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Flashcards in 2018 Deck (240)
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1. A 68-year-old male presents to your office with a 2-day history of headache, muscle aches,
and chills. His wife adds that his temperature has been up to 104.1°F and he seems confused
sometimes. His symptoms have not improved with usual care, including ibuprofen and
increased fluid intake. He and his wife returned from a cruise 10 days ago but don’t recall
anyone having a similar illness on the ship. This morning he started to cough and his wife
was concerned because she saw some blood in his sputum. He also states that he experiences
intermittent shortness of breath and feels nauseated. His blood pressure is 100/70 mm Hg,
heart rate 98/min, temperature 39.4°C (102.9°F), and oxygen saturation 95% on room air.
Which one of the following would be the preferred method to confirm your suspected
diagnosis of Legionnaires’ disease?
A) Initiating azithromycin (Zithromax) to see if symptoms improve
B) A chest radiograph
C) Legionella polymerase chain reaction (PCR) testing
D) A sputum culture for Legionella
E) Urine testing for Legionella pneumophila antigen

Item 1
A urine test for Legionella pneumophila antigen is the preferred method to confirm Legionnaires’ disease.
This test is rapid and will only detect Legionella pneumophila antigen. A sputum culture is the gold
standard for the diagnosis of Legionnaires’ disease but it requires 48–72 hours. A chest radiograph does
not confirm the diagnosis but may show the extent of disease. Responding to antibiotic treatment does not
confirm a specific diagnosis.


Which one of the following factors related to pregnancy and delivery increases the risk of
developmental dysplasia of the hip in infants?
A) A large-for-gestational age infant
B) Twin birth
C) Breech presentation
D) Cesarean delivery
E) Premature birth

Risk factors for developmental dysplasia of the hip in infants include a breech presentation in the third
trimester, regardless of whether the delivery was cesarean or vaginal. Other indications to evaluate an
infant for this condition include a positive family history, a history of previous clinical instability, parental
concern, a history of improper swaddling, and a suspicious or inconclusive physical examination. Twin
birth, a large-for-gestational age infant, and prematurity are not considered risk factors.


A healthy 2-month-old female is brought to your office for a routine well baby examination
by both of her parents, who have no concerns. The parents refuse routine recommended
vaccines for their daughter because of their personal beliefs.
You want to incorporate patient-centeredness and are also concerned about improving the
health of the population. You decide to follow the CDC recommendations by
A) accepting their decision without further action
B) not offering vaccines at future visits to preserve a positive doctor-patient relationship
C) having the parents sign a refusal to vaccinate form
D) dismissing the family from the practice
E) pursuing a court order for vaccine administration since the child has no medical

Experts recommend that a refusal to vaccinate form be signed by patients or parents who refuse a
recommended vaccine. This form should document that the patient/parents were provided the vaccine
information statement (SOR C). The CDC recommends against dismissing a patient or family from a
practice if they refuse vaccination. Physicians should continue to discuss the benefits of immunizations at
subsequent visits, because some patients/parents may reconsider their decision not to vaccinate.


4. A 50-year-old male carpet layer presents with swelling of his right knee proximal to the
patella. He does not have any history of direct trauma, fever, chills, or changes in the
overlying skin. On examination the site is swollen but minimally tender, with no warmth or
Which one of the following would be most appropriate at this point?
A) Rest, ice, and compression
B) Aspiration of fluid for analysis
C) Injection of a corticosteroid
D) An oral corticosteroid taper
E) Referral to an orthopedic surgeon for resection

Prepatellar bursitis is a common superficial bursitis caused by microtrauma from repeated kneeling and
crawling. Other terms for this include housemaid’s knee, coal miner’s knee, and carpet layer’s knee. It
is usually associated with minimal to no pain. This differs from inflammatory processes such as acute
gouty superficial bursitis, which presents as an acutely swollen, red, inflamed bursa and, in rare cases,
progresses to chronic tophaceous gout with minimal or no pain.
The proper management of prepatellar bursitis is conservative and includes ice, compression wraps,
padding, elevation, analgesics, and modification of activity. There is little evidence that a corticosteroid
injection is beneficial, even though it is often done. If inflammatory bursitis is suspected, a corticosteroid
injection may be helpful. Fluid aspiration is indicated if septic bursitis is suspected. Surgery can be
considered for significant enlargement of a bursa if it interferes with function.


