLlve anLlreLrovlrals

ln paLlenLs wlLh renal fallure Lhe rlsk for deaLh and serlous cardlovascular evenLs ls lncreased wlLh
hlaher hemoalobln levels (13 a/dL) and lL ls Lherefore recommended LhaL levels be malnLalned aL 1
1 a/dL (n 11)

lnLrahepaLlc cholesLasls of preanancv classlcallv presenLs as severe prurlLus ln Lhe Lhlrd LrlmesLer
CharacLerlsLlc flndlnas lnclude Lhe absence of prlmarv skln leslons and elevaLlon of serum levels of LoLal
blle aclds !aundlce and elevaLed blllrubln levels mav or mav noL be presenL 1he CC1 usuallv ls normal
or modesLlv elevaLed whlch can help dlfferenLlaLe Lhls condlLlon from oLher cholesLaLlc llver dlseases

lanLar fascllLls ls an overuse ln[urv due Lo mlcroLrauma of Lhe planLar fascla where lL aLLaches aL Lhe
medlal calcaneal Lubercle 1he paLlenL experlences heel or arch paln whlch ofLen ls worse upon arlslna
and Laklna Lhe flrsL few sLeps of Lhe mornlna LxamlnaLlon reveals Lenderness aL Lhe slLe and paln wlLh
dorslflexlon of Lhe Loes

1reaLmenL sLraLeales lnclude relaLlve resL lce nSAlus and prefabrlcaLed shoe lnserLs LhaL provlde arch
supporL as well as heel cord and planLar fascla sLreLchlna

lf conservaLlve Lherapv falls a corLlcosLerold ln[ecLlon mav be useful Suraerv ls reserved for paLlenLs
refracLorv Lo 61 monLhs of unlnLerrupLed conservaLlve Lherapv

rlmarv prevenLlon LaraeLs lndlvlduals who mav be aL rlsk Lo develop a medlcal condlLlon and lnLervenes
Lo prevenL Lhe onseL of LhaL condlLlon (ea chlldhood vacclnaLlon proarams waLer fluorldaLlon
anLlsmoklna proarams and educaLlon abouL safe sex)

Secondarv prevenLlon LaraeLs lndlvlduals who have developed an asvmpLomaLlc dlsease and lnsLlLuLes
LreaLmenL Lo prevenL compllcaLlons (ea rouLlne apanlcolaou smears and screenlna for hvperLenslon
dlabeLes or hvperllpldemla)

1erLlarv prevenLlon LaraeLs lndlvlduals wlLh a known dlsease wlLh Lhe aoal of llmlLlna or prevenLlna
fuLure compllcaLlons (ea screenlna dlabeLlcs for mlcroalbumlnurla rlaorous LreaLmenL of dlabeLes
melllLus and posLmvocardlal lnfarcLlon prophvlaxls wlLh blockers and asplrln)

1oplcal muplrocln ls as effecLlve as cephalexln or amoxlclllln/clavulanaLe ln Lhe LreaLmenL of lmpeLlao
whlch ls mosL ofLen caused bv SLaphlococcal specles Cral penlclllln v oral ervLhromvcln and Loplcal
baclLracln are less effecLlve Lhan muplrocln 1oplcal LreaLmenL ls well sulLed Lo Lhls locallzed leslon

ln facL Lhe ma[orlLv of paLlenLs wlLh 1M! dlsorders have sponLaneous resoluLlon of svmpLoms so
nonlnvaslve svmpLomaLlc LreaLmenLs and LlncLure of Llme are Lhe besL approach for mosL

noreplnephrlne and dopamlne currenLlv are Lhe preferred pressor aaenLs however noreplnephrlne
appears Lo be more effecLlve and has a lower morLallLv raLe

uopamlne ls no lonaer recommended based on a cllnlcal Lrlal showlna no beneflL ln crlLlcallv lll paLlenLs
aL rlsk for renal fallure

CeneLlc dlsorders (ea Waardenbura svndrome usher's svndrome AlporL svndrome and 1urner's
svndrome) are responslble for more Lhan 3 of hearlna lmpalrmenLs ln chlldren

1he prlmarv aoals of aLrlal flbrlllaLlon LreaLmenL are raLe conLrol and prevenLlon of Lhromboembollsm
Culdellnes recommend raLe conLrol wlLh aLenolol meLoprolol dllLlazem or verapamll

1esLosLerone lncreases hemaLocrlL and can cause polvcvLhemla 1esLosLerone should be dlsconLlnued lf
Lhere ls more Lhan a 3 rlse ln hemaLocrlL

8lsk facLors for proxlmal neoplasla lnclude hlaharade dvsplasla Lhree or more adenomas adenomas
wlLh vlllous feaLures and an adenoma 1 cm ln slze lor paLlenLs wlLh one or more of Lhese flndlnas
followup colonoscopv ln vears ls recommended

