2017 Flashcards
(40 cards)
- A 3-year-old male is brought to your office for a well child visit. The history indicates that the child has a vocabulary of about 100 single words and has not begun to speak in 2-word phrases. An ear examination is normal and the parents have no concerns regarding the child’s hearing. They report that the child is interacting with others normally.
Which one of the following would you propose?
A) Reassessment in 6 months
B) Limiting screen time to 2 hours per day
C) A 4-week intensive parent-administered reading program
D) Referral to a local early developmental intervention program
Item 1
ANSWER:
D
In a 3-year-old, red flags that would suggest the need for immediate speech-language evaluation include the inability to understand prepositions or action words or the child having a vocabulary that consists of less than 200 words (SOR C). A child should use 2-word phrases by 2½ years of age.
The evaluation should be performed through a local early developmental intervention program or a speech-language pathologist. The therapeutic response to parent-administered programs varies greatly, with programs lasting longer than 8 weeks having more success. Limiting screen time would not address this child’s problem. Many family physicians would implement a parent-completed developmental survey such as Ages and Stages.
- A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints are affected.
The most likely cause of this problem is
A) varicella-zoster virus
B) measles (rubeola) virus
C) parvovirus B19
D) adeno
Item 2
ANSWER:
C
Also known as erythema infectiosum or fifth disease, parvovirus B19 infection is a fairly common cause of an exanthematous rash and arthritis in younger women. This infection should be particularly suspected in health care workers who have frequent contact with children. By the age of 15 approximately 50% of children have detectable IgG antibodies to the virus, and this figure rises to 90% in the elderly. Within households and caregivers the secondary infection rate, especially among nonimmune children and young adults, approaches 50%. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.
- A previously healthy 5-year-old male is brought to your office because of painful swelling in his neck. His mother noted the swelling about 3 or 4 days ago and it has grown rapidly. This morning he was sent home from school with a temperature of 101.2°F.
On further questioning the patient reports no other symptoms and his mother confirms he has not complained of anything besides the pain in his neck. He has been eating well and has had no weight loss. They do not have a cat and he has not been around any cats. He is up to date on immunizations.
A physical examination reveals normal vital signs with the exception of a temperature of 38.5°C (101.3°F). He has a tender, erythematous, slightly fluctuant, enlarged lymph node in the left anterior cervical chain. He has no other enlarged lymph nodes and the examination is otherwise unremarkable.
Which one of the following would be the most appropriate next step?
A) Monitoring for up to 4 weeks to see if the problem resolves
B) Empiric antibiotic therapy directed at Staphylococcus aureus and group A Streptococcus
C) CT of the neck
D) Referral for a fine-needle aspiration biopsy of the enlarged lymph
Item 3
ANSWER:
B
Cervical lymphadenopathy in children may be due to several causes, and the evaluation should focus on a complete history and physical examination to determine if observation or more urgent evaluation is indicated. When signs of infection are present it is appropriate to treat the patient with antibiotics, with evaluation for improvement in 2–3 days. If there are signs of malignancy (size >3 cm; a hard, firm, immobile mass; associated type B symptoms) the child should be referred urgently to an otolaryngologist. Fine-needle aspiration (FNA) of a lymph node can be helpful in some circumstances, but the initial evaluation should determine whether referral for excision may be needed, particularly if the history and examination suggest malignancy. In this patient, an infection is most likely and FNA would not be indicated at this time. If imaging is needed in children under the age of 14, the recommended initial study is ultrasonography. For those over 14 years of age, CT is recommended.
- A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of a 2-week history of decreased appetite, lethargy, and confusion. Laboratory evaluation reveals the following:
Serum calcium - 15.8 mg/dL (N 8.4–10.0) Serum phosphorus - 3.9 mg/dL (N 2.6–4.2) Serum creatinine - 1.1 mg/dL (N 0.7–1.3) Total serum protein - 5.0 g/dL (N 6.0–8.0) Albumin - 3.1 g/dL (N 3.7–4.8)
Which one of the following would be the most appropriate INITIAL management?