5. An 85-year-old female with a previous history of diabetes mellitus, hypertension, dementia,
and peptic ulcer disease has been in a skilled nursing facility for 4 weeks for rehabilitation
after a hip fracture repair secondary to a fall during an ischemic stroke. She is transported
to the emergency department today when she develops confusion, shortness of breath, and
diaphoresis. Her blood pressure is 172/98 mm Hg, her heart rate is 122 beats/min with an
irregular rhythm, and her respiratory rate is 22/min. An EKG demonstrates atrial fibrillation
and 0.2 mV ST-segment elevation compared to previous EKGs. Her first troponin level is
Which one of the following conditions in this patient is considered an ABSOLUTE
contraindication to fibrinolytic therapy?
A) Poorly controlled hypertension
B) Peptic ulcer disease
C) Alzheimer’s dementia
D) Hip fracture repair
E) Ischemic stroke

A history of an ischemic stroke within the past 3 months is an absolute contraindication to fibrinolytic
therapy in patients with an ST-elevation myocardial infarction (STEMI), unless the stroke is diagnosed
within 4½ hours. Poorly controlled hypertension, dementia, peptic ulcer disease, and major surgery less
than 3 weeks before the STEMI are relative contraindications that should be considered on an individual


6. An otherwise healthy 57-year-old female presents with a sudden onset of hearing loss. She
awoke this morning unable to hear out of her left ear. There was no preceding illness and
she currently feels well otherwise. She does not have ear pain, headache, runny nose,
congestion, or fever, and she does not take any daily medications.
On examination you note normal vital signs and find a normal ear, with no obstructing
cerumen and with normal tympanic membrane motion on pneumatic otoscopy. You perform
a Weber test by placing a tuning fork over her central forehead. She finds that the sound
lateralizes to her right ear. The Rinne test shows sounds are heard better with bone
conduction on the left and with air conduction on the right.
You refer her to an otolaryngologist for further evaluation including audiometry. You should
also consider initiating which one of the following medications at this visit in order to
optimize the likelihood of recovery?
A) Acyclovir (Zovirax)
B) Amoxicillin/clavulanate (Augmentin)
C) Aspirin
D) Nifedipine (Procardia)
E) Prednisone

This patient has sudden sensorineural hearing loss (SSNHL) of the left ear without any accompanying
features to suggest a clear underlying cause. An appropriate evaluation will fail to identify a cause in
85%–90% of cases. Idiopathic SSNHL can be diagnosed if a patient is found to have a 30-dB hearing loss
at three consecutive frequencies and an underlying condition is not identified by the history and physical

The most recent guideline from the American Academy of Otolaryngology–Head and Neck Surgery
recommends that oral corticosteroids be considered as first-line therapy for patients who do not have a
contraindication. While there is equivocal evidence of benefit, for most patients the risk of a short-term
course of corticosteroids is thought to be outweighed by the potential benefit, especially when considering
the serious consequences of long-term profound hearing loss. Because the greatest improvement in hearing
tends to occur in the first 2 weeks, corticosteroid treatment should be started immediately. The
recommended dosage is 1 mg/kg/day with a maximum dosage of 60 mg daily for 10–14 days.
Antiviral medications, antiplatelet agents, and vasodilators such as nifedipine have no evidence of benefit.
Antibiotics also have no evidence of benefit in the absence of signs of infection.


7. You are the team physician for the local high school track team. During a meet one of the
athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She
is able to bear weight but with significant pain. She reports pain across her right midfoot.
An examination reveals edema over the lateral malleolus and diffuse tenderness, but she
does not have any pain with palpation of the navicular, the base of the fifth metatarsal, or
the posterior distal lateral and medial malleoli.
Which one of the following would be most appropriate at this time?
A) Radiographs of the right ankle only
B) Radiographs of the right foot only
C) Radiographs of the right foot and ankle
D) Lace-up ankle support, ice, compression, and clinical follow-up
E) Crutches and no weight bearing for 2 weeks, followed by a slow return to weight