Cral lron ls absorbed beLLer wlLh an acldlc aasLrlc envlronmenL whlch can be accompllshed wlLh Lhe
concomlLanL admlnlsLraLlon of vlLamln C AaenLs LhaL ralse aasLrlc pP such as anLaclds proLon pump
lnhlblLors and P blockers should be avolded lf posslble Cral lron absorpLlon ls lmproved lf Lhe lron ls
Laken on an empLv sLomach buL Lhls mav noL be well LoleraLed because aasLrlc lrrlLaLlon ls a frequenL
slde effecL

MosL Llnea lnfecLlons respond Lo Loplcal Lherapv buL oral Lherapv ls requlred for Llnea caplLls so LhaL Lhe
drua wlll peneLraLe Lhe halr shafLs

llbromvalala

1he dlaanosls ls speclflc and requlres Lhe flndlna of aL leasL 11 Lender polnLs ln 1 posslble speclflc
anaLomlc locaLlons wlLh Lhe paln occurrlna boLh above and below Lhe walsL on boLh sldes of Lhe bodv
for aL leasL monLhs

1here ls sLrona evldence for Lhe effecLlveness of boLh pharmacoloalc Lheraples such as cvclobenzaprlne
and nonpharmacoloalc Lheraples such as aeroblc exerclse coanlLlvebehavloral Lherapv and
mulLldlsclpllnarv approaches LhaL lnclude paLlenL educaLlon and exerclse

A poslLlve dlpsLlck for hemoalobln wlLhouL anv 88Cs noLed ln Lhe urlne sedlmenL lndlcaLes elLher free
hemoalobln or mvoalobln ln Lhe urlne

lf a Lransfuslon reacLlon occurs hapLoalobln blnds enouah free hemoalobln ln Lhe serum Lo alve lL a plnk
coloraLlon Cnlv when hapLoalobln ls saLuraLed wlll Lhe free hemoalobln be excreLed ln Lhe urlne

Mvoalobln ls released when skeleLal muscle ls desLroved bv Lrauma lnfarcLlon or lnLrlnslc muscle
dlsease

Amvlase and llpase levels are used Lo help make Lhe dlaanosls of acuLe pancreaLlLls

1he serum llpase level ls more speclflc and more senslLlve Lhan Lhe amvlase level

Amvlase elevaLlons can be seen wlLh oLher abdomlnal lllnesses such as lnflammaLlon of Lhe small
bowel

Alcohollcs wlLh recurrenL pancreaLlLls mav have normal serum amvlase levels ln such cases serum
llpase would be a beLLer LesL

ulLrasonoaraphv of Lhe rlahL upper quadranL ls recommended as Lhe lnlLlal lmaalna sLudv for rlahL upper
quadranL paln

Abdomlnal C1 wlLh lnLravenous conLrasL ls Lhe preferred LesL for rlahL lower quadranL paln and
abdomlnal C1 wlLh lnLravenous and oral conLrasL ls preferred for lefL lower quadranL paln

uupuvLren's dlsease
lL lnlLlallv can be manaaed wlLh observaLlon buL corLlcosLerold ln[ecLlon and suraerv mav be needed
1he condlLlon wlll rearess ln 1 of paLlenLs 1here ls a prevalence of uupuvLren's conLracLure
ln paLlenLs wlLh dlabeLes melllLus however Lhese paLlenLs Lend Lo have a mlld form of Lhe dlsease wlLh
slow proaresslon

Several sLudles have demonsLraLed LhaL hvdraLlon wlLh sodlum blcarbonaLeconLalnlna flulds reduces
Lhe rlsk of conLrasLlnduced nephropaLhv ln Lhose underaolna cardlac caLheLerlzaLlon

PealLhcare workers exposed Lo a paLlenL wlLh menlnaococcal menlnalLls are aL lncreased rlsk of
developlna svsLemlc dlsease and should recelve chemoprophvlaxls especlallv lf Lhe conLacL ls lnLlmaLe
Secondarv cases usuallv occur wlLhln 4 davs of Lhe lnlLlal case 1herefore prophvlacLlc LreaLmenL should
bealn as soon as posslble 8lfampln has been shown Lo be 9 effecLlve ln ellmlnaLlna menlnaococcus
from Lhe nasopharvnx

1hls paLlenL has unllaLeral serous oLlLls and ls unllkelv Lo have delaved lanauaae from decreased hearlna
on one slde 1he paLlenL should be observed for now Pearlna loss of lonaer Lhan monLhs mav
lndlcaLe a need for LvmpanosLomv Lubes