A) Calcitonin-salmon (Miacalcin) subcutaneously
B) Pamidronate by intravenous infusion
C) Normal saline intravenously
D) Furosemide intravenously
Item 4
ANSWER:
C
The initial management of hypercalcemia of malignancy includes fluid replacement with normal saline to correct the volume depletion that is invariably present and to enhance renal calcium excretion. The use of loop diuretics such as furosemide should be restricted to patients in danger of fluid overload, since these drugs can aggravate volume depletion and are not very effective alone in promoting renal calcium excretion. Although intravenous pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy, it should be considered only after the patient has been made euvolemic by saline repletion. The same is true for the other calcium-lowering agents listed.
- A 40-year-old white male has seen you in the past for hypertension and alcohol abuse. He comes to your office for an acute visit due to a swollen, painful right knee that developed over the past few days. He says he has been treated for gout flares in the past by another physician. He tells you his pain has always been in his knee, and he always has marked swelling of the knee when the pain is severe. He has never had any other swollen joints. The fluid from his knee has never been evaluated to his knowledge, although it has been drained, which resulted in pain relief. No past record of a uric acid level is found, and he does not recall having it checked. He has no fever, no systemic signs of illness, and no injury to his knee.
A physical examination reveals a swollen knee with no evidence of internal derangement, no erythema, and no other swollen joints. No nodules are appreciated. A knee radiograph reveals only the swelling within the joint. His uric acid level is 5.1 mg/dL (N 4.0–8.0).
Which one of the following would be most appropriate at this point?
A) Dietary changes to decrease the risk of gout flares
B) Allopurinol (Zyloprim) for gout flare prevention
C) Colchicine (Colcrys) for the gout flare
D) Corticosteroid injection into the painful knee
E) Aspiration and evaluation of fluid from the knee joint, including crystal analysis
Item 5
ANSWER:
E
Although this patient reports a history of gout, the diagnosis is not entirely clear. Gout can be diagnosed clinically if at least six of the following findings are present:
- asymmetric swelling within a joint on radiography
- an attack of monoarticular arthritis
- a joint fluid culture that is negative for microorganisms during an attack of joint inflammation
- development of maximal inflammation within 1 day
- hyperuricemia
- joint redness
- more than one attack of acute arthritis
- pain or redness in the first metatarsophalangeal joint
- a subcortical cyst without erosions on radiography
- a suspected tophus
- a unilateral attack involving the tarsal joint
In the absence of a diagnosis based on clinical criteria, the diagnosis can be confirmed by the presence of characteristic urate crystals in the joint fluid or the presence of a tophus proven to contain urate crystals by chemical means or polarized light microscopy. As this patient does not meet these clinical criteria, it would be appropriate to further evaluate whether his symptoms are truly from gout. It may also be reasonable to start treatment while studies are pending, but the diagnosis should be confirmed. Should gout be confirmed, dietary changes are recommended and allopurinol is a reasonable option for preventing future flares.
- Which one of the following patients should be tested for Helicobacter pylori infection and, if positive, treated with eradication therapy without endoscopy?
A) A 45-year-old male with a 2-month history of epigastric burning after eating
B) A 45-year-old male who has progressive epigastric pain with associated anorexia and weight loss
C) A 53-year-old female with a 6-week history of burning in the chest after eating
D) A 60-year-old female with a 2-month history of constant epigastric burning
E) A 60-year-old male who takes daily aspirin and has developed epigastric burning and associated vomiting over the past month
Item 6
ANSWER:
A
The test-and-treat strategy is appropriate for patients with dyspepsia who are younger than 55 years of age and have no alarm symptoms for gastric cancer. Testing for Helicobacter pylori in patients with GERD is not recommended.
- In patients with an acute ST-elevation myocardial infarction, fibrinolysis may be preferred as a reperfusion strategy over percutaneous coronary intervention (PCI), depending on factors such as when the symptoms began and the transport time to the nearest PCI-capable hospital. In which one of the following situations would fibrinolysis be most appropriate?