The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot and ankle
injuries. A radiograph of the ankle is recommended if there is pain in the malleolar zone along with the
inability to bear weight for at least four steps immediately after the injury and in the physician’s office or
emergency department (ED), or tenderness at the tip of the posterior medial or lateral malleolus. A
radiograph of the foot is recommended if there is pain in the midfoot zone along with the inability to bear
weight for four steps immediately after the injury and in the physician’s office or ED, or tenderness at the
base of the fifth metatarsal or over the navicular bone. The Ottawa foot and ankle rules are up to 99%
sensitive for detecting fractures, although they are not highly specific. In this case there are no findings
that would require radiographs, so treatment for the ankle sprain would be recommended. Compression
combined with lace-up ankle support or an air cast, along with cryotherapy, is recommended and can
increase mobility. Early mobilization, including weight bearing as tolerated for daily activities, is
associated with better long-term outcomes than prolonged rest.


8. A 65-year-old male with type 2 diabetes mellitus, hypertension, and obstructive sleep apnea
sees you for follow-up. He does not use tobacco or other drugs, and his alcohol consumption
consists of two drinks per day. His BMI is 31.0 kg/m2, and he just started a fitness program.
The patient tells you that his brother was recently diagnosed with atrial fibrillation and he
asks you if this increases his own risk.
Which one of the following factors would increase the risk of atrial fibrillation in this
A) Alcohol use
B) Treatment with lisinopril (Prinivil, Zestril)
C) Treatment with pioglitazone (Actos)
D) Use of a continuous positive airway pressure (CPAP) device
E) Physical stress

Alcohol consumption greater than one drink/day has been associated with atrial fibrillation. While not
recommended to prevent atrial fibrillation, pioglitazone and lisinopril have both been associated with lower
rates of atrial fibrillation compared to alternative therapies. Treatment of obstructive sleep apnea, along
with a regular fitness regimen, has been associated with a decrease in the recurrence of atrial fibrillation.


9. You have diagnosed a 32-year-old female with moderate iron deficiency anemia, presumed
to be due to chronic menstrual blood loss. She has no gastrointestinal or genitourinary
symptoms, and no bruising or bleeding other than menstrual bleeding. Her vital signs are
normal and a physical examination is unremarkable. You initiate a trial of oral iron therapy.
Which one of the following would be the best way to assess the patient’s response to oral
A) A reticulocyte count in 1–2 weeks
B) A repeat hematocrit in 2 weeks
C) A peripheral smear to look for new RBCs in 4 weeks
D) A serum total iron binding capacity and ferritin level in 6 weeks

The reticulocyte count is the first and best indicator of iron absorption and bone marrow response to oral
iron therapy in the treatment of iron deficiency anemia. An increase in reticulocytes is seen as early as 4
days, peaking at 7–10 days. The rate of production of new RBCs slows thereafter due to a compensatory
decrease in erythropoietin as more iron becomes available. It typically takes 4–6 weeks before seeing
recovery in the hematocrit, and for the RBC count and indices to normalize. However it is usually 4–6
months before iron stores are fully restored to normal levels, so treatment should continue for at least that


10. You see an adult patient who has chronic urticaria and no other known chronic conditions.
He continues to experience hives after a 3-month course of daily loratadine (Claritin).
Which one of the following would be the most appropriate addition to his treatment regimen
at this time?
A) A short course of oral corticosteroids
B) Cyclosporine
C) Ranitidine (Zantac)
D) Narrow-band UV light treatment

First- and second-generation H1 antihistamine receptor antagonists are generally considered first-line
treatment for chronic urticaria, and approximately 60% of patients experience a satisfactory result.
Second-generation options such as loratadine have the added benefit of a lower likelihood of side effects
such as drowsiness. For those who fail to achieve the desired result with monotherapy using an H1
antihistamine receptor antagonist, the addition of an H2 antihistamine receptor antagonist such as cimetidine
or ranitidine is often beneficial. The tricyclic antidepressant doxepin has strong H1 and H2 antihistamine
receptor antagonist effects and has been used as an off-label treatment option in some studies. A short
course of oral corticosteroids, narrow-band UV light treatment, or cyclosporine can be used in the
management of recalcitrant chronic urticaria, but these are considered second- or third-line adjunctive