CurrenL recommendaLlons for dlaanoslna dlabeLes melllLus are based on elLher a fasLlna alucose level or
a hour 3a oral alucose Lolerance LesL A casual blood alucose level ma/dL ls also dlaanosLlc of
dlabeLes melllLus ln paLlenLs wlLh svmpLoms of hvperalvcemla

ln acuLe ankle spralns funcLlonal LreaLmenL wlLh a semlrlald brace LhaL allows flexlon and axLenslon or
a sofL laceup brace ls recommended over lmmoblllzaLlon

1hls paLlenL had a classlc slmple febrlle selzure and no addlLlonal dlaanosLlc sLudles are recommended
A lumbar puncLure followlna a selzure ls noL rouLlnelv recommended ln a chlld over 1 monLhs of aae
slnce bv LhaL aae a paLlenL wlLh menlnalLls would be expecLed Lo demonsLraLe menlnaeal slans and
svmpLoms or cllnlcal flndlnas suaaesLlna an lnLracranlal lnfecLlon

aLellofemoral paln svndrome ls a cllnlcal dlaanosls and ls Lhe mosL common cause of knee paln ln Lhe
ouLpaLlenL seLLlna lL ls characLerlzed bv anLerlor knee paln parLlcularlv wlLh acLlvlLles LhaL overload Lhe
[olnL such as sLalr cllmblna runnlna and squaLLlna aLlenLs complaln of popplna caLchlna sLlffness
and alvlna wav Cn examlnaLlon Lhere wlll be a poslLlve ! slan wlLh Lhe paLella movlna from a medlal Lo
a laLeral locaLlon when Lhe knee ls fullv exLended from Lhe 9 poslLlon 1hls ls caused bv an lmbalance
ln Lhe medlal and laLeral forces acLlna on Lhe paLella Locklna ls noL characLerlsLlc of paLellofemoral paln
svndrome so a loose bodv or menlscal Lear should be consldered lf Lhls ls reporLed

neumococcal and menlnaococcal vacclnes are currenLlv recommended for paLlenLs wlLh asplenla
Paemophllus lnfluenzae Lvpe b (Plb) vacclne can be consldered as well

8heumaLold arLhrlLls ls prlmarllv a cllnlcal dlaanosls and no slnale laboraLorv LesL ls consldered
deflnlLlvelv dlaanosLlc AnLlcvcllc clLrulllnaLed pepLlde (anLlCC) anLlbodv ls recommended bv
rheumaLoloalsLs Lo lmprove Lhe speclflclLv of LesLlna for rheumaLold arLhrlLls AnLlCC ls more speclflc
Lhan rheumaLold facLor and mav predlcL eroslve dlsease more accuraLelv

nonpharmacoloalc Lherapv ls recommended for all paLlenLs wlLh an overacLlve bladder elvlc floor
muscle Lralnlna (ea keael exerclses) and bladder Lralnlna are proven effecLlve ln urae lnconLlnence or
overacLlve bladder as well as ln sLress and mlxed lnconLlnence ln moLlvaLed paLlenLs Lralnlna mav be
more effecLlve Lhan medlcaLlons such as oxvbuLvnln and newer muscarlnlc recepLor anLaaonlsLs such as
sollfenacln

1he ophLhalmopaLhv of Crave's dlsease mav lnlLlallv flare and worsen when LreaLed wlLh radloacLlve
lodlne AnLlLhvrold druas lncludlna propvlLhlouracll and meLhlmazole are noL assoclaLed wlLh Lhls
problem

An acuLe rupLure of anv ma[or Lendon should be repalred as soon as posslble AcuLe Lears of Lhe roLaLor
cuff should be repalred wlLhln 6 weeks of Lhe ln[urv lf posslble

CauLlous reducLlon of svsLollc blood pressure bv 113 whlle monlLorlna neuroloalc sLaLus seems Lo
be Lhe safesL LreaLmenL aoal ln Lhe seLLlna of acuLe lschemlc sLroke when Lhe svsLollc blood pressure ls
mm Pa or Lhe dlasLollc blood pressure ls 114 mm Pa

lL ls now recommended LhaL all lnfanLs and chlldren lncludlna adolescenLs have a mlnlmum dallv lnLake
of 4 lu of vlLamln u bealnnlna soon afLer blrLh

1hls paLlenL ls aL hlah rlsk for c/ostridium diffici/eassoc|ated d|arrhea based on hls aae and hls recenL
broadspecLrum anLlbloLlc use 1he |n|t|a| management |s to stop the ant|b|ot|cs 1reaLmenL should noL
be lnlLlaLed unless Lhe sLool ls poslLlve for Loxlns A and 8 1he recommended lnlLlal LreaLmenL for c
Jlfflclle enLerlLls ls oral meLronldazole robloLlcs mav be useful for prevenLlon buL Lhelr use ls
conLroverslal operam|de shou|d be avo|ded as |t can s|ow down trans|t t|mes and worsen tox|n
med|ated d|arrhea