A) An onset of symptoms 6 hours ago and a transport time of more than 2 hours
B) An onset of symptoms 10 hours ago and a transport time of approximately 30 minutes
C) An onset of symptoms 20 hours ago and evidence of ongoing ischemia when presenting to a PCI-capable hospital
D) A sudden onset of symptoms on day 2 of a hospitalization for an ischemic stroke and a transport time of more than 2 hours
Item 7
ANSWER:
A
Once an ST-elevation myocardial infarction is identified, a reperfusion strategy should be chosen as quickly as possible. In general, percutaneous coronary intervention (PCI) is preferred because it leads to improved outcomes compared to fibrinolysis when performed in high-volume medical facilities without treatment delays. If a patient’s first medical contact is at a PCI-capable hospital or the time from first medical contact to device time is less than 120 minutes, PCI is the preferred intervention for patients presenting with symptoms for less than 12 hours. If the transfer time to a PCI-capable hospital is not short, such as the example of a patient with an onset of symptoms 6 hours ago and a transport time to the nearest PCI-capable hospital of more than 2 hours, then fibrinolysis is the preferred management strategy.
If there are absolute contraindications to fibrinolysis (such as a history of an ischemic stroke within the past 3 months), then PCI is preferred even if the transport time will not be short. In cases where the onset of symptoms was more than 12 hours ago but less than 24 hours ago and evidence of ongoing ischemia exists, it is still reasonable to pursue reperfusion therapy, and PCI would be the preferred strategy if it is available.
- Which one of the following hypoglycemic medications is proven to reduce mortality rates in patients with type 2 diabetes mellitus?
A) Acarbose (Precose)
B) Glipizide (Glucotrol)
C) Metformin (Glucophage)
D) Rosiglitazone (Avandia)
Item 8
ANSWER:
C
Metformin has been shown to reduce mortality rates in patients with type 2 diabetes mellitus (SOR A). Acarbose, an -glucosidase inhibitor, reduces the risk of cardiovascular events, including myocardial infarction, in patients with impaired glucose tolerance or type 2 diabetes mellitus (SOR B). Rosiglitazone has been shown to be associated with an increased risk of myocardial infarction and death from cardiovascular causes (SOR A). To date, there is insufficient evidence to make any conclusions about the effect of sulfonylurea insulin secretagogues such as glipizide on cardiovascular morbidity and mortality (SOR B).
- A 74-year-old male with a history of diabetes mellitus, hypertension, and heart failure presents to the clinic with shortness of breath with an unknown etiology. Laboratory results that show an elevated procalcitonin level would help differentiate systolic heart failure from
A) diastolic heart failure
B) bacterial pneumonia
C) acute coronary syndrom
Item 9
ANSWER:
B
Procalcitonin is a biomarker that is elevated with bacterial infections but not with viral infections. The laboratory test for procalcitonin has a high sensitivity and can help exclude bacterial pneumonia in patients with acute heart failure, which can help expedite appropriate therapy with antibiotics. If the procalcitonin level is low a bacterial infection is less likely and antibiotics should not be given.
- A 38-year-old healthy female comes to your office for preventive care. Her medical history is significant only for nephrolithiasis and controlled hypothyroidism. Her sexual history is significant for vaginal intercourse with three male partners in the past year, including her current partner who uses intravenous heroin. She has no fever, sore throat, swollen nodes, or other signs of acute illness. A fourth-generation HIV antibody/antigen test is negative and her serum creatinine level is 0.6 mg/dL (N 0.5–1.1).
Which one of the following additional test results must be documented before offering preexposure prophylaxis for HIV with emtricitabine/tenofovir (Truvada)?
A) Hepatitis B surface antibody and antigen
B) Hepatitis C antibody
C) Liver enzymes
D) HIV viral load
E) Her sexual partner’s HIV status
Item 10
ANSWER:
A
Emtricitabine/tenofovir is the only currently approved regimen shown to be effective for HIV preexposure prophylaxis (PrEP) (SOR A). This patient has multiple sexual partners, including one at high risk for HIV infection due to intravenous drug use, and thus should be offered PrEP (SOR C). In patients without signs of acute HIV, PrEP may be initiated after documentation of negative fourth-generation HIV antibody/antigen testing, normal renal function, and hepatitis B infection and immunization status. Tenofovir can be toxic to the kidneys and is not recommended in patients with an estimated glomerular filtration rate <60 mL/min/1.73 m 2 .
