ABFM ITE 2019 Flashcards

Question

2019.25) In addition to a thorough history and physical examination, the routine evaluation of patients presenting with syncope should include A) a CBC, comprehensive metabolic panel, TSH level, and urinalysis B) orthostatic blood pressure measurements and an EKG C) cardiac stress testing D) echocardiography and Doppler ultrasonography of the carotid arteries E) CT or MRI of the brain

Answer 1

B) orthostatic blood pressure measurements and an EKG Orthostatic blood pressure measurement and an EKG are indicated in the routine evaluation of patients with syncope. All other testing should be directed by findings obtained in the history and on the physical examination.

Answer 2

A) A serum ferritin level (**REVIEW: 2019.190** ) Anemia is often diagnosed incidentally on laboratory testing and is often asymptomatic. It is associated with increased morbidity and mortality in older adults, and is often caused by nutritional deficiencies, chronic kidney disease, occult blood loss from gastrointestinal malignancies, or chronic inflammation. However, in many patients the cause remains unknown. A detailed history and physical examination are indicated. In patients with normocytic or microcytic anemia, a serum ferritin level should be ordered. A low serum ferritin level is associated with iron deficiency and should be further evaluated so the underlying cause can be addressed. * A **serum transferrin-receptor–ferritin index** should be determined for patients with a **serum ferritin level between 46 and 100 ng/mL** to distinguish between iron deficiency anemia and other types of anemia. * Referring this patient to a gastroenterologist would not be indicated at this time.

Answer 3

C) Physical therapy with eccentric calf-strengthening exercises (**REVIEW: 2018.111** ) This patient has typical symptoms and findings of **Achilles tendinopathy**. The best management involves eccentric calf-strengthening exercises. * A local injection with corticosteroids or with platelet-rich plasma is ineffective and may increase the risk of a tendon rupture. * Immobilization and surgical debridement may be considered if more conservative therapies have failed.

Answer 4

B) Bupropion (Wellbutrin), 150 mg twice daily Bupropion can improve antidepressant-related sexual arousal dysfunction (SOR B). * Black cohosh is considered a safe alternative for treating menopausal vasomotor symptoms, but not for treating sexual arousal dysfunction in women who are premenopausal. * Ethinyl estradiol may be taken to improve sexual dysfunction related to menopausal symptoms. * Vaginal estrogen therapy is recommended over oral estrogen when vaginal dryness is the primary symptom. * Ospemifene is indicated for dyspareunia related to vulvar and vaginal atrophy due to menopause. * Testosterone has proven to be effective for treating menopause-related low sexual desire but the evidence is limited due to the lack of long-term data. The Endocrine Society recommends consideration of a 3- to 6-month course of testosterone specifically for postmenopausal women with low sexual desire.

Answer 5

A) Warm compresses and gentle cleansing with a mild shampoo This patient has **blepharitis**, a chronic inflammation of the eyelids. Seborrhea is a common cause in older adults. In younger patients including children, colonization with Staphylococcus may be a contributing factor. Meibomian gland dysfunction is often part of this condition, contributing to a reduced quality of tear films, which leads to dry eyes and irritation. Other diagnoses to consider in this patient include conjunctivitis, preseptal cellulitis, and Sjögren’s syndrome. * Conjunctivitis typically involves the conjunctiva and an eye discharge but less involvement of the eyelids is present. * Cellulitis is an acute rather than chronic condition and involves more pain and swelling. * Sjögren’s syndrome causes dry eye but not inflammatory changes of the lid. The initial treatment of blepharitis consists of lid hygiene using **warm compresses** to remove dried secretions and debris. **Mild shampoo** can help in this process and aid in keeping the bacterial colonization load down. In severe or recalcitrant cases a **topical antibiotic** ointment may be applied to the lids. **Oral antibiotics** can be considered for more severe cases.

Answer 6

B) Nonnutritive sweeteners are acceptable to use Nonnutritive sweeteners contain few or no calories. According to the American Diabetes Association, nonnutritive sweeteners may be acceptable to use instead of nutritive sweeteners such as sucrose. They should be used in moderation if they are used. The use of nonnutritive sweeteners can help to reduce overall intake of carbohydrates and calories. They do not significantly affect glycemic control. Research is inconsistent regarding the effects of nonnutritive sweeteners on weight loss, but most systematic reviews and meta-analyses demonstrate a benefit. There is no recommendation to avoid sucralose or aspartame in patients with type 2 diabetes. Beverages sweetened with sugar are associated with an increased risk of type 2 diabetes.

Answer 7

A) Chronic rhinosinusitis (**REVIEW: 2018.215** ) The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of **two of four cardinal symptoms**, which include 1. nasal **drainage**, 2. nasal **obstruction**, 3. facial **pain** or pressure, and 4. hyposmia or **anosmia**, along with 5. **objective signs** on examination or radiographic studies. This patient has three cardinal symptoms of chronic rhinosinusitis and objective evidence on the physical examination. * No nasal polyps were seen on the examination. * Granulomatosis with polyangiitis and sarcoidosis can both present similarly but are uncommon causes of chronic rhinosinusitis. * Allergic rhinitis can be associated with chronic rhinosinusitis but would also present with allergic symptoms.

Answer 8

D) Order an urgent MRI Malignant epidural spinal cord compression is an oncologic emergency that requires urgent MRI to confirm the diagnosis. It is caused by a tumor compressing the dural sac and should be suspected with new-onset progressive back pain that is worse when the patient is lying down. It is most commonly associated with breast cancer and develops in approximately 5% of all patients with cancer. Once the diagnosis is confirmed, an urgent management approach is needed. * Corticosteroids and neurosurgical intervention can preserve motor and sensory function. * Attempting to alleviate the pain would not address this emergency.

Answer 9

B) Inconsistent answers to questions In order for patients to show they have the capacity to make a decision they must demonstrate an understanding of the situation, including the risks, benefits, and consequences of the decision or refusal of care. If a patient gives inconsistent answers to questions after multiple explanations, this indicates that there is a lack of understanding and would meet one of the criteria to determine that the patient lacks the capacity to make that decision. * The presence of dementia can be associated with an increased incidence of having a lack of capacity; however, a diagnosis of dementia by itself does not indicate that the patient lacks the capacity to make a decision. * While disorientation to time or a lower score on the Mini-Mental State Examination is associated with an increased risk of lacking capacity, these findings alone would not be enough to determine that the patient lacks capacity. * The patient asking that her son be her medical decision maker instead of her daughter would not be an indication that she lacks capacity.

Answer 10

C) Echocardiography According to national guidelines **echocardiography is the preferred** initial noninvasive testing modality when pulmonary hypertension is suspected (SOR C). * Pulmonary function tests provide helpful information in regard to pulmonary capacity but are not necessarily diagnostic of pulmonary hypertension. * CT of the chest with contrast will not provide pulmonary pressures but may assist in the detection of pulmonary emboli. * A coronary calcium scan may be indicated to evaluate for coronary artery disease but it is not a diagnostic test for pulmonary hypertension. * Although right heart catheterization would provide pulmonary pressure values it is considered more invasive than echocardiography and is not always necessary for making the diagnosis.

Answer 11

D) Pes anserine bursitis This patient has medial knee pain related to repetitive use, most likely caused by pes anserine bursitis. Iliotibial band syndrome is often related to overuse but causes pain in the lateral knee. * The fibular head is also lateral to the knee joint. * Osgood-Schlatter disease is also often related to overuse but causes pain at the insertion of the patellar ligament on the midline proximal tibia. * A medial meniscal tear would localize to the medial joint line rather than distal to the joint line and would more likely be associated with positive findings from other examinations, such as a McMurray test.

Answer 12

D) Trichomoniasis Trichomoniasis classically presents as a greenish-yellow, frothy discharge with a foul odor. Erythema and inflammation of the vagina and cervix are often present and can include punctate hemorrhages (strawberry cervix). * Atrophic vaginitis may cause a thin, clear discharge and is usually associated with a thin, friable vaginal mucosa. * Irritant/allergic vaginitis causes burning and soreness with vulvar erythema but usually does not cause any significant discharge. * Bacterial vaginosis more commonly presents as a thin, homogenous discharge with a fishy odor and no cervical or vaginal inflammation. * Vulvovaginal candidiasis presents with white, thick, cheesy, or curdy discharge.

Answer 13

C) mumps can cause orchitis, possibly resulting in decreased fertility Prodromal symptoms of **mumps** include 1. myalgia, 2. fatigue, 3. loss of appetite, 4. fever, and 5. headache. 6. Parotitis is the most common manifestation. 7. Infertility, meningitis, and encephalitis are serious complications of orchitis. * Measles is characterized by 1. cough, 2. coryza, 3. conjunctivitis, and 4. Koplik spots. * Varicella is characterized by a pruritic rash with fluid-filled blisters. * MMR vaccine is indicated for this child.

Answer 14

C) SGLT2 inhibitors such as empagliflozin (Jardiance) (**REVIEW: 2018.136** ) SGLT2 inhibitors are known to cause an increased risk of yeast vaginitis because their mechanism of action involves blocking renal uptake of glucose, which results in an increase in glucosuria (SOR A). * Common side effects of metformin include gastrointestinal upset. * DPP-4 inhibitors have very few side effects. * GLP-1 receptor agonists typically cause nausea and early satiety and weight loss. * Sulfonylureas are associated with weight gain and hypoglycemia. **PCC 4-5**

Answer 15

B) Liver function tests and serum bile acid levels Whenever a pregnant woman presents with pruritus without a primary rash, it is important to evaluate her for **intrahepatic cholestasis** of pregnancy. This diagnosis is associated with increased fetal mortality and warrants increased antenatal surveillance as well as **possible induction by 35–37 weeks gestation**. It is most appropriate to check for **elevation of liver function tests** and **serum bile acids**. * Emollients, topical corticosteroids, and oral antihistamines can all be helpful for pruritus and certain rashes, but in this patient it is most important to promptly look for the cause of the pruritus. * Varicella-zoster immune globulin would be indicated if she had no immunity to varicella and had been exposed to varicella or if she had a rash that was suspected to be chickenpox.

Answer 16

B) 50 To mitigate the risk of opioid harm, it is essential to understand morphine milligram equivalents (MME). The evidence shows that the r**isk of an opioid overdose** increases at the **threshold of 50 MME/day**. It is therefore recommended by the CDC that a prescription for **naloxone be ordered** when an opioid dosage reaches 50 MME/day, which is a high dosage. * In general one should **avoid prescribing \>90 MME/day** because of the substantially higher risk of an overdose at this dosage level.

Answer 17

A) Elevated parathyroid hormone (PTH) and elevated phosphorus Chronic kidney disease–mineral and bone disorder (CKD-MBD) is found in many patients with CKD and is associated with an increased risk of bone fractures and cardiovascular events due to vascular calcification. In patients with CKD, **phosphate is not appropriately excreted** and the **subsequent hyperphosphatemia leads to secondary hyperparathyroidism** and binding of calcium. Decreased production of calcitriol in patients with CKD also leads to hypocalcemic hyperparathyroidism. Patients with CKD stages 3a–5 should have phosphorus, calcium, parathyroid hormone, and 25-hydroxyvitamin D levels checked regularly, and consultation with a nephrologist or endocrinologist should be obtained if CKD-MBD is suspected.

Answer 18

B) ultrasonography Recognizing clinically significant abnormalities on the newborn examination is important. Newborns with small sacral dimples located far from the anal verge, without other skin findings such as hair, do not need imaging to rule out **spinal dysraphism (tethered cord)**. While the exact parameters of what is considered large (\>0.5 cm diameter) and close (within 2.5 cm of the anal verge) can easily be found in reference materials, the dimple described here is clearly concerning and needs imaging. **Ultrasonography can accurately and safely** detect spinal dysraphism in these cases.