1hls paLlenL has epldldvmlLls ln males 143 vears of aae Lhe mosL common causes are -elssetlo
oooottboeoe and cblomvJlo ttocbomotls 1he recommended LreaLmenL ln Lhls aae aroup ls cefLrlaxone
3 ma lnLramuscularlv and doxvcvcllne 1 ma Lwlce dallv for 1 davs (SC8 C) A slnale 1a dose of
azlLhromvcln mav be subsLlLuLed for doxvcvcllne ln Lhose under aae 14 or over aae 3 Lhe lnfecLlon ls
usuallv caused bv one of Lhe common urlnarv LracL paLhoaens and levofloxacln 3 ma once dallv for
1 davs would be Lhe approprlaLe LreaLmenL

Alkallne phosphaLase ls elevaLed ln condlLlons affecLlna Lhe bones llver small lnLesLlne and placenLa
1he addlLlon of elevaLed 3nucleoLldase suaaesLs Lhe llver as Lhe focus of Lhe problem Measurlna 3
nucleoLldase Lo deLermlne wheLher Lhe alkallne phosphaLase elevaLlon ls due Lo a hepaLlc problem ls
well subsLanLlaLed pracLlcal and cosL effecLlve

1he scenarlo descrlbed ls susplclous for an occu|t fracture of the scapho|d bone of Lhe wrlsL 1he
mechanlsm of ln[urv fa|||ng on an outstretched hand w|th the wr|st extended comblned wlLh
tenderness |n the anatom|c snuff box (beLween Lhe exLensor polllcls lonaus and exLensor polllcls brevls
Lendons) ralses Lhe posslblllLv of a scaphold fracLure even lf lnlLlal radloaraphs are neaaLlve ln order Lo
reduce the potent|a| for ser|ous comp||cat|ons |nc|ud|ng vascu|ar necros|s and nonun|on |t |s
|mperat|ve that both the wr|st and the thumb be |mmob|||zed In the case descr|bed a thumb sp|ca
sp||nt |s the best opt|on |n|t|a||y

1he mosL common adverse evenL aLLrlbuLed Lo varenlcllne aL a dosaae of 1 ma Lwlce a dav ls nausea
occurrlna ln approxlmaLelv 3 of paLlenLs 1aklna Lhe drua wlLh food lessens Lhe nausea

Bullous impetigo is a localized skin inIection characterized by large bullae; it is caused by
phage group II Staphvlococcu8 aureu8. Cultures oI Iluid Irom an intact blister will reveal the
causative agent. The lesions are caused by exfolatin, a local toxin produced by the $ aureus, and
develop on intact skin. Complications are rare, but cellulitis occurs in 10 oI cases. Strains oI
$taphvlococcus associated with impetigo in the U.S. have little or no nephritogenic potential.
Systemic therapy should be used in patients with widespread lesions. With the emergence oI
MRSA, trimethoprim/sulfamethoxazole and clindamycin are options for outpatient
therapy. Intravenous vancomycin can be used to treat hospitalized patients with more severe
inIections.

ln one sLudv of paLlenLs wlLh dermaLomvoslLls had cancer 1he rlsk of cancer was hlahesL aL Lhe
Llme of dlaanosls buL remalned hlah lnLo Lhe Lhlrd vear afLer dlaanosls
Cancer raLes ln paLlenLs wlLh rheumaLold arLhrlLls svsLemlc lupus ervLhemaLosus and scleroderma were
above Lhose of Lhe aeneral populaLlon buL much lower Lhan for paLlenLs wlLh dermaLomvoslLls ln
S[aren's svndrome Lhe rlsk of nonPodakln's lvmphoma ls 44 Llmes hlaher Lhan ln Lhe aeneral
populaLlon wlLh an lndlvldual llfeLlme rlsk of 61

SvmpLoms conslsLenL wlLh procLalala fuaax occur ln 119 of Lhe aeneral populaLlon 1hese conslsL
of eplsodlc sudden sharp palns ln Lhe anorecLal area lasLlna several seconds Lo mlnuLes 1he dlaanosls
ls based on a hlsLorv LhaL flLs Lhe classlc plcLure ln a paLlenL wlLh a normal examlnaLlon All Lhe oLher
dlaanoses llsLed would be evldenL from Lhe phvslcal examlnaLlon excepL for sacral nerve neuralala
whlch would noL be lnLermlLLenL for vears and would be lonaer lasLlna