Emtricitabine and tenofovir are both also active against hepatitis B virus (HBV) infection, so the use of PrEP in patients with active HBV must be carefully considered. If a patient with active HBV stops taking PrEP, reactivated HBV can cause liver damage. Patients susceptible to HBV infection should be immunized. Hepatitis C testing would be prudent in this case, but the results are not needed to begin therapy with emtricitabine/tenofovir.
- An 8-year-old female with a history of persistent asthma is interested in participating in a mile-long race for a school fundraiser. Her mother is very concerned and thinks she should not run, and she brings in a form to fill out to excuse the child from participation. The child states that she wants to participate. Her medications include fluticasone (Flovent HFA), 44 g twice daily; loratadine (Claritin), 5 mg daily; and albuterol (Proventil, Ventolin) as needed. She has no nighttime symptoms, has not used her inhaler at all in the past week, and can keep up with other children during recess.
The best course of action is to
A) fill out the form as requested with no change in medication
B) recommend that she take 2 puffs of albuterol 30 minutes prior to the event and let her run
C) increase the fluticasone dosage to 110 g twice daily and let her run
D) add montelukast (Singulair) to her regimen and let her run
E) add a long-acting -agonist to her regimen and let her run
Item 11
ANSWER:
B
This child has well controlled asthma, as evidenced by her normal daily activities, lack of nighttime symptoms, and limited use of her rescue inhaler. There is no reason that the diagnosis of asthma should limit her activities. Because her asthma is well controlled there is no need to add additional medications or increase the dosage of her current medications. Long-acting -agonists are not recommended before the age of 12. Prophylactic pretreatment with a short-acting -agonist has very little harm associated with it and may prevent the need for a rescue inhaler during an athletic event. Children should have ready access to their rescue inhalers at school and in other settings; this has been shown to reduce emergency department visits.
- A 28-year-old white male presents with pain in the right wrist since falling 2 weeks ago. On examination he is tender in the anatomic snuffbox. A radiograph reveals a nondisplaced fracture of the distal third of the carpal navicular bone (scaphoid).
Which one of the following would be most appropriate at this time?
A) A bone scan
B) A referral for physical therapy
C) A Velcro wrist splint
D) A short arm cast
E) A thumb spica cast
Item 12
ANSWER:
E
Scaphoid fracture is the most common carpal bone injury. This injury tends to occur when the wrist is hyperextended and the hand is pronated and radially deviated. The presentation can range from disabling wrist pain to mild swelling and decreased range of motion. There is exquisite tenderness in the anatomic snuffbox with axial loading of the thumb or a pincer grasp.
Radiographs should include PA, lateral oblique, and ulnar deviated views. Nondisplaced fractures can be missed on radiographs, and if a fracture is suspected and the initial radiographs are negative for fracture, the management is the same as it would be for a fracture until a fracture can be ruled out by advanced imaging or by follow-up radiographs in 7 days. Treatment decisions depend upon fracture location and displacement. A thumb spica cast (a short arm cast with the thumb immobilized) for 6–10 weeks is appropriate for nondisplaced distal fractures. Surgical treatment should be considered for displaced or proximal fractures.
There is some controversy about the wrist position for immobilization, whether neutral, in extension, or in flexion, but the key treatment is cast immobilization. Follow-up evaluations should take place every 2–3 weeks, including out-of-cast radiographs, until union is confirmed. Nonunion occurs in approximately 10% of all scaphoid fractures. It is more common with proximal scaphoid fractures due to the precarious reverse blood supply. If union fails to occur the patient should be referred to an orthopedist.
- A 65-year-old male with a 40-pack-year history of smoking presents with shortness of breath on exertion. Spirometry reveals the following:
FEV 1 /FVC - 65% of predicted
FVC - Normal
Bronchodilator therapy - no improvement in FEV 1
Which one of the following is suggested by these results?
A) Normal spirometry
B) Reversible obstructive lung disease
C) Irreversible obstructive lung disease
D) Restrictive lung disease
E) Mixed obstructive and restrictive lung disease
Item 13
ANSWER:
C
These spirometry results indicate an irreversible obstructive pattern. Patients with a restrictive component to their lung disease have a decreased FVC. Reversible obstruction improves with bronchodilator therapy.