11. A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a
bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There
are no other historical or physical examination findings to suggest active tuberculosis
infection and a chest radiograph is normal.
Which one of the following would be most appropriate at this point?
A) Monitoring with annual tuberculin skin testing
B) Observation and repeat tuberculin skin testing in 3 weeks
C) Rifampin (Rifadin) daily for 4 months
D) Isoniazid daily for 9 months
E) Once-weekly isoniazid and rifampin for 3 months

This patient’s close contact with a person known to be infected with tuberculosis (TB) places him at risk
for infection, so screening for TB is indicated. For this patient, testing with either a tuberculin skin test
or an interferon-gamma release assay is appropriate. Based on CDC guidelines an induration 5 mm at
48–72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been
in recent contact with a person with infectious TB, those with radiographic evidence of prior TB,
HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the
threshold for a positive test is an induration 10 mm at 48–72 hours. For those with no known risks for
TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is
no indication for additional skin tests.

A positive screening test along with a review of systems, a physical examination, and a chest radiograph
that do not show evidence of active infection confirms the diagnosis of latent TB. For children age 2–11
years, treatment with isoniazid, 10–20 mg/kg daily or 20–40 mg/kg twice weekly for 9 months, is the
preferred and most efficacious treatment regimen. The shorter 6-month treatment course is considered an
acceptable option for adults, but it is not recommended for children. The use of rifampin alone or in
combination with isoniazid is also an acceptable option for adults but not for children under the age of 12.


12. A 62-year-old female with diabetes mellitus presents to your office with left lower quadrant
pain and guarding. She has a previous history of a shellfish allergy that caused hives and
Further evaluation of this patient should include which one of the following?
A) Ultrasonography of the abdomen
B) CT of the abdomen and pelvis with oral and intravenous (IV) contrast
C) Oral corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral
and IV contrast
D) Intravenous corticosteroids and antihistamines, then CT of the abdomen and pelvis
with oral and IV contrast
E) Laparotomy

Evaluation of this patient should include CT of the abdomen and pelvis with oral and intravenous (IV)
contrast. There is no reason to inquire about shellfish allergies prior to CT with IV contrast, because
premedication is not needed. There is no correlation between shellfish allergies and allergic reactions to
contrast. Patients with moderately severe to severe reactions to IV contrast in the past would need
pretreatment with corticosteroids


13. A 45-year-old female who works as a house cleaner presents with left shoulder pain. On
examination she has pain and relative weakness when pushing toward the midline against
resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still
at 90° she is unable to keep her left hand away from her body when you position her hand
behind her back.
This presentation is most consistent with an injury of which one of the following tendons?
A) Deltoid
B) Infraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres minor

This patient’s pain and weakness while pushing against resistance reveals weakness on internal rotation
of the shoulder, which suggests a possible tear of the subscapularis tendon. The inability to keep her hand
away from her body when it is placed behind her back describes a positive internal lag test, also suggesting
involvement of the subscapularis tendon. The infraspinatus and teres minor are involved in external
rotation rather than internal rotation. The supraspinatus and deltoid are involved in abduction of the


14. An 8-year-old male is brought to your office because of acute lower abdominal pain. He is
not constipated and has never had abdominal surgery. You suspect acute appendicitis.
Which one of the following would be most appropriate at this point?
A) Plain radiography
B) Ultrasonography
C) CT without contrast
D) CT with contrast

Ultrasonography is recommended as the first imaging modality to evaluate acute abdominal pain in
children. It avoids radiation exposure and is useful for detecting many causes of abdominal pain, including
appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis.
Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history
of previous abdominal surgery.
The American Academy of Pediatrics Choosing Wisely recommendation on the evaluation of abdominal
pain states that CT is not always necessary. The American College of Surgeons Choosing Wisely
recommendation on the evaluation of suspected appendicitis in children says that CT should be avoided
until after ultrasonography has been considered as an option.