ApproxlmaLelv 3 of cases of acuLe lnLersLlLlal nephrlLls resulL from a druarelaLed hvpersenslLlvlLv
reacLlon oLher cases are due Lo mechanlsms such as an lmmunoloalc response Lo lnfecLlon or an
ldlopaLhlc lmmune svndrome PvperLenslon and dehvdraLlon do noL cause lnLersLlLlal nephrlLls
MedlcaLlons LhaL mosL commonlv cause acuLe lnLersLlLlal nephrlLls Lhrouah hvpersenslLlvlLv reacLlons
lnclude penlcllllns sulfa druas and nSAlus
urlnalvsls Lvplcallv reveals moderaLe Lo mlnlmal proLelnurla excepL ln nSAlulnduced acuLe lnLersLlLlal
nephrlLls ln whlch proLelnurla mav reach Lhe nephroLlc ranae CLher Lvplcal flndlnas lnclude sLerlle
pvurla Lhe absence of red blood cell casLs and frequenLlv eoslnophllurla buL none of Lhese flndlnas ls
paLhoanomonlc WlLhdrawal of Lhe causaLlve aaenL leads Lo resoluLlon of Lhe problem wlLhln 1 davs
ln Lhe ma[orlLv of cases and mosL paLlenLs have a aood recoverv

1he recvcllna of scalp halr ls an onaolna process wlLh Lhe halr folllcles roLaLlna Lhrouah Lhree phases
1he acLlvelv arowlna anaaenphase halrs alve wav Lo Lhe caLaaen phase durlna whlch Lhe folllcle shuLs
down followed bv Lhe resLlna Leloaen phase durlna whlch Lhe halr ls shed 1he normal raLlo of anaaen
Lo Leloaen halrs ls 91
1hls paLlenL mosL llkelv has a Leloaen effluvlum a nonscarrlna sheddlna halr loss LhaL occurs when a
sLressful evenL such as a severe lllness suraerv or preanancv Lrlaaers Lhe shlfL of larae numbers of
anaaenphase halrs Lo Lhe Leloaen phase 1eloaenphase halrs are easllv shed 1eloaen effluvlum occurs
abouL monLhs afLer a Lrlaaerlna evenL 1he halr loss wlLh Leloaen effluvlum lasLs 6 monLhs afLer Lhe
removal of Lhe sLressful Lrlaaer
Anaaen effluvlum ls Lhe dlffuse halr loss LhaL occurs when chemoLherapeuLlc medlcaLlons cause rapld
desLrucLlon of anaaenphase halr Alopecla areaLa whlch causes round paLches of halr loss ls felL Lo
have an auLolmmune eLloloav lemalepaLLern halr loss affecLs Lhe cenLral porLlon of Lhe scalp and ls
noL assoclaLed wlLh an lnclLlna Lrlaaer or sheddlna ulscold lupus ervLhemaLosus causes a scarrlna
alopecla

1he uS revenLlve Servlces 1ask lorce recenLlv concluded LhaL Lhere ls moderaLe cerLalnLv" LhaL
screen|ng asymptomat|c pat|ents for CCD us|ng sp|rometry has ||tt|e or no benef|t and |s not
recommended 1hls recommendaLlon applles Lo oLherwlse healLhv lndlvlduals wlLhouL a famllv hlsLorv
of
1
anLlLrvpsln dlsease

LrvLhema lnfecLlosum ls caused bv parvovlrus 819 lL presenLs wlLh Lhe Lvplcal vlral prodrome alona
wlLh mlld upper resplraLorv svmpLoms 1he hallmark rash has Lhree sLaaes 1he flrsL ls a faclal flushlna
descrlbed as a slapped cheek" appearance ln Lhe nexL sLaae Lhe exanLhem can spread concurrenLlv Lo
Lhe Lrunk and proxlmal exLremlLles as a dlffuse macular ervLhemaLous rash llnallv cenLral clearlna of
Lhls rash creaLes a lacv reLlculaLed appearance as seen ln llaure 1 1hls rash Lends Lo be on Lhe
exLensor surfaces and spares Lhe palms and soles lL resolves ln 1 weeks buL can recur wlLh heaL
sLress and exposure Lo sunllahL

1rlqueLral fracLures Lvplcallv occur wlLh hvperexLenslon of Lhe wrlsL uorsal avulslon fracLures are more
common Lhan fracLures of Lhe bodv of Lhe bone 1enderness ls characLerlsLlcallv noLed on Lhe dorsal
wrlsL on Lhe ulnar slde dlsLal Lo Lhe ulnar sLvlold 1he Lvplcal radloloalc flndlna ls a small bonv avulslon
vlslble on a laLeral vlew of Lhe wrlsL

denos|ne an expenslve lnLravenous drua ls hlahlv effecLlve |n term|nat|ng many resu|tant
supraventr|cu|ar arrhythm|as AlLhouah lL can cause hvpoLenslon or LranslenL aLrlal flbrlllaLlon
adenoslne ls probablv safer Lhan verapamll because lL dlsappears from Lhe clrculaLlon wlLhln seconds
8ecause of lLs safeLv manv cardloloalsLs now prefer adenoslne over verapamll for LreaLmenL of
hvpoLenslve supravenLrlcular Lachvcardla IV am|odarone IV proca|nam|de or IV sota|o| for susta|ned
V tach (|onger than 30 seconds) trop|ne |s |nd|cated |n the treatment of s|nus bradycard|a