- A 52-year-old male presents with moderate symptoms of prostatism. A prostate examination is normal. His post-void residual volume is 90 mL. His PSA level is 0.75 ng/mL (N 0.0–4.0). He says his nocturia has become troublesome and you decide to initiate therapy.
This patient does NOT meet the criteria for use of which one of the following?
A) Doxazosin (Cardura)
B) Finasteride (Proscar)
C) Tadalafil (Cialis)
D) Tamsulosin (Flomax)
E) Silodosin (Rapaflo)
Item 14
ANSWER:
B
Pharmacologic options for benign prostatic hyperplasia and lower urinary tract symptoms include an -adrenergic blocker, a 5- -reductase inhibitor (if there is evidence of prostatic enlargement or a PSA level >1.5 ng/mL), a phosphodiesterase-5 inhibitor, or antimuscarinic therapy. The first three have proven efficacy as monotherapies.
- A 30-year-old male presents with intermittent right upper quadrant pain after meals. He has been in moderate pain for the past 3 hours. On examination the patient’s vital signs are normal except for a temperature of 38.1°C (100.6°F). Examination of the abdomen reveals a positive Murphy’s sign.
Laboratory Findings
WBCs …………………..8100/mm 3 (N 4300–10,800) ALT (SGPT)…………….42 U/L (N 10–55) AST (SGOT)…………...28 U/L (N 10–40) Alkaline phosphatase…128 U/L (N 45–115) Bilirubin……………….1.0 mg/dL (N 0.0–1.0) Lipase………………... 12 U/dL (N 3–19)
Ultrasonography reveals cholelithiasis, an enlarged gallbladder, and thickening of the gallbladder wall. The diameter of the common bile duct is normal.
Which one of the following is the most likely cause of this patient’s symptoms?
A) Choledocholithiasis
B) Acute cholecystitis
C) Acute cholangitis
D) Gallstone pancreatitis
Item 15
ANSWER:
B
Gallstones are often asymptomatic and are found incidentally on imaging. However, they may become symptomatic, usually causing pain in the right upper quadrant or epigastrium. Most patients with symptomatic gallstones present with chronic cholecystitis, which causes recurrent attacks of pain. The pain is constant and increases in severity at the beginning, and lasts from 1 to 5 hours. It often starts during the night after a fatty meal and may be associated with nausea and vomiting. Abdominal ultrasonography is the initial imaging method.
Patients with acute cholecystitis may have a history of symptoms consistent with chronic cholecystitis. With acute cholecystitis, however, the pain does not remit and may last for days. The patient may also have a fever on examination, and may have tenderness to deep palpation of the right subcostal area, known as Murphy’s sign. The WBC count may be somewhat elevated. Ultrasonography will show thickening of the bile duct wall (>4 mm).
Stones in the bile duct, or choledocholithiasis, typically lead to elevated transferase levels and bilirubin levels that are elevated but <15 mg/dL. The pain may be either mild or severe, and may be intermittent because of movement of the stones. Fever may be present. A bile duct >8 mm on ultrasonography in a patient with gallstones, jaundice, and biliary pain indicates that stones may be present in the duct.
The two main complications of choledochal stones are cholangitis and pancreatitis. Acute cholangitis is a bacterial infection. Bacterial growth is enhanced by obstruction of the duct. It may present as a mild self-limited disease but can also lead to sepsis. Cases typically present with fever, pain, and jaundice. Laboratory findings include an elevated WBC count, elevated bilirubin, and elevated transaminases and alkaline phosphatase. Ultrasonography will show a dilated bile duct in many cases, although it might not be dilated in acute obstruction.
Pancreatitis presents with pain, nausea, and vomiting. The pain is usually epigastric and radiates to the back. It reaches its maximum intensity within an hour and may last for days. The physical examination may reveal tachycardia, hypotension, tachypnea, and fever. The abdomen may be distended and is typically tender to palpation. The diagnosis requires two of three primary features: abdominal pain, elevation of serum amylase or lipase, and findings on imaging studies that are consistent with the diagnosis. Ultrasonography can show pancreatic enlargement or edema, and visualization of gallstones will suggest choledocholithiasis as the cause of the pancreatitis.