Answer 19

A) immobilization This patient has acute **Charcot neuroarthropathy**, an inflammatory condition that occurs in obese patients with peripheral neuropathy and ultimately leads to foot deformities (the classic rocker-bottom foot) and resultant ulcerations and infections. Its clinical appearance can easily be initially mistaken for cellulitis. However, the absence of tenderness and other signs of infection such as fever, an elevated WBC count, and inflammatory markers is not consistent with cellulitis. Radiography is an appropriate initial imaging modality but the results are often interpreted as normal early in the disease process. MRI is the modality of choice for a definitive diagnosis and may demonstrate periarticular bone marrow edema, adjacent soft-tissue edema, joint effusion, and microtrabecular or stress fractures. The treatment of acute Charcot neuroarthropathy is immobilization with total contact casting, which increases the total surface area of contact to the entire lower extremity, distributing pressure away from the foot. Immobilization is typically required for at least 3–4 months but in some cases may be needed for up to 12 months. Bisphosphonates were found to be ineffective as adjunctive therapy in acute Charcot neuroarthropathy. Corticosteroids and antibiotics have no role in the treatment of Charcot foot but would be appropriate therapy for cellulitis or gout, which are important alternative diagnoses to consider. The role of surgery is more controversial but may be indicated in the acute phase of Charcot neuroarthropathy in patients with severe dislocation or instability.

Answer 20

C) Perform a methacholine challenge Spirometry is central to confirming the diagnosis of asthma, which is characterized by a reversible obstructive pattern of pulmonary function. In this case the patient’s FEV1/FVC ratio is normal, which neither confirms nor rules out asthma. A **methacholine challenge** is recommended in this scenario to assess for the airway hyperresponsiveness that is the hallmark of asthma. Methacholine is a cholinergic agonist. Bronchoconstriction (defined as a reduction in **FEV1 \>20%**) observed at low levels of methacholine administration (**\<4 mg/mL**) is consistent with asthma. If the FEV1/FVC ratio is reduced on initial spirometry, a bronchodilator response should be tested. A fixed or partially reversible obstructive pattern suggests an alternative diagnosis such as COPD, and full reversal after bronchodilator use is consistent with asthma. Inhaled corticosteroids are not appropriate for intermittent asthma. PPC 13-3

Answer 21

A) Add atorvastatin (Lipitor) Management of asymptomatic **peripheral artery disease (PAD)** should initially be conservative and should include a walking program (SOR A), smoking cessation, and a healthy diet. 1. **Statins should be started for all patients** with PAD regardless of their LDL-cholesterol levels (SOR A). 2. High-intensity statins should be used if tolerated. 3. A single antiplatelet agent is recommended for patients with PAD. Both aspirin and clopidogrel are effective in the reduction of stroke, but the combination of the two is recommended only after revascularization surgery. * Blood pressure control is indicated in patients with PAD but no antihypertensive class is clearly superior to another, although there is some evidence that ACE inhibitors may have additional benefits in terms of walking and pain. In an 80-year-old patient, lowering blood pressure below 120/80 mm Hg can be associated with significant side effects, including a greater risk of falls. * Anticoagulants have not been shown to reduce the risk of major cardiovascular events in patients with PAD and they increase the risk of life-threatening bleeding. * Referral to a vascular surgeon or for angiography is indicated if conservative therapy fails or symptoms worsen acutely, pain occurs at rest, or the patient develops ulcerations or loss of tissue.

Answer 22

A) Avoiding dietary restrictions Effective interventions for weight loss in nursing home patients include providing meals in a pleasant, home-like environment. Avoiding dietary restrictions has low quality evidence of effectiveness. There is high quality evidence that initiating tube feedings in patients with severe dementia is not only ineffective but may lead to problems such as decubitus ulcers and aspiration. There is low to very low evidence of the effectiveness for prescribing appetite stimulants, selenium, vitamin B, or vitamin D supplements unless there is a documented deficiency. Neither quality of life nor survival is improved.

Answer 23

B) 130/80 mm Hg The latest American College of Cardiology/American Heart Association guidelines promote a radical change in the management of hypertension, which they now define as a blood pressure **\>130/80 mmHg**. 1. **120–129 / \<80 mmHg**: Elevated blood pressure 2. **130–139 / 80–89 mmHg**: stage 1 hypertension 3. **\>140 / \>90 mmHg**: stage 2 hypertension.

Answer 24

B) \<95 mg/dL The goal fasting blood glucose level in patients with gestational diabetes is \<95 mg/dL. * A fasting glucose level **\<80 mg/dL is associated with increased maternal and fetal complications**. * The **goal 2-hour postprandial** glucose level is **\<120 mg/dL** and the * **Goal 1-hour postprandial** glucose level is **\<140 mg/dL**.

Answer 25

A) Alendronate (Fosamax) (**REVIEW: 2018.207** ) Patients are at risk of developing glucocorticoid-induced osteoporosis if they are on long-term glucocorticoid therapy, defined as **\>2.5 mg of prednisone** for a **duration of 3 months or longer**. The American College of Rheumatology recommends pharmacologic treatment for these patients, as well as for patients receiving glucocorticoids who have a 1. bone mineral density **T-score \<–2.5** at either the **spine** or the **femoral neck** and are either 2. **male** and **\>50 years of age** or 3. **female and postmenopausal**. Therapy is also recommended in patients \>40 years of age who do not meet these criteria but have a **10-year risk of major osteoporotic fracture of at least 20%** or a **risk of hip fracture of at least 3%** according to the **FRAX tool**. **Oral bisphosphonates** are recommended as first-line agents for preventing glucocorticoid-induced osteoporotic fractures, although intravenous bisphosphonates can be used if patients are unable to use the oral forms. Supplementation of **calcium (800–1000 mg)** and **vitamin D (400–800 IU)** is also recommended. **Raloxifene** and **teriparatide** are options when bisphosphonate therapy fails or is contraindicated (SOR A).

Answer 26

C) Inability to follow one-step directions At **18 months** of age a child should **follow one-step directions**. * Approximately 90% of 18-month-olds say at least three words, and 50%–90% say six words. * The ability to **point to body parts or pictures** after they are named is expected at **2 years** of age. * Not walking at 18 months would be a red flag for delay, but running well may not yet be accomplished. * At 18 months a child would be expected to scribble spontaneously but not to copy a vertical line.

Answer 27

D) Recurrent or persistent upper respiratory symptoms Despite 10%–30% of the population being affected by allergic disease, allergy testing does have limitations and is most useful in certain clinical situations. Allergy testing can be helpful in patients with persistent sinus infections, allergic rhinitis, and poorly controlled asthma. * Allergy testing for insect stings is indicated only following systemic/anaphylactic or large local reactions, not with limited localized reactions. * Three days of fever followed by a diffuse urticarial rash likely represents a rash associated with a limited viral illness. * Allergy testing for penicillin has a negative predictive value of 95%–98%. Testing for allergy to other antibiotics has a much lower sensitivity and specificity but does have limited use to help guide medication choices in patients with multiple allergies and when limited antibiotic options are available. * Persistent epigastric pain following the ingestion of tomato products is more indicative of acid reflux symptoms rather than a tomato allergy.

Answer 28

C) Placement of a thumb spica splint, with a follow-up examination in 2 weeks The history, symptoms, and physical examination findings in this case suggest a **scaphoid fracture**. The scaphoid bone is the most commonly fractured carpal bone and a fall on an outstretched hand can produce enough force to cause this fracture. This fracture is most common in males 15–30 years of age. The finding of **anatomic snuffbox tenderness** is **highly sensitive** but not specific for a scaphoid fracture. Initial radiographs often do not demonstrate a fracture. When there is a high clinical suspicion for a scaphoid fracture but radiographs are negative, it is reasonable to immobilize in a thumb spica splint and reevaluate in 2 weeks. Treatment for a sprain with or without follow-up would not be ideal in a situation where a scaphoid fracture is suspected. MRI or bone scintigraphy can be considered if the patient desires or needs an immediate diagnosis, but CT and ultrasonography are not appropriate imaging modalities for this fracture.

Answer 29

B) dual antiplatelet therapy and an anticoagulant This patient is likely experiencing an acute **anterior wall** myocardial infarction with possible incipient **cardiogenic shock**. Along with initiating the hospital’s protocol for myocardial infarction, immediate treatment should include 1. **Dual antiplatelet therapy** with a **325-mg dose of nonenteric aspirin**, a 2. **P2Y12 inhibitor** (clopidogrel, prasugrel, or ticagrelor), and an 3. **Anticoagulant** (unfractionated heparin or bivalirudin). Given the possibility of cardiogenic shock, ß-blockers should not be used. Unless more than a 2-hour delay in percutaneous coronary intervention is expected, fibrinolytics should not be administered. An intravenous vasopressor is not indicated.

Answer 30

D) severe alcohol use disorder This patient presents with **6 out of 11 symptoms** of alcohol use disorder within a 12-month period, including 1. A strong **desire or urge** to use alcohol, 2. Recurrent alcohol use that has contributed to the **inability to fulfill work** obligations, 3. Continued alcohol use despite **interpersonal problems** with her family, 4. Continued alcohol use despite **knowledge** that it is causing physical damage to her liver, 5. Development of a **tolerance** to the effects of alcohol over time, and 6. **Withdrawal** symptoms that require treatment with benzodiazepines. Mild alcohol use disorder is defined by the presence of 2–3 of the 11 symptoms documented in the DSM-5, whereas 3–5 symptoms indicate moderate alcohol use disorder and 6 or more symptoms indicate severe alcohol use disorder. This patient has severe alcohol use disorder that is currently active. * **Early remission** is defined as the **absence of symptoms** for at least **3 months** but **less than 12 months**. * She is not currently intoxicated, and she does not currently have withdrawal symptoms related to her alcohol use over a week ago.

Answer 31

C) Aortic valve replacement (**REVIEW: 2018.180** ) This patient has symptomatic **severe aortic stenosis**. The only treatment that improves this condition is **aortic valve replacement** (SOR B). Transcutaneous aortic valve replacement may be an alternative for patients who are not candidates for surgery. ß-Blockers must be used with caution due to the risk of depressing left ventricular systolic function. They have not been shown to improve mortality. Antimicrobial prophylaxis is not indicated unless a patient has undergone valve replacement or has a history of endocarditis (SOR C). Atrial fibrillation is common in patients with aortic stenosis and rate control is important. Symptomatic **mitral valve regurgitation** **(MR)** may require mitral valve intervention. However, these murmurs are 1. **holosystolic**, 2. **high pitched**, and 3. best heard at the **cardiac apex**. A **ventricular septal defect (VSD)** can cause a loud **holosystolic** murmur with an **associated thrill** heard best at the **third/fourth interspace** along the sternal border.

Answer 32

B) a polymerase chain reaction (PCR) test When genital herpes occurs during pregnancy, the best method of diagnosis is either a tissue culture or a polymerase chain reaction (PCR) test, which is more sensitive. Enzyme-linked immunosorbent assays are sensitive, but not as sensitive or specific as PCR.

Answer 33

A) Drug-induced nephrogenic diabetes insipidus (**REVIEW: 2018.139** ) Polyuria occurs in 20%–70% of patients on long-term lithium therapy, even when plasma lithium levels are in the therapeutic range. This is a result of **impaired renal concentrating ability** that is **resistant to vasopressin** (**nephrogenic diabetes insipidus**). * Inappropriate antidiuretic hormone secretion causes hyponatremia and fluid retention. * The diuresis associated with diabetes mellitus is a result of the osmotic effect of increased serum glucose, which is not present in this case. * Patients with hypothalamic or pituitary injuries may develop central diabetes insipidus, which responds to exogenous vasopressin. * Psychogenic water drinking occurs in psychiatric patients, but would not be expected to cause impairment of renal concentration or hypernatremia.