en|ta| warts are Lvplcallv caused bv human paplllomavlrus (nV) types 6 and 11 whlch are rarelv
assoclaLed wlLh lnvaslve squamous cell carclnoma ln aeneral chemlcal LreaLmenLs are more effecLlve
on sofL molsL nonkeraLlnlzed aenlLal leslons whlle phvslcal ablaLlve LreaLmenLs are more effecLlve for
keraLlnlzed leslons D|agnos|s by b|opsy and v|ra| typ|ng |s no |onger recommended AceLowhlLe
sLalnlna has noL been shown Lo favorablv affecL Lhe course or LreaLmenL of PvassoclaLed aenlLal
warLs 1op|ca| 5 f|uorourac|| cream has been assoc|ated w|th severe |oca| react|ons and
teratogen|c|ty and |s no |onger recommended 1reaLmenL of aenlLal warLs has noL been shown Lo
reduce Lhe lncldence of cervlcal or aenlLal cancer

nV test|ng |s |nd|cated for th|s pat|ent's sexua| partners

evere hyperka|em|a (70 mLq/) requlres aaaresslve LreaLmenL Ca|c|um ch|or|de or g|uconate has
no effect on the p|asma potass|um |eve| but |t shou|d be g|ven f|rst as |t rap|d|y stab|||zes the
membranes of card|ac myocytes reduc|ng the r|sk of card|ac dysrhythm|as 1herap|es that
trans|ocate potass|um from the serum to the |ntrace||u|ar space shou|d be |nst|tuted next as they can
qu|ck|y (a|be|t temporar||y) |ower the p|asma concentrat|on of potass|um 1hese |ntervent|ons
|nc|ude sod|um b|carbonate g|ucose w|th |nsu||n and a|butero| 1oLal bodv poLasslum can be lowered
wlLh sodlum polvsLvrene sulfonaLe buL Lhls Lakes lonaer Lo affecL Lhe plasma poLasslum level Lhan
LranslocaLlon meLhods ln Lhe mosL severe cases acuLe hemodlalvsls can be lnsLlLuLed

Whole cow's mllk does noL supplv lnfanLs wlLh enouah vlLamln L lron and essenLlal faLLv aclds and
overburdens Lhelr svsLem wlLh Loo much proLeln sodlum and poLasslum

lor Lhese reasons cow's mllk ls noL recommended for chlldren under 1 monLhs of aae Puman breasL
mllk or lronforLlfled formula wlLh lnLroducLlon of solld foods afLer 46 monLhs of aae lf deslred ls
approprlaLe for Lhe flrsL vear of llfe

Anv chlld vounaer Lhan 9 davs old wlLh a fever and anv chlld who appears Loxlc reaardless of aae
should underao a compleLe sepsls workup and be admlLLed Lo Lhe hosplLal for observaLlon unLll culLure
resulLs are known or Lhe source of Lhe fever ls found and LreaLed

Chlldren 99 davs old who appear Lo be nonLoxlc and have neaaLlve screenlna laboraLorv sLudles
lncludlna a C8C and urlnalvsls can be senL home wlLh precauLlons and wlLh followup ln 4 hours

CbservaLlon onlv wlLh close followup ls recommended for nonLoxlc lnfanLs 6 monLhs of aae wlLh a
LemperaLure 9C (1l)

ulmonarv emboll anasLomoLlc leaks and resplraLorv fallure are responslble for of deaLhs ln Lhe
davs followlna barlaLrlc suraerv wlLh deaLh from pulmonarv embollsm belna Lhe mosL frequenL cause

ln a hemodvnamlcallv unsLable paLlenL wlLh a hlahrlsk mechanlsm of ln[urv and alLered menLal sLaLus
perlLoneal lavaae ls Lhe qulckesL mosL rellable modallLv Lo deLermlne wheLher Lhere ls a concomlLanL
lnLraabdomlnal ln[urv requlrlna laparoLomv

Lowdose Loplcal oral nasal and lnLraarLlcular corLlcosLerolds are noL lmmunosuppresslve and do noL
conLralndlcaLe admlnlsLraLlon of anv vacclne

1hls ls a classlc descrlpLlon of rlckeLLslal lllness (ln Lhe unlLed SLaLes Lhls would mosL llkelv be 8ockv
MounLaln SpoLLed lever) a hlsLorv of ouLdoor acLlvlLv Lhe sudden onseL of fever chllls and rash on Lhe
palms of Lhe hands and Lhe soles of Lhe feeL enlclllln cephalexln and azlLhromvcln do noL cover
rlckeLLsla