- A 62-year-old male with diabetes mellitus recently underwent angioplasty with placement of a drug-eluting stent for the treatment of left main coronary artery disease and acute coronary syndrome. The patient is not considered at high risk for bleeding and you initiate dual antiplatelet therapy with aspirin and clopidogrel (Plavix).
For how long should this patient continue dual antiplatelet therapy?
A) 1 month
B) 3 months
C) 6 months
D) 9 months
E) At least 12 months
Item 16
ANSWER:
E
Dual antiplatelet therapy should extend beyond 1 year for patients with acute coronary syndrome who are not considered at high risk of bleeding, especially those with risk factors associated with high ischemic risk such as diabetes mellitus, peripheral artery disease, left main stenting, or a history of a cardiovascular event. For dual antiplatelet therapy that continues beyond a year, either ticagrelor, 60 mg twice daily, or clopidogrel, 75 mg daily, is recommended in addition to aspirin. The patient’s bleeding and ischemic risk should be reevaluated at least annually.
Dual antiplatelet therapy should continue for at least 1 year in patients who are considered at high risk of bleeding. For patients who are at very high risk of bleeding or who experience significant bleeding while on dual antiplatelet therapy, a duration of less than 1 year is recommended.
- A 67-year-old female sees you because of a cough she has had for the past few days and a fever that started today. She is short of breath and generally does not feel well. She has no history of lung disease and is a nonsmoker. Her medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus, all of which are well managed with medications and diet.
A physical examination reveals a mildly ill-appearing female with a temperature of 38.2°C (100.8°F), a pulse rate of 90 beats/min, a respiratory rate of 21/min, a blood pressure of 110/60 mm Hg, and an oxygen saturation of 98% on room air. Her heart has a regular rhythm and her respirations appear unlabored. She has rhonchi in the left lower lung field but has good air movement overall. A chest radiograph reveals a left lower lobe infiltrate.
Which one of the following is the most appropriate setting for the management of this patient’s pneumonia?
A) Home with close monitoring
B) An inpatient medical bed without telemetry monitoring
C) An inpatient medical bed with telemetry monitoring
D) An inpatient intensive care bed
Item 17
ANSWER:
A
For community-acquired pneumonia, an important decision point is the severity of illness that indicates the need for inpatient care. There are multiple tools for evaluation of pneumonia severity, including SMART-COP (predicts the likelihood of the need for invasive ventilation or vasopressor support), the Pneumonia Severity Index (predicts the risk of 30-day mortality and the need for admission to the intensive-care unit), and CURB-65 or CRB-65. In an outpatient setting, CURB-65 and CRB-65 are easy to use, although they have weaker predictive values for 30-day mortality. In addition, clinical judgment should always be used. In this scenario, the patient does not clinically appear markedly ill, and her vital signs and physical examination do not fit any criteria for increased risk in any of the scoring systems. Her only risk factor is age 65 years, and those with zero or one criteria for CURB-65 or CRB-65 can be managed as outpatients.
- A 67-year-old female reports hearing a ringing sound when she is in a quiet room. The ringing is not bothersome to her, but she wonders what is causing it. She has not noticed any hearing loss.
According to the American Academy of Otolaryngology—Head and Neck Surgery, neurologic imaging (such as contrast-enhanced MRI of the brain) would be indicated if
A) the patient requests imaging
B) the tinnitus is nonpulsatile
C) the tinnitus is unilateral
D) treatment with an antidepressant such as fluoxetine (Prozac) fails
E) audiology testing identifies symmetric, mild, high-frequency hearing loss
Item 18
ANSWER:
C
Tinnitus that is bilateral and not bothersome can be treated conservatively with cognitive-behavioral therapy, sound therapy, and, if appropriate, hearing aids. Antidepressants are not recommended. Pulsatile tinnitus, unilateral tinnitus, or tinnitus associated with asymmetric hearing loss is more likely to be associated with a pathologic cause. Symmetric, mild, high-frequency hearing loss is common in elderly patients. Imaging should not be part of the routine management of tinnitus that does not have warning signs, and patients should be counseled on conservative measures as described.