Answer 34

B) Start a 4- to 8-week trial of a proton pump inhibitor (**REVIEW: 2018.183** ) Patients with symptoms typical for GERD can be treated conservatively initially unless there are warning signs such as anemia, weight loss, evidence of bleeding or obstruction, dysphagia, or persistent symptoms despite maximal treatment, or the patient is age 50 or over. In the absence of any of these concerns, medical therapy with a proton pump inhibitor can be initiated. While H2 histamine blockers can also treat reflux symptoms they are somewhat less effective, and stepwise therapy may increase costs. Routine testing for Helicobacter pylori in patients with GERD alone is not recommended because treating H. pylori has been shown in some studies to increase esophagitis and GERD symptoms. However, in the presence of dyspepsia (fullness, bloating, nausea), which can be associated with GERD, testing for and treating H. pylori is expected to be beneficial. This patient has classic signs and symptoms of GERD and abdominal ultrasonography would not be likely to reveal any helpful findings. In the presence of warning signs, esophagogastroduodenoscopy would be indicated to evaluate for a more serious pathology. Surgical intervention for GERD should be reserved for patients who fail maximal medical therapy or patients who are unable to take proton pump inhibitors.

Answer 35

A) Acetazolamide (Diamox Sequels) **Acetazolamide** is the preferred agent for preventing **acute mountain sickness (AMS)**. Multiple trials have demonstrated its efficacy in preventing AMS. Dexamethasone is a first-line treatment for acute mountain sickness of any severity but is a second-line drug for prevention because of its side-effect profile. * Tadalafil is advised as a second-line treatment after nifedipine for the prevention and treatment of high-altitude pulmonary edema. * Zolpidem may help with sleep but not AMS, and * Aspirin is not recommended for prevention of AMS.

Answer 36

B) hypertrophic cardiomyopathy Hypertrophic cardiomyopathy is the most common type of cardiomyopathy, with a prevalence of 1:500. It involves left ventricular hypertrophy without chamber dilatation. It is caused by **autosomal dominant** genetic mutations and is associated with **sudden death**. * Dilated cardiomyopathy is a leading cause of heart failure but most patients are symptomatic. * Peripartum cardiomyopathy may occur during and after pregnancy and presents as heart failure. * Restrictive cardiomyopathy presents with right-sided heart failure.

Answer 37

D) Henoch-Schönlein purpura **Henoch-Schönlein purpura (HSP)** is an **IgA vasculitis** that is usually diagnosed clinically. It presents as **palpable purpura** of the lower extremities without thrombocytopenia or coagulopathy. It is often associated with 1. **arthralgias** and **arthritis**, 2. a**bdominal pain**, and 3. **renal dysfunction**. It is self-limited and treatment is supportive only. * **Erythema infectiosum (fifth disease)** can be identified by an erythematous rash on the cheeks and a lacy reticular rash on the extremities. * **Gianotti-Crosti** syndrome is a sudden papular or papulovesicular eruption on the extensor surfaces of the arms, legs, buttocks, and face, and it is not purpuric. * **Hemolytic uremic syndrome (HUS)** presents with the classic triad of 1. hemolytic anemia, 2. thrombocytopenia, and 3. kidney injury. * **Thrombotic thrombocytopenic purpura (TTP)** is rare in the pediatric age group.

Answer 38

C) Low-dose chest CT at age 55 The 2013 U.S. Preventive Services Task Force **lung cancer screening** guidelines recommend **annual low-dose CT** screening for all adults between the **ages of 55 and 80** who have a **\>****30-pack-year**smoking history and either currently smoke or have smoked within the past**15 years** (B recommendation).

Answer 39

E) Thyroidectomy (**REVIEW: 2018.208** ) This patient has a medical history, physical examination, and radioactive iodine uptake scan consistent with **toxic multinodular goiter**, which is the **second most common** cause of **hyperthyroidism** in the United States. Although the addition of propranolol and an increase in methimazole may control her palpitations and other symptoms of hyperthyroidism, these measures will not permanently eliminate the problem. Radioactive iodine ablation and thyroidectomy with subsequent thyroid hormone replacement are both appropriate treatments for toxic multinodular goiter, but thyroidectomy is indicated for this patient because she has compressive symptoms from the goiter itself.

Answer 40

C) Men who have sex with men Factors associated with increased prevalence rates for syphilis in the United States include a history of incarceration or commercial sex work, living in the southern or western United States, residing in a major metropolitan area, African-American ethnicity, and being a male younger than 29 years of age. The **risk for syphilis** infection is highest among **men who have sex with men** and among persons who are **HIV-positive**.

Answer 41

B) Assessing the patient’s motivation for change and determining where they are in the process The Stages of Change Model assesses the patient’s motivation for change and determines which stage of the change process the patient is in. The stages include 1. Precontemplation, 2. Contemplation, 3. Preparation, 4. Action, and 5. Maintenance. Understanding this helps guide counseling strategies for each individual patient.

Answer 42

D) Plantar fasciitis (**REVIEW: 2018.170** ) **Plantar fasciitis** is the most common cause of heel pain, affecting more than 2 million people each year. The pain is typically worst when the patient **first gets out of bed** and improves with activity. * Calcaneal stress fractures follow an increase in activity, and the pain tends to worsen with activity and is eventually present all of the time. * Achilles tendinopathy is an aching pain that also worsens with increased activity, and there is often tenderness along the tendon. * Neuromas present with a burning, tingling, or numb sensation and a painful lump.

Answer 43

A) Hematocrit Knowing the severity of pancreatitis helps predict how aggressive management should be. **Hematocrit**, **BUN**, and **creatinine** levels are the most useful predictors of the severity of pancreatitis, reflecting the degree of **intravascular volume depletion**. * C-reactive protein is often elevated, but it is not as useful as hematocrit for predicting severity. * Serum amylase and lipase have no prognostic value. * CT evidence of severe pancreatitis lags behind clinical and laboratory evidence, and early CT underestimates the severity of the acute process.

Answer 44

D) If they suspect that a child has experienced abuse or neglect Although each state has its own laws regarding obligations to report child abuse, all 50 U.S. states require physicians, whether as a specified professional group or as a part of universal mandated reporting, to report a suspicion of child abuse. The standard is generally **suspicion or cause to believe** that abuse has occurred. If the possibility of abuse is briefly considered but rejected, or if nonspecific signs are present that do not create a significant suspicion of abuse, this standard is not met. There is no burden of proof placed on the physician to make such a report.

Answer 45

A) A serum fructosamine level This patient with sickle cell disease has a new onset of diabetes mellitus. **Hemoglobinopathies falsely lower hemoglobin A1c** as a result of **hemolysis** and **abnormal glycation**. * **Fructosamine** correlates well with hemoglobin A1c levels and is recommended instead of hemoglobin A1c for monitoring glucose control in patients with diabetes and hemoglobinopathies. A 2-hour glucose tolerance test or hemoglobin electrophoresis would not provide useful information. Referral to an endocrinologist is not indicated at this point because the patient has not failed primary care management.

Answer 46

B) A spot urine protein/creatinine ratio (**REVIEW: 2018.55**) Individuals with **nephrotic syndrome** often present with edema and fatigue with no evidence of severe liver disease or heart failure. Hallmarks of this problem include **heavy proteinuria**, **hypoalbuminemia**, and **peripheral edema**, often with **hyperlipidemia** as well. While most of these cases are idiopathic, secondary causes such as diabetes mellitus, systemic lupus erythematosus, and medication reactions should be considered. To confirm proteinuria in the nephrotic range a **spot urine protein/creatinine ratio** is now suggested instead of a 24-hour collection of urine. * Checking urine for eosinophils has been recommended in the past for evaluation for acute interstitial nephritis but subsequent studies have shown a lack of specificity and sensitivity. * Renal ultrasonography would be indicated if the glomerular filtration rate were reduced. * Echocardiography would be appropriate if heart failure were suspected. * While a renal biopsy is often recommended, it is most useful in patients with suspected underlying systemic lupus erythematosus or similar disorders when a biopsy can guide management decisions and prognosis.

Answer 47

C) Discontinue aspirin and begin apixaban (Eliquis) **_CHA₂DS₂-VASc Score_** **C**ongestive heart failure **H**ypertension **A**ge ( \> 65 = 1 point, \> 75 = **2 points**) **D**iabetes **S**troke/transient ischemic attack, previous (**2 points**) **V**ascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and **S**ex (female gender) This patient has a **CHA₂DS₂-VASc score of 3** (hypertension, age 65–74, female), which classifies her as **high risk for thromboembolism**. Oral anticoagulation is indicated for patients with a score of 2 or more, who are at high risk for pulmonary embolism/deep vein thrombosis (PE/DVT) (SOR C). Patients with a score of 0–1 have a low to medium risk and may use aspirin with or without clopidogrel. In patients with atrial fibrillation and stable coronary artery disease, novel oral anticoagulants are preferred (SOR A). They reduce the risk of reinfarction, stroke, and overall mortality in patients with a past history of myocardial infarction, and also help prevent PE/DVT.

Answer 48

C) A smooth philtrum (**REVIEW: 2018.21**) The classic facial dysmorphologies associated with **fetal alcohol syndrome** are a 1. **Smooth philtrum**, 2. **Shortened palpebral fissures**, and a 3. **Thin vermilion border** of the upper lip. **Two out of these three** characteristics are required for the diagnosis of fetal alcohol syndrome. Low-set ears and a central chin dimple are not associated findings.

Answer 49

A) Reassurance and surveillance over the next 3–6 months **Premature adrenarche *_without_* development of secondary sex characteristics** is usually **idiopathic** and does not lead to an abnormal pattern of development. Reassurance and surveillance over the next 3–6 months would be most appropriate at this time. Laboratory studies and radiography warrant consideration if the patient develops secondary sex characteristics before the age of 8, or if her height velocity increases rapidly during the surveillance period.

Answer 50

C) Renal ultrasonography Renal parenchymal diseases such as glomerulonephritis, congenital abnormalities, and reflux nephropathy are the **most common cause** of hypertension in preadolescent children. Preadolescent children with hypertension should be evaluated for possible secondary causes and renal ultrasonography should be the first choice of imaging in this age group. * **Renin** and **aldosterone** levels are indicated if there is a **reason to suspect primary hyperaldosteronism**, such as unexplained **hypokalemia**. Measurement of 24-hour urinary fractionated **metanephrines** and **normetanephrines** is used to diagnose **pheochromocytomas**, which are rare and usually present with a triad of symptoms including headache, palpitations, and sweating. * Doppler **ultrasonography of the renal arteries** is useful for diagnosing **renal artery stenosis**, which should be suspected in patients with coronary or peripheral atherosclerosis or young adults, especially women 19–39 years of age, who are more at risk for renal artery stenosis due to fibromuscular dysplasia. Sleep studies are indicated in patients who are obese or have signs or symptoms of obstructive sleep apnea.

Answer 51

E) Topiramate (Topamax) **Topiramate** (anticonvulsant or antiepileptic drug) **increases the risk of kidney stones**. It is a carbonic anhydrase inhibitor, which induces a **metabolic acidosis** that leads to **hypercalciuria** and the formation of **calcium phosphate stones**. The risk of kidney stones is not increased by escitalopram, levothyroxine, lisinopril, or metformin.

Answer 52

B) A compressive dressing with weight bearing and range-of-motion exercises as tolerated The **fifth metatarsal** has the **least cortical thickness** of all of the metatarsals. There are strong ligaments and capsular attachments on the proximal fifth metatarsal that can put significant stress on this area of the bone, leading to fractures. Nondisplaced tuberosity fractures can generally be treated with **compressive** dressings such as an **Aircast** or **Ace bandage**, with **weight bearing** and **range-of-motion exercises** as tolerated. Minimally displaced (\<3 mm) avulsion fractures of the fifth metatarsal tuberosity can be treated with a short leg walking boot. If the displacement is \>3 mm, an orthopedic referral is warranted.