1reaL wlLh doxv

1here should be a raLlonal approach Lo evaluaLlna welahL loss ln an elderlv paLlenL 1he workup should
be dlrecLed bv flndlnas ln Lhe hlsLorv and phvslcal examlnaLlon wlLh speclal emphasls alven Lo
neuroloalc and psvchosoclal aspecLs unless Lhe hlsLorv or phvslcal examlnaLlon polnL ln a speclflc
dlrecLlon sLandard LesLs should be performed flrsL lncludlna a C8C chemlsLrv panel sLool for occulL
blood and 1SP level

1he paLlenL descrlbed lnlLlallv showed slans of acuLe mounLaln slckness 1hese lnclude headache ln an
unaccllmaLlzed person who recenLlv arrlved aL an elevaLlon 3 m ( fL) plus Lhe presence of one
or more of Lhe followlna anorexla nausea vomlLlna lnsomnla dlzzlness or faLlaue 1he paLlenLs
condlLlon Lhen deLerloraLed Lo hlahalLlLude cerebral edema deflned as Lhe onseL of aLaxla and/or
alLered consclousness ln someone wlLh acuLe mounLaln slckness 1he manaaemenL of cholce ls a
comblnaLlon of descenL and supplemenLal oxvaen CfLen a descenL of onlv 31 m (16 fL)
wlll lead Lo resoluLlon of acuLe mounLaln slckness SlmulaLed descenL wlLh a porLable hvperbarlc
chamber also ls effecLlve buL descenL should noL be delaved whlle awalLlna hellcopLer dellverv lf
descenL and/or admlnlsLraLlon of oxvaen ls noL posslble medlcal Lherapv wlLh dexameLhasone and/or
aceLazolamlde mav reduce Lhe severlLv of svmpLoms

1here ls a 31 recurrence raLe for Craves' dlsease afLer LreaLmenL wlLh radloacLlve lodlne ?ears
mav pass before recurrence 8adloacLlve lodlne Lherapv ls conLralndlcaLed ln preanancv and lmmedlaLe
suraerv mlahL presenL hazards Lo boLh Lhe moLher and Lhe feLus ropranolol would conLrol Lhe
paLlenL's hearL raLe buL would do noLhlna abouL Lhe underlvlna hvperLhvroldlsm ropvlLhlouracll has
been used exLenslvelv ln preanancv and has never been shown Lo have anv LeraLoaenlc effecL 1he
comblnaLlon of propvlLhlouracll and levoLhvroxlne ls frequenLlv used for hvperLhvroldlsm ln
nonpreananL paLlenLs buL LransplacenLal passaae of Lhe levoLhvroxlne would be harmful Lo Lhe
developlna feLus MeLhlmazole crosses Lhe placenLa more readllv Lhan propvlLhlouracll and ls assoclaLed
wlLh aplasla cuLls

C1 for appendlclLls

WaldensLrm's macroalobullnemla 1hls lllness ls due Lo an unconLrolled prollferaLlon of lvmphocvLes
and plasma cells whlch produce laM proLelns wlLh kappa llahL chalns (aamma ln MM) 1he averaae aae
aL Lhe Llme of dlaanosls ls 63 vears Weakness faLlaue welahL loss bleedlna and recurrenL lnfecLlons
are common presenLlna svmpLoms Monoclonal laM causes hvpervlscoslLv svndrome hvslcal flndlnas
lnclude pallor hepaLosplenomeaalv and lvmphadenopaLhv 1vplcal laboraLorv flndlnas lnclude
moderaLe anemla and monoclonal laM peaks on serum elecLrophoresls 8ence!ones proLeln ls seen ln
of cases buL ls Lvplcallv absenL ln monoclonal aammopaLhv of undeLermlned slanlflcance unllke ln
mulLlple mveloma lvLlc bone leslons are noL seen and marrow blopsv reveals mosLlv lvmphocvLes

he cllnlcal presenLaLlon of WaldensLrm macroalobullnemla ls slmllar Lo LhaL of mulLlple mveloma (MM)
excepL LhaL (1) oraanomeaalv ls common ln WaldensLrm macroalobullnemla and ls uncommon ln
mulLlple mveloma and () lvLlc bonv dlsease and renal dlsease are uncommon ln WaldensLrm
macroalobullnemla buL are common ln mulLlple mveloma

1hls presenLaLlon ls conslsLenL wlLh a common ln[urv called a flahL blLe" 8adloaraphs are needed Lo
deLermlne lf Lhere ls a dlsLal meLacarpal fracLure so LhaL lL can be LreaLed approprlaLelv 8ecause human
blLes commonlv cause lnfecLlon prophvlacLlc anLlbloLlcs are recommended wlLh anv break ln Lhe skln lf
Lhe skln break ls superflclal Lhls ls sufflclenL ueeper wounds should be explored bv a suraeon buL
superflclal wounds should noL be probed lndlscrlmlnaLelv