- A pregnant 30-year-old female comes to your office in October and asks if she should receive influenza vaccine. She is at 12 weeks gestation by dates and has a past history of a severe egg allergy.
Which one of the following would you recommend?
A) No immunization, because of the pregnancy
B) No immunization, because of the egg allergy
C) Standard inactivated seasonal vaccine now
D) High-dose inactivated seasonal vaccine now
E) Immunization during the second trimester
Item 19
ANSWER:
C
Influenza vaccine is recommended for pregnant women regardless of trimester. This gives protection to the mother, and the infant may be protected up to 6 months. High-dose vaccines are recommended starting at age 65. An egg allergy is not a contraindication, but the vaccine should be given in a health care setting.
- A 2-year-old child stumbles, but his mother keeps him from falling by pulling up on his right hand. An hour later the child refuses to use his right arm and cries when his mother tries to move it.
The most likely diagnosis is
A) dislocation of the ulna
B) dislocation of the olecranon epiphysis
C) subluxation of the head of the radius
D) subluxation of the head of the ulna
E) anterior dislocation of the humeral head
Item 20
ANSWER:
C
Subluxation of the radial head, or nursemaid’s elbow, is one of the most common injuries in children under 5 years of age. It occurs when the child’s hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.
- A 56-year-old female comes to your office for evaluation of fatigue and shortness of breath. She has a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity. Her diabetes has been well controlled, and a recent hemoglobin A 1c was 6.7%.
She reports that she has been more tired than usual for the past several months and that walking more than a block or going up a flight of stairs has now become difficult. She has no chest pain, palpitations, dizziness, or cough. She has had mild, stable lower extremity edema for years, and this is unchanged. She lives alone and is not sure if she snores. She has had difficulties with sleep for years and does not feel refreshed upon awakening. She does not use tobacco or drink alcohol.
On examination she has a blood pressure of 128/78 mm Hg, a pulse rate of 76 beats/min, a respiratory rate of 14/min, a temperature of 37.1°C (98.8°F), an oxygen saturation of 95% on room air, and a BMI of 38.2 kg/m 2 . Auscultation of the heart reveals a regular rate and rhythm with no murmur. Her lungs are clear to auscultation bilaterally. She has 1+ pitting edema of both lower extremities.
A chest radiograph is normal and an EKG reveals normal sinus rhythm. Echocardiography shows a left ventricular ejection fraction of 60% without impaired diastolic function.
Which one of the following evaluations is most likely to reveal the cause of her fatigue?
A) 24-hour ambulatory blood pressure monitoring
B) Spirometry
C) A sleep study
D) CT angiography of the chest
E) Left heart catheterization
Item 21
ANSWER:
C
This patient has pulmonary hypertension that, based on her history, is most likely related to obstructive sleep apnea (OSA). Most patients with pulmonary hypertension have an underlying disease of the heart or lungs that leads to elevated pulmonary artery pressures. Common underlying conditions include chronic lung disease such as COPD, OSA, and left heart failure (with a reduced or preserved ejection fraction). Additional considerations include chronic thromboembolic disease and primary pulmonary arterial hypertension.
This patient’s obesity and unrefreshing sleep make OSA the likely underlying cause of her pulmonary hypertension. She does not have clinical features of thromboembolic disease or a history of COPD. Her echocardiogram does not show heart failure, and she has no symptoms to suggest obstructive coronary disease. Ambulatory blood pressure monitoring can aid in the diagnosis and optimal treatment of hypertension, but this would be unlikely to relate directly to her pulmonary hypertension.
- A 2-year-old white male is seen for a well child visit. His mother is concerned because he is not yet able to walk. A routine physical examination, including an orthopedic evaluation, is unremarkable. Speech and other developmental milestones seem normal for his age.
Which one of the following tests would be most appropriate?