Answer 53

A) Bupropion (Wellbutrin) When psychogenic erectile dysfunction (ED) coexists with depression, treatment of the underlying mood disorder is often an appropriate first step (SOR C). An antidepressant that is **LESS likely to worsen the ED**, such as **bupropion**, **mirtazapine**, or **fluvoxamine**, should be chosen. * Antidepressants that are **more likely to cause sexual side effects** should be avoided, including **SSRIs**, **SNRIs**, and **tricyclic** and **tetracyclic** antidepressants. * "**_E_**ffective **_F_**or **_S_**adness, **P**anics, & **_C_**ompulsions." (SSRI's menomic) * Citalopram (Celexa) * Escitalopram (Lexapro) * Fluvoxamine (Luvox) * Paroxetine (Paxil) * Sertraline (Zoloft) Phosphodiesterase-5 inhibitors are the first line of treatment for ED (SOR A) and can be used effectively in men with depression, in combination with treatments for mood disorders.

Answer 54

B) He should receive one dose of the vaccine now and no additional HPV vaccine in the future HPV vaccine is currently recommended for **males** and **females** at **age 11** (first dose up to 15). Catch-up vaccination is recommended **until age** * **21 in males,** and * **26 in females**. Children who receive the _first dose of the vaccine before the age of 15_ and _receive two doses_ are considered _adequately vaccinated_. * If the first dose is given after age 15, a three-dose series is recommended.

Answer 55

D) Atrial fibrillation refractory to medical therapy Atrial ventricular **nodal ablation** is recommended for patients whose atrial fibrillation is **refractory to medical therapy**, and requires that patients be **anticoagulated for at least 1 month** prior to the procedure and for several months afterward (SOR C). * Patients with atrial fibrillation who are **hemodynamically unstable** should be considered for **emergent cardioversion** (SOR C). Atrial ventricular nodal ablation is not necessary for patients successfully converted to sinus rhythm or for those who are successfully treated with medical interventions for rate control and anticoagulation.

Answer 56

A) No imaging **Uncomplicated** **acute** low back pain and/or **radiculopathy** is a **benign**, **self-limited** condition and early imaging is associated with worse overall outcomes and is likely to identify minor abnormalities even in asymptomatic patients. * Imaging for acute low back pain should be reserved for cases that are suspicious for cauda equina syndrome, malignancy, fracture, or infection. * In the absence of red flags such as progressive motor or sensory loss, new urinary retention or overflow incontinence, a history of cancer, a recent invasive spinal procedure, or significant trauma relative to age, imaging is not warranted regardless of whether radiculopathy is present, unless symptoms persist despite a trial of at least 6 weeks of medical management and physical therapy.

Answer 57

A) Amoxicillin/clavulanate (Augmentin) Prophylactic antibiotics should be given for all closed-fist injuries unless the skin has not been penetrated, and for puncture wounds caused by cat bites. The antibiotic should have both aerobic and anaerobic activity and include Pasteurella coverage for animal bites and Eikenella coverage for human bites. Suggested regimens include amoxicillin/clavulanate. If the patient is allergic to penicillin, clindamycin plus levofloxacin or moxifloxacin, which has anaerobic coverage, can be used. Azithromycin, cephalexin, and metronidazole are not first-line antibiotics following a cat bite.

Answer 58

A) A follow-up visit and a repeat chest radiograph in 6 months (**REVIEW: 2018.112** ) Given this patient’s age, lack of symptoms, and possible family history, the presence of **asymptomatic bilateral hilar lymphadenopathy** most likely represents **stage 1 pulmonary sarcoidosis**. Because the patient does not have any symptoms and stage 1 sarcoidosis **resolves in most cases**, the most prudent course is to reevaluate her in 6 months with a careful history, a physical examination, and a chest radiograph. Given the normal spirometry results, pulmonary function tests are not needed at this time. Neither CT nor a lung biopsy would change management at this time. Treatment is not indicated in stage 1 sarcoidosis but would be merited if she developed increasing pulmonary symptoms or any extrapulmonary symptoms.

Answer 59

B) Combined estrogen and progesterone This patient presents with typical **vasomotor symptoms** that can begin in **perimenopause** and affect sleep quality. **Hormone therapy is the gold standard** for treatment of vasomotor symptoms. * **Combination** **estrogen** and **progesterone** therapy is highly effective for vasomotor symptoms and provides **protection against uterine neoplasia**. Although micronized progesterone decreases vasomotor symptoms there are no long-term studies to assess the safety of progestin-only treatment for menopausal symptoms. Compounded bioidentical hormone therapy creates safety concerns and is not a first-line therapy due to limited government regulation and monitoring, the potential for overdosing and underdosing, impurities or lack of sterility, and the lack of labeling describing risks. Testosterone alone is not FDA-approved for use in women. Additionally, it has not been shown to be beneficial for treatment of vasomotor symptoms in combination with hormone therapy and is associated with significant side effects. It may be useful for hypoactive sexual desire in postmenopausal women. There is insufficient data to recommend the use of herbal remedies such as black cohosh.

Answer 60

E) Catheter ablation Catheter ablation is the most appropriate treatment for a patient with symptomatic Wolff-Parkinson-White syndrome (WPW). Catheter ablation has a very high immediate success rate (96%–98%). The most significant risk associated with the procedure is permanent atrioventricular block, which occurs in approximately 0.4% of procedures. Adenosine and amiodarone are used for the acute management of supraventricular tachycardia, but not for long-term management. Node-blocking medications such as diltiazem and metoprolol should not be used for the long-term treatment of WPW, due to the increased risk of ventricular fibrillation.

Answer 61

B) Immunization now with quadrivalent inactivated vaccine The CDC’s Advisory Committee on Immunization Practices recommends that **patients with egg allergy receive influenza vaccination**. Previously unvaccinated patients ages **6 months to 8 years** should receive **two** doses of either trivalent or quadrivalent vaccine **separated by 1 month**.

Answer 62

E) Zenker’s diverticulum A **Zenker’s diverticulum** is an oropharyngeal structural lesion and is most common in the **elderly population**, with an estimated prevalence of 1:1000 to 1:10,000 in this age group. * The pathogenesis involves **stenosis of the cricopharyngeus** and increased hypopharyngeal pressure during swallowing that causes a pulsion diverticulum above the cricopharyngeus. The radiographic findings in this case are consistent with a Zenker’s diverticulum. A pharyngeal neoplasm would not necessarily retain barium in this fashion. A cervical web or Schatzki ring would be identified by a short segment of narrowing without diverticula. Barium would be seen in the trachea with a tracheoesophageal fistula.

Answer 63

B) 3 months Patients who have a venous thromboembolism (**VTE**) require **anticoagulation** therapy for treatment and prevention of recurrence. The risk of recurrence is greatest in the first year after the event and remains elevated indefinitely. The risk for VTE recurrence is dependent on patient factors, such as active cancers and thrombophilia. Current guidelines recommend treatment for **at least 3 months**. In patients who have a **reversible provoking factor** such as surgery, anticoagulation beyond 3 months is not recommended.

Answer 64

A) Topical 20% aluminum chloride (Drysol) The recommended first-line treatment for **primary focal hyperhidrosis** is topical **20% aluminum chloride**. It should be applied to affected areas **nightly** for 6–8 hours and works by obstructing the eccrine sweat glands and destroying secretory cells. * **Iontophoresis** and **botulinum toxin** are alternative first- or second-line therapies for palmar and plantar hyperhidrosis and hyperhidrosis affecting the axillae, palms, soles, or face. **Topical 2% glycopyrrolate** must be compounded by a pharmacy and is indicated only for **craniofacial hyperhidrosis**. * Oral **anticholinergics** such as **oxybutynin** can be considered if other first-line treatments fail. However, up to 10% of patients will stop taking these medications due to side effects such as dry mouth, constipation, urinary retention, and blurred vision. Microwave technology is a newer treatment option that has shown some promising results but should not be recommended as a first-line treatment. * Sympathetic denervation should be used only if other less invasive therapies have already been tried.

Answer 65

E) Metformin (Glucophage) With the advent of new medications to treat diabetes mellitus, including many medications that help lower cardiovascular risk, it is tempting to begin treatment with these medications. Unless there are contraindications, however, **metformin is still the initial medication of choice** for patients with **newly diagnosed diabetes**. If this patient’s hemoglobin **A1c were \>10%**, it would be reasonable to start **insulin** therapy. If it becomes necessary to add an additional antidiabetic agent it would be reasonable to consider a **GLP-1 receptor agonist** or a **DPP-4 inhibitor** in addition to metformin at that time, given the patient’s history of coronary artery disease. **PPC 4-5**

Answer 66

C) satisfactory improvement of vision in almost all patients LASIK corrective vision surgery has become increasingly common over the last 20 years. A laser is used to cut a flap the size of a contact lens consisting of corneal epithelium and stroma. This flap is repositioned and heals without sutures. It is important to counsel patients on realistic expectations. Vision following the procedure may not be as clear as with glasses or contact lenses and some individuals still require external correction. Up to 40% of patients experience dry eyes following the surgery (SOR B). These symptoms may be worse in patients with chronic pain syndromes such as fibromyalgia, migraine, and irritable bowel syndrome (SOR C). Glares, halos, and starbursts may affect up to 20% of patients following LASIK. This may be especially bothersome at night (SOR B). LASIK does not correct age-related presbyopia (SOR C). Reading glasses may be necessary if this develops in certain patients. Overall, however, most patients are satisfied with their results and only 3% are unhappy with their vision following surgery (SOR C).

Answer 67

A) Written self-management plans that include smoking cessation plans Written self-management plans have been shown to decrease respiratory-related hospitalizations in patients with COPD. Although regular physical activity has clear health benefits, the methods are so varied in studies of physical activity that there is currently no strong evidence to show it reduces hospitalizations in COPD patients. Although FEV1 is important for predicting hospitalizations for a population, it is not accurate enough to be useful in an individual patient. Daily oxygen therapy does not help to postpone the first hospitalization. Nightly CPAP therapy reduces hospitalizations in patients with COPD and sleep apnea, but not those with COPD alone.

Answer 68

D) Sertraline (Zoloft) **Somatic symptom disorders** account for approximately **5%** of **primary care visits**. Effective pharmacologic treatment includes sertraline and other **SSRI-based therapy** in addition to cognitive-behavioral therapy (SOR B). "**_E**_ffective _**F**_or _**S**_adness, _**P**_anics, & _**C_**ompulsions." * Effective – **Escitalopram** * For – **Fluoxetine**, **Fluvoxamine** * Sadness – **Sertraline** * Panic – **Paroxetine** * Compulsions – **Citalopram** Bupropion, monoamine oxidase inhibitors such as selegiline, anticonvulsants such as topiramate, and antipsychotics such as clozapine are ineffective.

Answer 69

A) lower than in the nonpregnant state The **TSH** reference range is **lower during pregnancy** because of the **cross-reactivity** of the **alpha-subunit of hCG**. * Levels of **hCG peak during weeks 7–13** of pregnancy, and **hCG has mild TSH-like activity**, leading to slightly **high free T4** levels in early pregnancy. This leads to a **feedback decrease in TSH**.

Answer 70

C) Serum protein electrophoresis This patient’s laboratory results and **back pain** suggest **multiple myeloma (MM)**. * He has a **normocytic anemia** and evidence of **renal insufficiency**, which can **indicate MM**. The laboratory findings along with worsening back pain indicate a need to order serum protein electrophoresis to look for MM. * **Flow cytometry** is generally used in patients with an elevated WBC count and suspected **lymphoma**. The remainder of this patient’s CBC is normal, which makes a bone marrow issue less likely. His **mean corpuscular volume** is also **normal**, making **vitamin B12 deficiency less likely**. * A **haptoglobin** level could be ordered, but protein electrophoresis is a better choice because the **peripheral smear** demonstrated **no evidence of a hemolytic problem**.