SLress fracLures of Lhe femoral neck are mosL commonlv seen ln mlllLarv recrulLs and runners 1hev
presenL wlLh perslsLenL aroln paln and llmlLed hlp flexlon and lnLernal roLaLlon 8adloaraphs mav be
normal earlv llloLlblal band svndrome also occurs ln runners and presenLs wlLh sLlnalna paln over Lhe
laLeral femoral eplcondvle CsLelLls publs occurs ln dlsLance runners and presenLs wlLh paln ln Lhe
anLerlor pelvlc area and Lenderness over Lhe svmphvsls publs

ehav|ora| symptoms such as ag|tat|on and wander|ng become common as |zhe|mer's d|sease
progresses Cho||nesterase |nh|b|tors may |mprove some of these symptoms lf Lhev perslsL use of a
psvchoLroplc aaenL mav be necessarv typ|ca| agents can he|p contro| prob|emat|c de|us|ons
ha||uc|nat|ons severe psychomotor ag|tat|on and combat|veness ome behav|ors such as wander|ng
and pac|ng are not amenab|e to drug therapy

A helpful auldellne for assesslna normal arowLh ln Lhe verv vouna lnfanL ls LhaL blrLh welahL should be
reaalned bv Lhe 14Lh dav

1he eLloloav of prepuberta| |ab|a| adhes|ons |s |d|opath|c 1he adheslons mav be parLlal or compleLe ln
some cases onlv a small plnhole orlflce mav be seen LhaL allows urlne Lo exlL from Lhe fused labla 1hls
problem mav be asvmpLomaLlc buL Lhe pat|ent may a|so have a pu|||ng sensat|on d|ff|cu|ty w|th
vo|d|ng recurrent ur|nary tract |nfect|ons or vag|n|t|s lf Lhere ls enouah lablal fuslon Lo lnLerfere wlLh
urlnaLlon LreaLmenL should be underLaken 1he use of top|ca| estrogen cream tw|ce da||y at the po|nt
of the m|d||ne fus|on w||| usua||y resu|t |n reso|ut|on of the prob|em

Wheezlna ls characLerlsLlc of boLh vlral and mvcoplasmal dlsease 8esplraLorv svncvLlal vlrus ls Lhe mosL
common cause of pneumonla ln chlldren aae 4 monLhs Lo 4 vears A 6vearold ls more llkelv Lo have
mvcoplasmal dlsease

ln paLlenLs wlLh reduced muscle mass such as Lhe elderlv (especlallv Lhose older Lhan vears of aae)
uslna serum creaLlnlne concenLraLlon Lo esLlmaLe Lhe alomeruler fllLraLlon raLe mav be mlsleadlna and
creaLlnlne clearance should be deLermlned lf creaLlnlne clearance ls mL/mln meLformln should noL
be prescrlbed

Secondarv causes of nausea and vomlLlna are more llkelv Lo be presenL lf Lhe onseL of svmpLoms occurs
afLer 9 weeks aesLaLlon MeLoclopramlde ls safe ln preanancv

1hls paLlenL has lron deflclencv anemla 1here are several subsLances LhaL decrease Lhe absorpLlon of
lron lncludlna anLaclds sov proLeln calclum Lannln (whlch ls ln Lea) and phvLaLe (whlch ls found ln
bran) Slnce an acldlc envlronmenL lncreases lron absorpLlon ascorblc acld (vlLamln C) can enhance
absorpLlon of an lron supplemenL

LrvLhema nodosum (Ln) ls a pannlcullLls mosL ofLen appearlna on Lhe shlns ln 333 of cases no
cause ls found Ln has been assoclaLed wlLh preanancv and oral conLracepLlves CLher druas lncludlna
sulfonamldes bromldes lodldes and omeprazole have been assoclaLed wlLh Ln lnfecLlous aaenLs
assoclaLed wlLh Ln lnclude beLahemolvLlc sLrepLococcl MvcobacLerlum ?erslnla funal svphllls
CampvlobacLer hepaLlLls C and LpsLeln8arr vlrus lnflammaLorv condlLlons assoclaLed wlLh Ln lnclude
lnflammaLorv bowel dlsease sarcoldosls Lofaren's svndrome and 8ehceL's svndrome

Whereas manv anLlbloLlcs Lemporarllv suppress nasopharvnaeal colonlzaLlon bv Paemophllus lnfluenzae
Lvpe b onlv rlfampln ls effecLlve ln eradlcaLlna Lhe oraanlsm lL should Lherefore be admlnlsLered Lo all
aLLendees and sLaff of a davcare faclllLv ln whlch Lwo or more chlldren have been dlaanosed wlLh
dlsease caused bv P lnfluenzae reaardless of prevlous lmmunlzaLlon sLaLus 1he paLlenLs should also
recelve rlfampln before reLurnlna Lo Lhe cenLer

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