15. You see a patient with a serum sodium level of 122 mEq/L (N 135–145) and a serum
osmolality of 255 mOsm/kg H2O (N 280–295). Which one of the following would best
correlate with a diagnosis of syndrome of inappropriate antidiuresis?
A) A fractional excretion of sodium below 1%
B) Elevated urine osmolality
C) Elevated serum glucose
D) Elevated BUN
E) Low plasma arginine vasopressin

The syndrome of inappropriate antidiuresis (SIAD, formerly SIADH) is related to a variety of pulmonary
and central nervous system disorders in which hyponatremia and hypo-osmolality are paradoxically
associated with an inappropriately concentrated urine. Most cases are associated with increased levels of
the antidiuretic hormone arginine vasopressin (AVP). Making a diagnosis of SIAD requires that the patient
be euvolemic and has not taken diuretics within the past 24–48 hours, and the urine osmolality must be
high in conjunction with both low serum sodium and low osmolality. The BUN should be normal or low
and the fractional excretion of sodium >1%.
Fluid restriction (<800 cc/24 hrs) over several days will correct the hyponatremia/hypo-osmolality, but
definitive treatment requires eliminating the underlying cause, if possible. In the case of severe, acute
hyponatremia with symptoms such as confusion, obtundation, or seizures, hypertonic (3%) saline can be
slowly infused intravenously but might have dangerous neurologic side effects.
Elevated serum glucose levels may cause a factitious hyponatremia, but not SIAD.


16. A 45-year-old African-American male returns to your clinic to evaluate his progress after
6 months of dedicated adherence to a diet and exercise plan you prescribed to manage his
blood pressure. His blood pressure today is 148/96 mm Hg. He is not overweight and he
does not have other known medical conditions or drug allergies.
Which one of the following would be the most appropriate initial antihypertensive treatment
option for this patient?
A) Chlorthalidone
B) Hydralazine
C) Lisinopril (Prinivil, Zestril)
D) Losartan (Cozaar)
E) Metoprolol

Lifestyle modifications addressing diet, physical activity, and weight are important in the treatment of
hypertension, particularly for African-American and Hispanic patients. When antihypertensive drugs are
also required, the best options may vary according to the racial and ethnic background of the patient. The
presence or absence of comorbid conditions is also important to consider. For African-Americans, thiazide
diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens,
have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II
receptor blockers, or -blockers, and should be considered as first-line options over the other classes of
antihypertensive drugs unless a comorbid condition is present that would be better addressed with a
different class of drugs. Racial or ethnic background should not be the basis for the exclusion of any drug
class when multidrug regimens are required to reach treatment goals.


17. An 85-year-old female with metastatic breast cancer requests hospice care. She has type 2
diabetes mellitus, stage 3 renal failure, and heart disease.
The patient’s eligibility for hospice care will be based on her
A) age
B) cancer diagnosis
C) comorbid conditions
D) life expectancy
E) Medicare Part B plan

Eligibility for hospice care is based on a life expectancy of 6 months or less in the natural course of an
illness. A majority of hospice patients have cancer but it is not a requirement to qualify for hospice care.
Age is not relevant. Comorbid conditions may affect longevity but are not required. For those insured by
Medicare, Medicare Part A provides hospice care but Medicare Part B does not.


18. A 15-year-old female presents with a 3-month history of intermittent abdominal pain and
headaches. She does not have any associated weight loss, fever, nausea, change in bowel
habits, or other worrisome features. An examination is unremarkable. She does report being
stressed at school and has a PHQ-2 score of 4.
Which one of the following would be most appropriate at this point?
A) Further evaluation for depression
B) Laboratory studies
C) Abdominal imaging
D) Citalopram (Celexa)
E) Fluoxetine (Prozac)

The U.S. Preventive Services Task Force recommends depression screening for all adolescents 12–18
years of age. Although this patient has abdominal pain, the history and physical examination suggest that
depression may be playing a role in her somatic complaints. She had a positive initial depression screen
on her PHQ-2. This is a brief screening tool, and a positive result merits further evaluation. The evaluation
should include a full PHQ-A or a discussion with a qualified clinician. If the patient meets the criteria for
major depressive disorder then she should receive treatment for her depression, which could include
medication. Both fluoxetine and citalopram have been approved by the FDA to treat depression in this age
group. She could also be referred for psychotherapy. Further laboratory studies and imaging may be
appropriate at some point, but the most urgent need is to evaluate her positive depression screen.