Answer 71

A) A history and physical examination only **Breast cancer survivors** should undergo a **history and physical** examination **every 3–6 months** for the **first 3 years** after treatment, * then **every 6–12 months** for the **next 2 years**, and * then **annually thereafter** (SOR C). Papanicolaou testing guidelines do not change for patients with a history of breast cancer. Screening should be repeated every 3–5 years according to American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. Mammograms of both breasts or the remaining breast are recommended no more often than yearly (SOR A). Breast MRI is not recommended on a regular basis unless the patient has a high risk of recurrence, a significant family history of breast or ovarian cancer, or a personal history of Hodgkin’s disease (SOR C). While it is important to be alert for signs of cardiotoxicity due to prior chemotherapy, echocardiography is indicated only if the patient has cardiac symptoms. Routine echocardiography is not recommended (SOR C).

Answer 72

E) The inability to take more than two steps (**REVIEW: 2018.7** ) Several decision support tools can help guide the decision to order imaging of an injured knee, such as the Ottawa Knee Rule, the Pittsburgh Knee Rule, and American College of Radiology (ACR) criteria. The **inability to take four or more steps immediately after an injury** or in the emergency setting is an **indication for radiography** in **all three rules**. Age is an indication for radiography in acute knee pain in patients over 55 years of age according to the Ottawa rule, or under 12 or over 50 years of age according to the Pittsburgh rule. The patient’s sex does not factor into the criteria for imaging. Bony tenderness is an indication for imaging according to the ACR and Ottawa rules, but only if isolated over the proximal fibula or over the patella without other bony tenderness. The inability to flex the knee to 90° is also an indication for imaging according to the ACR and Ottawa rules.

Answer 73

E) Tamsulosin (Flomax) Tamsulosin promotes passage of ureter stones that are **5–10 mm** in diameter. The **number needed to treat** is **five patients** to cause the **expulsion of one stone** (SOR B). There was no difference in the percentage of patients passing stones smaller than 5 mm when comparing tamsulosin to placebo, as these stones have a high rate of spontaneous passage without any intervention. Naproxen and promethazine are sometimes used for the management of pain and nausea associated with stones, but they have not been shown to facilitate stone expulsion. Ciprofloxacin and nitrofurantoin are used to treat urinary tract infections but have not been shown to facilitate stone expulsion.

Answer 74

C) Methylprednisolone (Medrol) This patient has severe community-acquired pneumonia based on clinical criteria, including an elevated respiratory rate, confusion, and hypotension requiring aggressive fluid resuscitation. Corticosteroids such as methylprednisolone have been shown to improve clinical outcomes such as length of stay, duration of antibiotic treatment, and the risk of developing adult respiratory distress syndrome. The preferred choice of antibiotic treatment for patients in the intensive-care unit is a **ß-lactam antibiotic** (ceftriaxone, cefotaxime) or ampicillin/sulbactam, plus a **macrolide** alone or a macrolide and a respiratory fluoroquinolone. * The addition of levofloxacin is not necessarily preferred over just ceftriaxone and azithromycin. * Clindamycin is not indicated in the absence of risk factors for anaerobic infection such as aspiration or alcoholism. * Oseltamivir is not indicated in the absence of known or suspected influenza infection.

Answer 75

A) Radioactive iodine uptake **Postpartum** thyroiditis is defined as a transient or persistent thyroid dysfunction that occurs **within 1 year** of childbirth, miscarriage, or medical abortion. Release of **preformed** **thyroid** **hormone** in the bloodstream initially results in **hyperthyroidism**. * During the hyperthyroid phase, **radioactive iodine uptake** will be **low**, which can help to confirm the diagnosis. Pregnancy and breastfeeding are contraindications to radionuclide imaging. * **Thyroid peroxidase antibody** levels are elevated with chronic autoimmune thyroiditis (**Hashimoto’s** thyroiditis), and patients present with symptoms of **hypothyroidism**. T * he Endocrine Society and American Association of Clinical Endocrinologists do not recommend routine thyroid ultrasonography in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland. * **Thyrotropin receptor antibody** levels are **positive** in **Graves** disease.

Answer 76

B) Resistance training Frailty is an increasingly common problem in the geriatric population, especially as individuals are living longer. The current literature supports **resistance training** to improve physical function **before aerobic exercise** is introduced. Although there was hope that nutritional counseling would improve outcomes, it does not seem to have an effect. Vitamin D supplementation also does not improve outcomes in these individuals. Mirtazapine is on the Beers list, and without a compelling indication such as weight loss with depression it should be avoided in the elderly.

Answer 77

E) Intramuscular prochlorperazine Multiple studies have determined that **parenteral antiemetics** have benefits for the treatment of a**cute migraine** beyond their effect on nausea. Most outpatient clinics do not have the ability to administer **intravenous metoclopramide**, which is the preferred treatment. However, most clinics do have the ability to administer intramuscular **prochlorperazine** or **promethazine**. Due to concerns about oversedation, misuse, and rebound, treatment with parenteral opiates is discouraged but may be an option if other treatments fail. Oral butalbital/acetaminophen/caffeine and oral ergotamine/caffeine have less evidence of success in the treatment of acute migraine. **Sumatriptan is contraindicated within 24 hours of the use of rizatriptan.**

Answer 78

B) Allowing the patient an oral diet as tolerated The American Gastroenterological Association guidelines on acute pancreatitis recommend initiating **oral feedings early** in the course in order to **protect the gut-mucosal barrier,** which may limit infectious complications and does not increase hospital length of stay or other complications. Nasogastric or nasojejunal tube feeding may be considered at 3–5 days if oral feedings are not tolerated. Total parenteral nutrition is indicated only when enteral feedings cannot supply adequate caloric intake or are not possible for other reasons. The incidence of single or multiple organ failure or infected necrosis is significantly increased with the use of total parenteral nutrition.

Answer 79

E) A biopsy Solar lentigines occur on sun-exposed skin and are known commonly as liver spots. A **biopsy** should be performed if they **grow** rapidly, **change** rapidly, are **painful**, **itch**, **bleed** easily, **heal poorly**, or have an **atypical** or **suspicious** **appearance**. If no suspicious changes or symptoms are present there are various options for treatment, including topical therapy with hydroquinone or retinoids, or ablative therapy with chemical peels, cryotherapy, intense pulsed light, or laser therapies.

Answer 80

A) Aspirin, 81 mg daily For women at high risk of developing preeclampsia, the U.S. Preventive Services Task Force (USPSTF) recommends starting **low-dose aspirin** after **12 weeks** gestation (B recommendation). While calcium appears to be helpful in preventing preeclampsia for women with a diet deficient in calcium, the evidence is not yet conclusive. The USPSTF recommendation does not address the use of fish oil, magnesium gluconate, vitamin C, or vitamin D for the prevention of preeclampsia.

Answer 81

E) MRI This patient has a **calcaneal stress fracture** as suggested by the history of increased running on a hard surface, improvement with rest, and a positive calcaneal squeeze on examination. A **delay in diagnosis** increases the risk of **delayed union**. * MRI is the preferred imaging modality because **radiographs often do not detect a calcaneal stress fracture**. A C-reactive protein level could be indicated if there were symptoms or signs of infection or autoimmune illness. The clinical picture does not suggest a neurologic condition, so nerve conduction velocity testing is not appropriate. While there are some case reports of the diagnosis of stress fractures using ultrasonography, this is not the preferred imaging method.

Answer 82

B) koilonychia **Koilonychia**, also known as **spoon nail**, is a finding that can be associated with multiple systemic conditions such as **iron deficiency**, **hypothyroidism**, and **systemic** **lupus** **erythematosus**. * Clubbing of the nails involves thickening of the soft tissue proximal to the nail. * Leukonychia is a white discoloration of the nail plate and can be a normal variant. * Onychomycosis is a fungal infection generally presenting as a thickened, yellow, dystrophic nail. * Squamous cell carcinoma presents as an erythematous, proliferating mass that disrupts normal nail morphology.

Answer 83

A) Hyper-androgenism Several professional organizations have published criteria for the diagnosis of polycystic ovary syndrome (PCOS) using various combinations of hyperandrogenism (clinical or biochemical), ovulatory dysfunction (typically oligomenorrhea), and the presence of at least one polycystic ovary by imaging criteria. Hypertension, hypothyroidism, infertility, and obesity are common symptoms in patients with PCOS but are not diagnostic. * The **National Institutes of Health** advises that patients must have **both hyperandrogenism** and **oligomenorrhea** to meet the criteria for **PCOS**. The Endocrine Society recommends diagnosing PCOS based on the 2003 Rotterdam criteria, which require the presence of two of the following: hyperandrogenism, ovulatory dysfunction, and at least one polycystic ovary. * The Androgen Excess and PCOS Society says that patients must have hyperandrogenism plus either oligomenorrhea or at least one polycystic ovary for the diagnosis to be made.

Answer 84

C) statin therapy, and repeat ultrasonography in 1 year Asymptomatic carotid artery disease is considered a **coronary artery disease risk equivalent**; therefore, **statin therapy is indicated**. Repeating ultrasonography annually to monitor for progression of the disease and to guide intervention is also considered reasonable. * According to the 2014 guidelines for the primary prevention of stroke issued by the American Heart Association/American Stroke Association, **prophylactic carotid artery stenting** might be considered in highly selected asymptomatic patients with **\>70% carotid stenosis**, but the effectiveness of this intervention compared with statin therapy alone is not well established. The guidelines also state that it is reasonable to consider carotid endarterectomy for asymptomatic patients with \>70% stenosis if the risks of perioperative complications are low.

Answer 85

A) Budesonide oral suspension, 1 mg twice daily The clinical presentation and esophagogastroduodenoscopy findings indicate **eosinophilic esophagitis (EoE)** in this patient. In the absence of other causes of eosinophilia, the presence of **\>15 eosinophils/hpf** is considered **diagnostic**. * Application of **corticosteroids** to the esophagus is generally the treatment of choice, either in the form of an **oral suspension** of budesonide or an **inhaled corticosteroid** sprayed into the mouth and **swallowed**. Although EoE can occur in patients with other atopic illnesses, this patient does not have any symptoms of allergies or asthma, so an antihistamine such as fexofenadine is not needed. EoE does not respond to proton pump inhibitor therapy or H2-blocker therapy and systemic corticosteroids are not necessary.

Answer 86

E) Venlafaxine (Effexor XR) It is important for patients with posttraumatic stress disorder (**PTSD**) to receive psychotherapy. For those who continue to have symptoms it is appropriate to initiate medications. **SSRIs** and **venlafaxine** are considered first-line medications for the treatment of PTSD. * Bupropion and buspirone have not been found to be effective treatments. * The use of benzodiazepine medications is not recommended because of the high risk of misuse. * Antipsychotic medications would be appropriate in patients with disabling symptoms and behaviors that do not respond to psychological or drug treatment.

Answer 87

D) She does not have a penicillin allergy and can use penicillin and its derivatives in the future This patient was inadvertently challenged with amoxicillin and did not develop an allergic reaction. Her demonstrated tolerance allows the future use of all penicillin antibiotics. Although a low-risk history allows for an amoxicillin challenge in the clinic under medical observation, patients with moderate-risk histories of an urticarial or other pruritic rash should undergo skin testing. If that testing is negative, it should be followed with an amoxicillin challenge under observation. **RAST testing is not indicated** for penicillin allergy testing.

Answer 88

E) Supervised exercise The goals of osteoarthritis therapy are to minimize pain and improve function. The American Academy of Orthopedic Surgery and the American College of Rheumatology have agreed that first-line treatment includes aerobic exercise, resistance training, and weight loss. For patients with osteoarthritis of the knee, supervised exercise was found to reduce pain and improve physical function and quality of life (SOR A). Vitamin D is not currently recommended, and glucosamine and chondroitin are less effective than placebo. Initial pharmacotherapy includes full-strength acetaminophen, or oral or topical NSAIDs. If patients have an inadequate response to these agents other treatments to consider include tramadol, other opioids, duloxetine, or intra-articular injections with corticosteroids or hyaluronate.

Answer 89

A) carry the pregnancy to term and keep the baby While recent data is not available, 45% of pregnancies in the United States in 2011 were unintentional. About 42% of pregnant women with unintended pregnancies chose to terminate the pregnancy by one means or another. Of the 58% that chose to carry the pregnancy to term, only about 1% placed the infant for adoption.