A) A TSH level
B) Random urine for aminoaciduria
C) Phenylketonuria screening
D) A serum creatine kinase level
E) Chromosome analysis
Item 22
ANSWER:
D
The diagnosis of Duchenne muscular dystrophy, the most common neuromuscular disorder of childhood, is usually not made until the affected individual presents with an established gait abnormality at the age of 4–5 years. By then, parents unaware of the X-linked inheritance may have had additional children who would also be at risk.
The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. The mean age for walking in affected boys is 17.2 months, whereas over 75% of developmentally normal children in the United States walk by 13.5 months. Massive elevation of creatine kinase from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies.
Hypothyroidism and phenylketonuria could present as delayed walking. However, these diseases cause significant intellectual disability and would be associated with global developmental delay. Furthermore, these disorders are now diagnosed in the neonatal period by routine screening. Disorders of amino acid metabolism present in the newborn period with failure to thrive, poor feeding, and lethargy. Gross chromosomal abnormalities would usually be incompatible with a normal physical examination at 18 months of age.
- A 20-year-old female with a history of persistent depression sees you for follow-up. She reports unplanned weight loss, chronic insomnia, fatigue, a loss of interest in hobbies that she previously enjoyed, and decreased concentration. She has seen other physicians and has tried antidepressant medications, including paroxetine (Paxil), bupropion (Wellbutrin), and citalopram (Celexa). She reports that there was a week when her mood felt much more normal. She needed only about 3 hours of sleep each night during that week. She admits she was somewhat impulsive, however, and experienced racing thoughts. She does not abuse any substances but has several family members who are drug abusers. Her mother and older sister committed suicide. Her examination, laboratory work, and drug screen are all unremarkable.
Which one of the following is most likely to help this patient?
A) Escitalopram (Lexapro)
B) Mirtazapine (Remeron)
C) Quetiapine (Seroquel)
D) Trazodone (Oleptro)
E) Venlafaxine (Effexor XR)
Item 23
ANSWER:
C
Bipolar disorders often present in late childhood or early adolescence. Outcomes can be improved by early recognition. Manic episodes that occur with bipolar I disorder are usually easy to identify. However, patients with bipolar II disorder may have a hypomanic episode that goes unrecognized, and the patient may present with persistent depression. There is usually a family history of bipolar disorder or multiple relatives having persistent depression, obsessive-compulsive disorder, attention-deficit disorder, or panic disorder. There may be multiple instances in the family of suicide, drug abuse, alcohol abuse, or incarceration. The patient has likely failed to respond to at least three antidepressant drugs and may have a history of multiple divorces.
There are options for the treatment of bipolar depression. Quetiapine usually leads to a response after 1 week of therapy but is associated with weight gain and extrapyramidal side effects. Olanzapine may also be used but should be combined with an SSRI. Lithium may also be effective for acute depression. Lamotrigine is effective but titration should be spread over at least 6 weeks in order to decrease the risk of Stevens-Johnson syndrome.
- A 62-year-old male with a history of COPD sees you because of fever, chills, and redness and swelling in his right lower extremity that has been progressing. He has a temperature of 38.0°C (100.4°F), a blood pressure of 112/72 mm Hg, and a pulse rate of 94 beats/min. The physical examination is remarkable for an erythematous area with increased warmth that extends approximately 18 cm (7 in) between the knee and ankle. You note no apparent abscess formation. The patient does not recall any specific injury that could have caused this problem.
According to the guidelines of the Infectious Diseases Society of America, which one of the following would be the most appropriate antibiotic regimen for this patient?
A) Ceftriaxone (Rocephin)
B) Piperacillin/tazobactam (Zosyn)
C) Vancomycin (Vancocin)
D) Vancomycin plus ceftriaxone
E) Vancomycin plus piperacillin/tazobactam
Item 24
ANSWER:
A
The most common pathogen for nonpurulent cellulitis is -hemolytic streptococci. Guidelines from the Infectious Diseases Society of America recommend treating moderate nonpurulent cellulitis with penicillin, ceftriaxone, cefazolin, or clindamycin alone. Vancomycin would be indicated if the patient had a history of illicit drug use, purulent drainage, concurrent evidence of MRSA infection elsewhere, nasal colonization with MRSA, or severe cellulitis.