19. A 69-year-old male with type 2 diabetes mellitus, obesity, and a history of coronary artery
disease sees you for follow-up of his diabetes. His hemoglobin A1c has increased to 8.7%
despite therapy with metformin (Glucophage), 1000 mg twice daily, and insulin glargine
Which one of the following additional medications would be most effective for reducing his
blood glucose level and lowering his risk of cardiovascular events?
A) Exenatide (Byetta)
B) Glipizide (Glucotrol)
C) Liraglutide (Victoza)
D) Rosiglitazone (Avandia)
E) Sitagliptin (Januvia)

Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been
shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this
indication. Glipizide (a sulfonylurea), rosiglitazone, and sitagliptin have not been associated with improved
cardiovascular outcomes. Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary
prevention of cardiovascular disease.


20. A 2-year-old African-American male with a history of sickle cell disease is brought to your
office for a well child check. Which one of the following would be most appropriate for
screening at this time?
A) A chest radiograph
B) A DXA scan
C) Abdominal ultrasonography
D) Renal Doppler ultrasonography
E) Transcranial Doppler ultrasonography

Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle
cell patients 2–16 years of age should be screened with transcranial Doppler ultrasonography (SOR A).
A chest radiograph, abdominal ultrasonography, a DXA scan, and renal Doppler ultrasonography are not
recommended for screening patients with sickle cell disease.


21. You perform the initial newborn examination on a male on his first day of life, following an
uncomplicated vaginal delivery at an estimated gestational age of 37 weeks and 6 days. The
prenatal course was significant for the initial presentation for prenatal care at 22 weeks
gestation. You note that the infant’s upper lip is thin and the philtrum is somewhat flat.
Which additional finding would increase your concern for fetal alcohol syndrome?
A) Curvature of the fifth digit of the hand (clinodactyly)
B) A supernumerary digit of the hand
C) Flattening of the head (plagiocephaly)
D) Metatarsus adductus in one foot
E) Syndactyly of the toes (webbed feet)

In addition to clinodactyly, fetal alcohol syndrome is associated with camptodactyly (flexion deformity of
the fingers), other flexion contractures, radioulnar synostosis, scoliosis, and spinal malformations. It is
also associated with many neurologic, behavioral, and cardiovascular abnormalities, as well as other types
of abnormalities. Plagiocephaly, supernumerary digits, syndactyly, and metatarsus adductus are common
in newborns but are not related to fetal alcohol spectrum disorders.


22. An otherwise healthy 3-year-old child with no allergies is found to have otitis media with
effusion in the right ear. Which one of the following would you recommend?
A) No treatment, and follow-up in 3 months
B) Amoxicillin
C) Oral antihistamines
D) Nasal corticosteroids
E) Tympanostomy tube placement

This child has otitis media with effusion, and the recommended course of action is to follow up in 3
months. Medications, including decongestants, antihistamines, antibiotics, and corticosteroids, are not


23. A 32-year-old male presents with a 4-week history of persistent low back pain. He started
feeling tightness in his low back after helping a friend move into a new apartment. The pain
does not radiate, there is no associated paresthesia or numbness, and he has not had any
bowel or bladder incontinence. The pain is constant and worsens with prolonged sitting. He
rates the pain as 6 on a scale of 10. Ibuprofen has provided minimal relief.
Examination of the lumbar area over the paraspinous muscles reveals minimal tenderness.
A neurovascular examination and a straight leg raise are normal in both lower extremities.
Which one of the following would be most appropriate at this point?
A) Imaging studies of the lumbar spine
B) A short course of an oral corticosteroid
C) Gabapentin (Neurontin) started at a low dose and titrated to effect
D) A skeletal muscle relaxant and an NSAID
E) A short-acting opioid and an NSAID

This patient has acute to subacute nonspecific low back pain. Combination treatment with an NSAID and
a skeletal muscle relaxant is recommended as second-line therapy when an NSAID is ineffective as
monotherapy. Opioids have not been shown to have significant benefit when added to an NSAID and
would not be recommended as a second-line treatment. Systemic corticosteroids do not have evidence to
support their use in the treatment of acute nonspecific back pain. Gabapentin does not have evidence to
support its use in treating acute back pain and has been shown to produce only minimal improvement in
chronic back pain. This patient has no red-flag symptoms so imaging studies are not recommended at this