Answer 90

D) Phenytoin (Dilantin) Medications reported to be associated with osteoporosis and increased fracture risk include * **antiepileptic drugs**, * long-term heparin, * cyclosporine, * tacrolimus, * aromatase inhibitors, * glucocorticoids, * gonadotropin-releasing hormone agonists, * thiazolidinediones, * excessive doses of levothyroxine, * proton pump inhibitors, * SSRIs, * parenteral nutrients, * medroxyprogesterone contraceptives, * methotrexate, and * aluminum antacids. Atorvastatin, hydrochlorothiazide, metformin, and ranitidine are not associated with osteoporosis.

Answer 91

D) A long duration of smoking The following factors have been found to increase the risk for developing an abdominal aortic aneurysm (AAA): a history of smoking, advanced age, above-average height, having a first degree relative with an AAA, a personal history of atherosclerosis, high cholesterol levels, and hypertension. Smokers have a seven times greater risk of developing an AAA compared with nonsmokers. This single factor outweighs all of the other risk factors except age. Although women are less likely to develop an AAA, they have a 2–3 times greater chance of an AAA rupturing if it is present. In addition to significantly increasing the risk for AAA development, current smoking increases the risk for further AAA expansion and rupture. Epidemiologic studies suggest that the duration of smoking influences the risk for AAA significantly more than the total number of cigarettes smoked. The U.S. Preventive Services Task Force currently recommends one-time screening for AAA in males between the ages of 65 and 75 who have ever smoked (B recommendation). There was not enough evidence to determine the risk and benefits of screening females with the same risk factors (I recommendation).

Answer 92

D) Washing clothing and bedding in hot water and drying with hot air (**REVIEW: 2018.137** ) The appropriate recommendation for head lice is to wash any recently used **bedding and clothing** with **hot water** or expose them for **5 minutes** to a temperature **\>130°F** to kill lice and eggs. Items that cannot be washed or dried in this manner or dry-cleaned should be **sealed in a plastic bag for 2 weeks**. Additional or alternative treatments include topical ivermectin, benzoyl alcohol, malathion, and spinosad. * Other recommended measures include removal of any visible nits (eggs) with a nit comb, not a brush. * Topical petroleum jelly is not an effective treatment. * Conditioners can interfere with the action of permethrin, decreasing its effectiveness. * Human head lice are specific to humans, so pets are not affected.

Answer 93

D) A nonsolid “ground glass” appearance Characteristics that are more commonly associated with **malignant** lesions include 1. a nonsolid “**ground glass**” appearance, 2. a size **\>6 mm**, 3. **noncalcified** lesions, 4. a lesion size or **volume doubling time between 1 month and 1 year,** and 5. **irregular** or **spiculated** borders. Findings on a chest radiograph that are more commonly associated with **benign** lesions include * a lesion size **\<6 mm**, * **concentric** or “**popcorn-like**” calcifications, * doubling times of \<1 month or \>2–4 years, * dense solid-appearing lesions, and * lesions with smooth regular borders. Other diagnostic imaging modalities are also utilized, including CT and PET, and a biopsy is sometimes necessary to establish the diagnosis. Chest radiographs are still useful for monitoring patients with multiple findings that correlate most often with benign lesions. Informed decision making by the patient and family physician can sensibly guide the follow-up of patients with solitary pulmonary nodules without automatically referring them to specialists or ordering the most sophisticated imaging.

Answer 94

E) Wasp stings Wasp stings, penicillin, shellfish, and tree nuts are all relatively common causes of severe allergic reactions, including anaphylaxis. **Immunotherapy** is available and recommended for the **stings of insects**, including wasps and bees, to prevent recurrent anaphylaxis (SOR B). It is not available for penicillin, poison ivy, shellfish, or tree nut allergens. Poison ivy typically causes a type 4 hypersensitivity contact dermatitis rather than anaphylaxis.

Answer 95

D) HIV, hepatitis A, hepatitis B, hepatitis C, and TB Persons who inject drugs are at increased risk for * HIV, * hepatitis A, * hepatitis B, * hepatitis C, and * latent tuberculosis. These patients should be screened at the initial visit and treated for any conditions found, according to routine guidelines. If titers are low or absent for hepatitis A or B, the patient should be vaccinated. Although **gonorrhea** and **Chlamydia** screening is recommended for **females** **under 25 years** of age who use **injectable drugs**, it is not appropriate in this asymptomatic patient.

Answer 96

A) No imaging This patient has **Osgood-Schlatter** disease, a common cause of knee pain in active children with immature skeletons. It occurs as a result of abnormal development, injury, or overuse of the growth plate and the surrounding ossification centers. Osteochondrosis is a more general term for this condition, which can occur at growth plates around other joints, including the hip, foot, elbow, and back. In Osgood-Schlatter disease repetitive traction of the patellar tendon on the tibial tubercle ossification center leads to inflammation and pain. **Imaging is not required** to make the diagnosis when patients present with **typical symptoms** and **physical examination findings**. Radiographs may be obtained if there is uncertainty about the diagnosis. Radiographic findings in Osgood-Schlatter disease include soft-tissue swelling and fragmentation of the tibial tubercle. This condition is **self-limited** and treatment consists of **activity modification** and the use of **acetaminophen** or **NSAIDs**. An orthopedic referral is indicated if symptoms persist in a patient with a mature skeleton.

Answer 97

D) Topical mupirocin (Bactroban) **Bullous impetigo** is caused by **Staphylococcus** **aureus**, which produces a **toxin** responsible for **flaccid bullae** and is more likely to affect the intertriginous areas. * This usually **resolves within 3 weeks without scarring**. Impetigo, either bullous or nonbullous, may be treated with **topical antibiotics** such as **mupirocin**. Because of emerging drug resistance, oral azithromycin and other macrolides should not be used. Oral penicillin is no longer recommended because it is less effective than other antibiotics such as amoxicillin/clavulanate, cephalexin, clindamycin, or dicloxacillin. **Bacitracin/neomycin/polymyxin B is not indicated for either form of impetigo**. Nystatin is recommended for Candida infections.

Answer 98

D) Tdap (**REVIEW: 2018.114** ) Maternal vaccination helps prevent disease in newborn infants. Currently, two vaccines are recommended for women during each pregnancy: **Tdap** and inactivated **influenza** vaccine. * Live vaccines, such as MMR and varicella, are contraindicated. * Hepatitis B vaccine is recommended for high-risk women but not routinely. * Pneumococcal vaccine is currently being studied for this use but is not recommended.

Answer 99

C) Ceftriaxone and azithromycin (Zithromax) Current recommendations state that **nursing home–acquired pneumonia** should be **treated as community-acquired pneumonia** unless patients have severe illness, chronic wounds, foreign bodies in the airway, a history of antibiotic use in the last 90 days or recent hospitalization, colonization with multidrug-resistant pathogens, or very low functional status, or reside in a facility with a high prevalence of multidrug-resistant pathogens. Community-acquired pneumonia should be treated with either a **respiratory fluoroquinolone** or an **advanced macrolide** plus a **ß-lactam antibiotic**. Doxycycline could also be used in place of the macrolide.

Answer 100

A) Furosemide (Lasix), 20 mg daily This patient has **diastolic heart failure**, also called **heart failure with preserved ejection fraction** (HFpEF). Patients who have HFpEF with active fluid overload should be treated with **diuretics** such as furosemide (SOR B). If concomitant hypertension is present along with HFpEF, the patient’s blood pressure should be treated according to accepted evidence-based hypertension guidelines (SOR C). Although this patient’s blood pressure is elevated, a diagnosis of hypertension has not been confirmed, so antihypertensives are not warranted at this time.

Answer 101

D) Offer gonadotropin-releasing hormone analogue treatment Hormonal intervention therapy should not be offered prior to puberty. However, stage 2 or 3 of sexual maturity is an appropriate time to consider **gonadotropin-releasing hormone analogue therapy** (SOR B). Individuals who receive hormone therapy often report less anxiety, increased self-esteem, and better quality of life (SOR A). Delaying gender-affirming therapy may actually increase emotional distress and gender-associated abuse. It is unethical and against recommended guidelines to convert a person’s gender identity to the sex assigned at birth (SOR C). This patient has brought medical records to the appointment, making it unnecessary to order confirmatory testing, which may also induce emotional harm and additional medical costs.

Answer 102

D) Intimate partner violence Intimate partner violence and the abuse of older or vulnerable adults are common in the United States. Immediate effects such as injury and death and other health consequences, including mental health conditions, substance abuse, sexually transmitted infections, unintended pregnancies, and chronic pain, often affect the traumatized individual. The U.S. Preventive Services Task Force recommends **screening for intimate partner violence in all women of reproductive age** (B recommendation). Screening for breast cancer, colon cancer, ovarian cancer, or hepatitis C is not appropriate for this patient at this time.

Answer 103

A) No additional treatment **Elevated ammonia** levels may occur with * urea cycle disorders, * portosystemic shunting, * urinary tract infection from urease-producing organisms, * gastrointestinal bleeding, * shock, * renal disease, * heavy exercise, * smoking, * parenteral nutrition, * salicylate intoxication, * use of medications including diuretics, and * alcohol use. In patients with chronic liver disease, hepatic encephalopathy is diagnosed based on the overall clinical presentation and not on ammonia levels. A normal ammonia level does not exclude the diagnosis of hepatic encephalopathy, nor does an elevated ammonia level establish the diagnosis. This patient had an elevated serum ammonia level that was found incidentally during his hospital admission for gastrointestinal bleeding. Because there was no clinically significant encephalopathy, treatment based on ammonia levels is not indicated. The patient’s **elevated ammonia level** was probably from **diuretic use**. Lactulose, methotrexate, neomycin, or prednisone would not be appropriate.

Answer 104

B) The infant’s cheeks are dimpled during feeding An infant’s **dimpled cheeks** during breastfeeding is a sign of a **poor latch**, with the infant not getting enough of the breast in the mouth. * With a good latch, most or all of the mother’s areola is completely in the infant’s mouth and thus not visible during breastfeeding. * The infant’s chin, not the nose, should be against the breast. * Inverted (rather than everted) or very large nipples may be problematic and require additional lactation support. * The transition of the infant stool from dark meconium stools to yellow stools is a sign that the infant is digesting milk.

Answer 105

A) Cellulitis (**REVIEW: 2019.189** ) The most common complications for patients who inject drugs are **skin and soft-tissue infections**. These are the most frequent infections **leading to hospitalization**. This patient is also at risk for endocarditis, osteomyelitis, pneumonia, and pyelonephritis, but these infections are less common.

Answer 106

C) Immobilization of the left thumb in a thumb spica cast or brace for 6 weeks (**REVIEW: 2017.12** ) **Ulnar collateral ligament (UCL)** disruption, or “**skier’s thumb**,” should be suspected in traumatic thumb injuries. It is important to recognize and treat this injury because it can lead to **joint instability** and a **weak pincer grip** if untreated. * Initial treatment of UCL disruption involves **immobilization** of the affected thumb in a thumb **spica cast** or brace for **6 weeks**. * In the absence of an avulsion fracture, indications for referral to an **orthopedic surgeon** would include **35°–40° of joint opening** or **no end point** on **stress abduction** testing. * A Stener lesion (entrapment of the UCL outside of the adductor aponeurosis) would usually present with joint instability and a tender mass and would necessitate an orthopedic referral.

Answer 107

D) TSH The best laboratory assessment of thyroid function is a serum TSH test, which is the preferred test for diagnosing primary hypothyroidism. If an elevated serum TSH level is detected and hypothyroidism is suspected, then a free T4 measurement would be indicated.

Answer 108

E) Turner syndrome **Turner syndrome** is associated with higher risks of * **endometrial** **cancer**, * **celiac disease**, and * **structural heart defects**. Physicians providing primary care to patients with Turner syndrome should recognize these increased risks and provide testing for celiac disease and serial screening for cardiac and/or aortic defects, and should also have a low threshold for evaluating any abnormal uterine bleeding. Complete androgen insensitivity syndrome, gonadal dysgenesis, congenital adrenal hyperplasia, and Klinefelter syndrome carry increased risks of other conditions, but not endometrial cancer, celiac disease, or structural heart defects.

Answer 109

E) Upper airway cough syndrome (**REVIEW: 2018.205** ) The most common causes of chronic cough in adults include 1. upper airway cough syndrome (postnasal drip syndrome) 2. tobacco use, 3. GERD, 4. asthma, and 5. ACE inhibitor use. The physical examination of this patient is most consistent with upper airway cough syndrome, previously referred to as **postnasal drip syndrome**. Given the patient’s lack of tobacco use and normal blood pressure, bronchogenic carcinoma and obstructive sleep apnea are less likely. There are no risk factors in this patient’s history to suggest chronic aspiration or tuberculosis.

Answer 110

A) Colchicine (Colcrys) (**REVIEW: 2018.209** ) Strong evidence suggests that **prophylaxis** with either **colchicine** or **NSAIDs** reduces the risk for acute gout attacks in patients **starting urate-lowering therapy**. The optimal duration of such prophylactic therapy is unknown, but moderate evidence suggests that it should be **longer than 8 weeks**. Although prednisone would be helpful it is not the preferred agent in this patient with normal renal function. Prophylaxis with aspirin, methotrexate, or probenecid is also not appropriate.

Answer 111

B) Discontinue hydrochlorothiazide (**REVIEW: 2018.198** ) This patient has **hypercalcemia with a normal albumin level**. **Hydrochlorothiazide** can cause **drug-induced hypercalcemia**. Alendronate, lisinopril, and omeprazole do not cause hypercalcemia. A high vitamin D level can cause hypercalcemia, so increasing vitamin D is not appropriate at this point. A laboratory evaluation can help differentiate between PTH- and non–PTH-mediated hypercalcemia.

Answer 112

A) Use of a functional ankle brace with early mobilization Early mobilization leads to better outcomes with ankle sprains, and using a functional ankle brace such as a semi-rigid air stirrup brace or a soft lace-up ankle brace will protect the ankle from inversion and eversion sprains while still allowing for mobility during physical activity. These braces lead to improved functional outcomes at 1 month when compared to elastic compression taping. Patellar tendon straps relieve the pain associated with patellar tendinopathy but are not indicated with acute ankle sprains. Use of a semi-rigid air stirrup splint has been shown to be superior to neuromuscular training for prevention of recurrent ankle sprains.

Answer 113

A) 40 mg daily for 5 days For patients with a COPD exacerbation, systemic glucocorticoids can improve FEV1, improve oxygenation, shorten recovery time, and reduce the length of hospitalization (level of evidence A). * **Prednisone, 40 mg daily for 5 days**, is recommended for **COPD exacerbations**. Studies have shown that oral administration is equally efficacious compared to the intravenous route. The duration of therapy **should not be longer than 5–7 days** (level of evidence A).

Answer 114

D) Abnormal uterine bleeding Abnormal uterine bleeding is the most common cause of iron deficiency anemia in premenopausal women, accounting for 20%–30% of cases. Gastrointestinal causes are less common but should be considered if the gynecologic evaluation is normal or the anemia fails to resolve with iron supplementation. Blood donation and hematuria are less common causes.

Answer 115

C) Androgenetic alopecia Androgenetic alopecia is associated with bitemporal thinning of the frontal and vertex scalp in men, but in women the frontal hairline is spared and hair thinning is most apparent at the vertex. There is often a family history of hair loss in patients with androgenetic alopecia. Alopecia areata results in acute, patchy hair loss. * Anagen effluvium results in diffuse hair loss days to weeks after exposure to chemotherapeutic agents. The incidence of anagen effluvium after chemotherapy is estimated at 65%. * Tinea capitis is a dermatophyte infection of the hair shaft and follicles that results in patchy hair loss and requires systemic antifungal treatment. * Trichorrhexis nodosa is characterized by breaks in the hair secondary to trauma or because of fragile hair, often due to excessive brushing, heat application, or hairstyles that lead to pulling on hairs.

Answer 116

A) Topical adapalene (Differin) and benzoyl peroxide Acne affects 85% of 12- to 25-year-olds in the United States. This patient has **mild acne** as evidenced by the absence of cystic lesions and localization to the facial T-zone. * **Topical retinoids** are **first-line** treatment for **any level of severity** of acne (SOR A). * **Adapalene** is an **effective retinoid** and is available **over-the-counter**. * Benzoyl peroxide is also very effective in the control of acne because it reduces the concentration of cystic acne with no risk of bacterial resistance. The **combination** of a **topical retinoid** and **benzoyl peroxide** is **more effective** than either agent alone. Topical antibiotics such as clindamycin and erythromycin should not be used as monotherapy due to high rates of microbial resistance. There is little evidence that salicylic acid is effective in combating acne despite its widespread use. * Tazarotene is effective in the treatment of acne but is teratogenic (pregnancy category X) and should be avoided in women of reproductive age. * Combined oral contraceptives can be effective, but norethindrone and other first-generation progestins are androgenic and can worsen acne.

Answer 117

A) no EKG The U.S. Preventive Services Task Force (USPSTF) recommends **against** **screening with either resting or stress EKGs** to prevent cardiovascular disease (CVD) events in asymptomatic individuals at low risk of CVD events (D recommendation). **Potential harms** of EKG screening include invasive confirmatory testing and treatment. The USPSTF concluded that current evidence is insufficient to determine the balance of benefits and harms of screening with resting or stress EKGs to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events (I recommendation).

Answer 118

D) The percentage of the population age 65 and older Americans who live in rural areas face many health challenges compared to their counterparts who live in urban areas. This includes health care workforce shortage problems. The number of primary care and specialty care physicians, physician assistants, advanced practice nurses, registered nurses, dentists, and mental health professionals per 10,000 residents is lower. People who live in rural areas are also affected by socioeconomic factors. They tend to be older and poorer on average, with a higher percentage living below the poverty level. Rural areas also have higher unemployment rates. In 2017, 18.1% of rural populations were over the age of 64 compared to 14.3% of urban populations. Residents of rural areas are more likely to be uninsured and rely more heavily on the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. Fewer 18- to 24-year-olds in rural areas have high school diplomas. Tobacco use is higher among rural youth, including cigarette smoking and smokeless tobacco use. Transportation difficulties are also more common. Health inequity issues are also challenges in rural areas, including higher rates of diabetes mellitus and coronary heart disease. Deaths related to drug overdoses have been rising and in 2017 overtook the death rate for people who live in urban areas. Family physicians are only 15% of the U.S.

Answer 119

D) Full-body immersion in an ice bath **Heatstroke** can be nonexertional from prolonged exposure to a high heat index, or it can be exertional, as in this case. A core temperature **\>40°C (104°F)** is consistent with heatstroke. In treating patients with either clinical variant of heatstroke, **cold or ice-water immersion** is the **most effective** treatment and should be initiated as soon as possible, without delaying for transfer to the hospital setting (SOR A). Treatment should continue until the core body temperature is **\<39°C (102°F)**. If cold water immersion is not possible other forms of cooling such as cold intravenous fluids, ice packs, cold water immersion of the extremities, and evaporative cooling have been shown to have some benefit. Once the body temperature is decreased patients should be transferred to a hospital for evaluation for known complications of heatstroke, including coagulopathy, renal and hepatic dysfunction, hypoglycemia, electrolyte disturbance, and rhabdomyolysis.

Answer 120

C) Screen for hepatitis and hemochromatosis This patient most likely has **nonalcoholic fatty liver disease (NAFLD)**. The initial evaluation should include studies to rule out uncommon, but not rare, causes of liver disease. This would include viral hepatitis studies, iron studies for hemochromatosis, serum albumin levels, and a CBC. * Discontinuing **statin** therapy is generally not necessary because statins have been shown to be safe for patients with chronic liver disease. * **Metformin** is not commonly associated with elevated transaminases. If NAFLD is determined to be the most likely cause, an NAFLD fibrosis score should be calculated to preclude the need for a liver biopsy.

Answer 121

E) Urgent surgical consultation **Pyogenic flexor tenosynovitis** usually develops 2–5 days after a penetrating hand injury. The flexor tendon sheath has a poor vascular supply and the synovial fluid is a prime growth medium for bacteria. Flexor tenosynovitis is a clinical diagnosis characterized by the **four “Kanavel” signs**: 1. pain with passive extension, 2. tenderness with palpation of the tendon sheath, 3. flexed position of the involved finger, and 4. fusiform swelling of the finger. Treatment includes prompt intravenous **antibiotics** and surgical **debridement** and irrigation. Flexor tenosynovitis requires urgent surgical consultation and treatment. Patients with suspected flexor tenosynovitis should be seen by a surgeon **within 72 hours** of symptom onset (SOR C). * Oral antibiotics and splinting of the hand alone are insufficient treatments for the condition. * Incision and drainage would also not be sufficient to clear the infection. * Ordering MRI can unnecessarily delay surgical consultation, although the surgeon may obtain one to guide treatment.

Answer 122

C) overscreening Overscreening is defined as the use of screening tests at ages younger or older than the range recommended by national guidelines or at shorter intervals than recommended. * Current guidelines from the U.S. Preventive Services Task Force recommend **screening** for **colon cancer** starting at **age 50** and continuing until **age 75** (A recommendation). The decision to screen adults 76–85 years of age should be an individual one, taking into account the patient’s overall health and prior screening history (C recommendation). In this case ordering a screening colonoscopy would be an example of overscreening because the patient is above the recommended upper age of 75 and he has multiple comorbid conditions that limit his life expectancy. Overscreening can result in increased cost, morbidity, and/or mortality, especially in older individuals. Overdiagnosis is when a diagnosis is made correctly, but the diagnosis is irrelevant because it will never cause symptoms or death during a patient’s ordinarily expected lifetime. Overtreatment refers to unnecessary medical interventions.

Answer 123

B) Forgetting to change an etonogestrel/ethinyl estradiol vaginal ring (NuvaRing) when the current ring has been in place for 6 weeks In patients who use the etonogestrel/ethinyl estradiol vaginal ring, emergency contraception is recommended if they have intercourse when the same ring has been in place for **\>5 weeks**. * Backup protection is advised until the new ring has been in place for 1 week. Backup protection is generally unnecessary with the **depot medroxyprogesterone** injection unless the patient is more than **2 weeks late** for her injection. Backup protection is then recommended for 7 days after the injection. * Emergency contraception is recommended for women who **miss two or more** doses of their **combined contraceptive** in 1 month, especially if these doses were missed during the first week and unprotected intercourse occurs during that week. Backup protection should continue until the oral contraceptive pill has been taken for 7 consecutive days. Emergency contraception is generally only recommended up to 5 days after unprotected intercourse. * The progestin-only mini-pill is effective alone for contraception when taken as prescribed.

Answer 124

D) Hypersegmented polymorphonuclear WBCs **Vitamin B₁₂ deficiency**, which is most commonly related to a **deficiency of intrinsic factor** that is produced by the gastric mucosa and is necessary for **absorption** of vitamin B₁₂ in the terminal ileum, is manifested as a **megaloblastic** **macrocytic** anemia. In addition to an elevated mean corpuscular volume, the classic finding on microscopy of the peripheral smear is the presence of multiple (usually five or more) segments in the WBC nuclei. Vitamin B₁₂ levels are low and a high methylmalonic acid level helps to confirm the diagnosis. A methylmalonic acid level is recommended in patients who have borderline low vitamin B₁₂ levels but are at risk for deficiency. Risk factors include chronic proton pump inhibitor use; chronic metformin therapy; chronic malnutrition due to alcoholism, chronic gastritis, or peptic ulcer disease; and diseases of the terminal ileum, such as Crohn’s disease. People who have had gastric bypass surgery are also at risk for vitamin B₁₂ deficiency, which is why supplementation should be provided in these patients. Microcytic, hypochromic RBCs are typical of iron deficiency anemia but may also be seen in anemia of chronic disease. Sickled or crescent-shaped cells are seen with sickle cell anemia, and basophilic stippling may be seen in anemia associated with lead toxicity. Schistocytes are seen in hemolytic anemia.