24. A 48-year-old female with GERD treated with a proton pump inhibitor for the past 2 years
sees you for a routine visit. She reports that she has paresthesia and numbness in both feet.
Her hemoglobin A1c is 5.8%, her hemoglobin level is 10.4 g/dL (N 12.0–16.0), and her
mean corpuscular volume is 102 m3 (N 81–99). Microfilament testing shows decreased
sensation in both feet.
Which one of the following is the most likely cause of her peripheral neuropathy?
A) Charcot-Marie-Tooth disease
B) Diabetic peripheral neuropathy
C) Hyperthyroidism
D) Tarsal tunnel syndrome
E) Vitamin B12 deficiency

This patient has polyneuropathy, macrocytic anemia, and a history of chronic proton pump inhibitor use.
The most likely cause is vitamin B12 deficiency and a serum level is indicated. Her hemoglobin A1c is
5.8%, which puts her at risk of developing diabetes mellitus but is not indicative of diabetes.
Charcot-Marie-Tooth disease is a rare cause of polyneuropathy and unlikely in this case. Hypothyroidism,
and not hyperthyroidism, is associated with polyneuropathy. Tarsal tunnel syndrome causes a


25. A 60-year-old male presents with a several-month history of a dry cough and progressive
shortness of breath with exertion. On examination he has tachypnea and bibasilar
end-inspiratory dry crackles, and a chest radiograph reveals interstitial opacities.
Which one of the following patient occupations would most likely support a diagnosis of
A) Baker
B) Firefighter
C) Stone cutter
D) Goat dairy farmer
E) High-tech electronics fabricator

Family physicians should be aware of the environmental exposures associated with pulmonary disease.
Stone cutting, sand blasting, mining, and quarrying expose patients to silica, which is an inorganic dust
that causes pulmonary fibrosis (silicosis). Occupational exposure to beryllium, which is also an inorganic
dust, occurs in the high-tech electronics manufacturing industry and results in chronic beryllium lung
disease. Exposure to organic agricultural dusts (fungal spores, vegetable products, insect fragments, animal
dander, animal feces, microorganisms, and pollens) can result in “farmer’s lung,” a hypersensitivity
pneumonitis. Other organic dust exposures, such as exposures to grain dust in bakers, can lead to asthma,
chronic bronchitis, and COPD. Firefighters are at risk of smoke inhalation and are exposed to toxic
chemicals that can cause many acute and chronic respiratory symptoms.


26. A 28-year-old female presents with a 3-month history of fatigue and postural
lightheadedness. On examination she is diffusely hyperpigmented, especially her skin creases
and areolae. A CBC and basic metabolic panel are normal except for an elevated potassium
level. You order a corticotropin stimulation test.
Prior to the corticotropin injection, you should order which one of the following tests to
confirm that this patient has a primary insufficiency and not a secondary (pituitary) disorder?
B) Aldosterone
C) Melanocyte-stimulating hormone
D) Renin

A plasma ACTH level is recommended to establish primary adrenal insufficiency. The sample can be
obtained at the same time as the baseline sample in the corticotropin test. A plasma ACTH greater than
twice the upper limit of the reference range is consistent with primary adrenal insufficiency. Aldosterone
and renin levels should be obtained to establish the presence of adrenocortical insufficiency, but these do
not differentiate primary from secondary adrenal insufficiency. The hyperpigmentation of Addison’s
disease is caused by the melanocyte-stimulating hormone (MSH)–like effect of the elevated plasma levels
of ACTH. ACTH shares some amino acids with MSH and also produces an increase in MSH in the blood.
TSH is not part of the feedback loop of adrenal insufficiency.


27. You see a 3-year-old female with a 2-day history of intermittent abdominal cramps, two
episodes of emesis yesterday, and about five watery, nonbloody stools each day. She does
not have a fever, her other vital signs are normal, and she has not traveled recently. Today
she has tolerated sips of fluid but still has mild fatigue and thirst. An examination is normal
except for mildly dry lips. A friend at preschool had a similar illness recently.
Which one of the following would be the most appropriate initial management of this
A) A sports drink and food on demand
B) Half-strength apple juice and food on demand
C) Ginger ale and no food yet
D) Water and no food yet
E) A bolus of intravenous normal saline and no food yet

Family physicians often see patients with diarrheal illnesses and most of these are viral. Patients sometimes
have misconceptions about preferred fluid and feeding recommendations during these illnesses. The World
Health Organization recommends oral rehydration with low osmolarity drinks (oral rehydration solution)
and early refeeding. Half-strength apple juice has been shown to be effective, and it approximates an oral
rehydration solution. Its use prevents patient measurement errors and the purchase of beverages with an
inappropriate osmolarity. Low osmolarity solutions contain glucose and water, which decrease stool
frequency, emesis, and the need for intravenous fluids compared to higher osmolarity solutions like soda
and most sports drinks. Water increases the risk of hyponatremia in children. This patient is not ill enough
to need intravenous fluids. Early refeeding has been shown to decrease the duration of illness.


28. A 32-year-old female requests a physical examination prior to participating in an adult
soccer league. Her blood pressure is 118/70 mm Hg and her pulse rate is 68 beats/min. The
examination is otherwise normal except for a systolic murmur that intensifies with Valsalva
maneuvers. She says that she has recently been experiencing mild exertional dyspnea and
moderate chest pain. The chest pain has been atypical and is not necessarily related to
exertion. Echocardiography reveals hypertrophic cardiomyopathy.
In addition to referring the patient to a cardiologist, you recommended initiating therapy with
A) amiodarone (Cordarone)
B) amlodipine (Norvasc)
C) furosemide (Lasix)
D) lisinopril (Prinivil, Zestril)
E) metoprolol

Hypertrophic cardiomyopathy is the most common primary cardiomyopathy, with a prevalence of 1:500
persons. Many patients with hypertrophic cardiomyopathy are asymptomatic and are diagnosed during
family screening, by auscultation of a heart murmur, or incidentally after an abnormal result on
electrocardiography. On examination physicians may hear a systolic murmur that increases in intensity
during Valsalva maneuvers. The main goals of therapy are to decrease exertional dyspnea and chest pain
and prevent sudden cardiac death. -Blockers are the initial therapy for patients with symptomatic
hypertrophic cardiomyopathy. Nondihydropyridine calcium channel blockers such as verapamil can be
used if -blockers are not well tolerated.


29. An 85-year-old female with advanced Alzheimer’s disease is brought to your office for
treatment of agitation, aggressive behavior, and delusions. Behavioral and psychological
interventions have had little success and the family is willing to try medications because they
prefer to keep the patient at home.
Which one of the following would most likely help control this patient’s symptoms?
A) Alprazolam (Xanax)
B) Aripiprazole (Abilify)
C) Clozapine (Clozaril)
D) Donepezil (Aricept)
E) Haloperidol

Nonpharmacologic interventions are the first-line treatment for patients with behavioral and psychological
symptoms of dementia. Antipsychotic medications can be prescribed for refractory cases but this is an
off-label use. Both the patient and family should be aware that the use of atypical antipsychotics for
behavioral symptoms of dementia is associated with increased mortality. Patients should be monitored for
side effects and the medication should be discontinued if there is no evidence of symptom improvement
after a month.
Typical antipsychotics such as haloperidol have significant side effects and would not be a good choice.
Donepezil is initiated early in the course of Alzheimer’s disease to delay progression of the disease.
Benzodiazepines are likely to cause significant side effects including sedation, increased confusion, and
falls. Several of the antipsychotics, such as ziprasidone and clozapine, are ineffective. Results with
olanzapine, quetiapine, and risperidone are inconsistent. Aripiprazole produces small reductions in
behavioral and psychological symptoms of dementia, and it has the least adverse effects of the atypical


30. A 30-year-old female with anovulatory uterine bleeding asks about treatment options. An
examination is normal and blood testing is negative. She is unmarried and is undecided about
having children.
Which one of the following would be the most appropriate treatment for this patient?
A) Oral progestin during the luteal phase
B) A levonorgestrel-releasing IUD
C) Endometrial ablation
D) Hysterectomy

Few treatments for dysfunctional uterine bleeding have been studied. NSAIDs, oral contraceptive pills,
and danazol have not been shown to have sufficient evidence of effect for the treatment of dysfunctional
uterine bleeding. Progestin is effective when used on a 21-day cycle, but not if used only during the luteal
phase. Hysterectomy and ablation are very effective, but both eliminate fertility. In a young woman unsure
about having children, the levonorgestrel-releasing IUD is the most effective treatment that preserves
fertility (SOR A).