Answer 125

D) praxis **Praxis** is the ability to **carry out intentional motor acts** and is commonly assessed by giving the patient a common object such as a hairbrush or pencil and asking the patient to show how it is used. _A patient unable to carry out such motor acts is referred to as having **apraxia**_ (SOR C). Several other common components of the cognitive assessment will be impaired in persons with dementia. * **Executive functioning** is the ordering and implementation of **cognitive** **functions** necessary to engage in appropriate behavior and is often assessed by asking a patient to **draw a clock** with the **hands set at a certain time**. **Gnosia** is the ability to **name objects** and **their function** and is often assessed by showing a patient a common object such as a pen, watch, or stethoscope and asking whether he or she can identify it and describe **how it is used**. * **Orientation** is the ability of the patient to **recognize his or her place in time and space**. Orientation is commonly assessed by asking a patient the date, the current location, his or her name, and his or her place of birth. **Visuospatial** proficiency is the ability to **perceive** and **manipulate objects** and **shapes in space**. It is often assessed by asking the patient to copy intersecting pentagons or a three-dimensional cube on paper.

Answer 126

A) Amlodipine (Norvasc), 2.5 mg daily This patient has a blood pressure that is elevated according to all major current guidelines. **Amlodipine**, a *long-acting dihydropyridine calcium channel blocker* (CCB), is the best pharmacologic choice because it will **lower blood pressure** and **treat angina** *without the risk of heart block*. * *Short-acting CCBs* such as non–extended-release **nifedipine** may cause reflex tachycardia and are not recommended. * *Nondihydropyridine CCBs* such as **diltiazem** would put this patient at risk for heart block because he is already taking long-acting metoprolol and his heart rate is in the 50s. * Long-acting **nitrates** and **ranolazine** are options to treat stable angina but would not be effective blood pressure medications.

Answer 127

A) Do not prescribe albuterol In a Cochrane review of five trials of 2-agonist therapy in adults, there was no significant difference between 2-agonists and placebo in cough reduction. Based on reports of adverse effects, the number needed to harm is 2. It is important to set reasonable expectations for cough duration after an acute respiratory illness.

Answer 128

D) IgA tissue transglutaminase antibody Celiac disease affects approximately 1% of the U.S. population and can affect all ages. Individuals with northern European ancestry are most commonly affected. The condition is caused by **autoimmunity** induced by gluten-containing foods in susceptible individuals. * Untreated celiac disease is associated with **anemia**, **malabsorption**, **osteoporosis**, **weight loss**, and gastrointestinal **lymphomas**. * In children, growth stunting and delayed puberty are also common. With strict adherence to a gluten-free diet most complications from celiac disease are preventable and, in children, growth and development return to normal. The World Gastroenterology Organisation recommends **annual monitoring** of children and adolescents with celiac disease by **anthropometry**, pubertal **development**, and **celiac serology**. * The preferred serology is **IgA antibody to tissue transglutaminase** (IgA anti-tTG) due to its balance of good performance and low cost. * Failure of IgA anti-tTG titers to decrease in 6 months suggests continued ingestion of gluten. Repeat duodenoscopy with a biopsy would be unnecessary and would subject the child to potential harm.

Answer 129

A) Folic acid (**REVIEW: 2018.202** ) Women of reproductive age should take a daily supplement of 0.4–0.8 mg of folic acid starting before conception in order to reduce the risk of neural tube defects. A higher folic acid dosage of 4 mg daily starting 1 month prior to conception is recommended for women who have a high risk of pregnancy complicated by a neural tube defect. This includes women with a previous pregnancy with a neural tube defect, a personal or family history of neural tube defects, type 1 diabetes, or a seizure disorder. Vitamin B6, vitamin B12, vitamin C, and vitamin D do not require supplementation prior to conception.

Answer 130

A) An otherwise healthy 9-month-old child who is up to date on all age-appropriate immunizations Measles outbreaks are becoming more common and the CDC has outlined who should receive postexposure prophylaxis with the MMR vaccine. To be effective as postexposure **prophylaxis** the vaccine must be administered **within 72 hours** of exposure. Infants \<12 months of age are considered to be at high risk for complications from measles and should receive postexposure MMR vaccine, although intramuscular immunoglobulin is also an option. Children who are otherwise fully vaccinated do not need additional prophylaxis. Pregnant women cannot receive the MMR vaccine due to fetal risk, but they should receive intravenous immunoglobulin if they do not have evidence of immunity. Health care workers only need to be given the MMR vaccine as prophylaxis if they did not receive two doses previously.

Answer 131

B) Potassium replacement Correcting the potassium level is the best treatment choice for this patient. A low serum potassium level in diabetic ketoacidosis (DKA) indicates a significant potassium deficiency, placing the patient at risk for a **cardiac arrhythmia**, among other complications. **Potassium deficiency** is usually the product of **urinary losses** due to **glucose osmotic diuresis** and secondary **hyperaldosteronism**. However, serum potassium can remain normal when there is a whole body deficiency, as a result of movement of potassium out of cells in response to the acidosis, insulin deficiency, and hyperosmolality. This patient’s serum potassium is low, which indicates severe deficiency. Sodium bicarbonate can be used in some cases of DKA but is not the most important next step in this case. If insulin therapy is initiated prior to potassium replacement the insulin can force more potassium into cells, worsening the serum deficiency. If the serum potassium level is \<3.3 mEq/L potassium should be replaced prior to insulin therapy. Ketone measurement can also be part of DKA management but is not the most appropriate next step for this patient.

Answer 132

D) can be initiated only after inpatient detoxification (**REVIEW: 2018.157** ) **Buprenorphine** therapy is an important option for **maintenance therapy** for patients with **opioid use disorder**. * It can be initiated in the outpatient setting but should be done when the patient is in **mild to moderate withdrawal** in order to **avoid the risk of precipitated withdrawal** (SOR C). Buprenorphine therapy is more convenient than methadone maintenance therapy and is equally as effective. **Buprenorphine/naloxone combinations are preferred** over buprenorphine monotherapy due to lower abuse potential, except when naloxone is contraindicated such as in patients who are pregnant or breastfeeding (SOR C). Because relapse rates are higher in patients who discontinue medication-assisted therapy for opioid use disorder, long-term use is recommended.

Answer 133

A) Atrial fibrillation Atrial fibrillation is characterized by an irregularly irregular rhythm, without any discernible P waves. In multifocal atrial tachycardia the P waves show varying morphology, and this rhythm is typically seen in patients with underlying lung disease, especially COPD. Acute ST-segment elevation myocardial infarction is characterized by the presence of hyperacute ST-segment and T-wave changes in contiguous EKG leads, accompanied by reciprocal changes. Pulmonary embolism is characterized by EKG findings of sinus tachycardia (a heart rate 100 beats/min), nonspecific ST-T changes, and new-onset right bundle branch block (SOR C).

Answer 134

B) Adhesive capsulitis **Risk** factors for **adhesive capsulitis** include **female** sex, age **between 40 and 60** years of age, **diabetes** mellitus, and **hypothyroidism**. * This is a **clinical diagnosis** of exclusion that is based on physical findings of **loss of active and passive range of motion**. Glenohumeral arthritis may present with similar findings but is ruled out by normal radiographs. * A patient with acromioclavicular arthritis will have radiographic findings and a painful cross-arm test. Rotator cuff disease and bursitis typically present with painful active range of motion but preserved passive range of motion and tenderness to palpation.

Answer 135

B) Hydrochlorothiazide (**REVIEW: 2019.135** ) Hyponatremia is an extremely common condition, affecting 4%–7% of the ambulatory population. While a number of medications can cause hyponatremia, among the most common offenders are SSRIs and thiazide diuretics. Acetaminophen and metoprolol are not known to affect sodium levels. Vitamin D deficiency has also been linked to hyponatremia so supplementation would likely improve rather than worsen hyponatremia.

Answer 136

E) Tiotropium (Spiriva) (**REVIEW: 2019.91, 2019.137, 2018.216** ) This patient has airflow obstruction consistent with a diagnosis of **COPD**, evidenced by an **FEV1/FVC ratio \<0.7**. An evidence-based standard approach to COPD is found in the annual guidelines published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). * According to the 2019 report, this patient’s **FEV1 of 75%** of predicted puts her in the **GOLD grade 2** (**moderate**) category of airflow limitation. * Her **symptoms** and **risk** of exacerbations places her in **GOLD group B**. Patients in this category have symptoms that **bother them regularly** without having frequent COPD exacerbations. Patients in this category benefit from daily use of **long-acting bronchodilators**, either 1. long-acting ß-agonists (**LABAs**) or 2. long-acting muscarinic agents (**LAMAs**). Long-acting agents such as **tiotropium (a LAMA)** or **salmeterol (a LABA)** are preferred over the short-acting agents ipratropium and albuterol for patients in this category of disease severity. Patients with persistent symptoms while using one of these agents may benefit from a combination of a LABA and a LAMA. * Monotherapy with inhaled corticosteroids has not been shown to improve mortality or prevent a long-term decline in FEV1. The **combination** of an inhaled **corticosteroid plus a LABA** has evidence of superiority over either agent alone for improving lung function and health status, and for reducing exacerbations in patients who have more severe disease. No improvement in all-cause mortality has been noted.

Answer 137

D) impacted molars **Impacted molars** are a **mechanical** **problem** where the tooth does not emerge properly because of abnormal angulation or not enough room in the mouth. Pregnant women may experience **impacted third molars (wisdom teeth)** because they typically emerge in the late teens or early twenties, but pregnancy itself does not predispose to this condition. However, the risk of dental caries, loose teeth, gingivitis, and periodontitis all increase during pregnancy. * Pregnant women are at higher risk for **dental caries** because the oral cavity is exposed to more **gastric acidity** due to **vomiting** with **morning sickness**, and **acid reflux** due to a lax esophageal sphincter and upward pressure from a gravid uterus. * Increased levels of **estrogen** and **progesterone** during pregnancy can relax the ligaments and bones that support the teeth, leading to a temporary **loosening of teeth**. * Gingivitis and periodontitis increase during pregnancy because of a fluctuation in estrogen and progesterone levels in combination with changes in oral flora and a decreased immune response. Periodontitis is of particular concern during pregnancy and should be treated because of its association with preterm birth and low birth weights.

Answer 138

E) Irritable bowel syndrome The Rome IV criteria for irritable bowel syndrome are symptom-based diagnostic criteria used to identify patients with irritable bowel syndrome (IBS). According to these criteria, IBS is defined as: 1. recurrent abdominal pain at least 1 day per week for at least 3 months. 2. At least two of the following must be present: 1. abdominal pain related to defecation, 2. a change in stool form, and/or 3. a change in stool frequency. The diagnosis can be made from the patient history, a physical examination, and a minimal laboratory evaluation. This patient meets the criteria. This patient does not have any “alarm” symptoms (a positive family history of colorectal cancer, rectal bleeding in the absence of documented bleeding hemorrhoids or anal fissures, unintentional weight loss, or anemia) so colon cancer would be unlikely. Celiac disease and inflammatory bowel disease are unlikely in a patient with constipation-predominant IBS. Serologic and inflammatory marker testing would be warranted in patients with predominant diarrhea or mixed types of IBS. Hyperparathyroidism does not usually present with this clinical picture, and calcium levels would likely be elevated.

Answer 139

C) Urethral catheter placement followed by continuous drainage for 3 days Acute symptomatic urinary retention should be treated with immediate urethral **catheterization**. The catheter should be **left in place for 3 days**, followed by a **voiding trial**. During this time the patient should be evaluated for underlying causes of the retention, such as infection, and prescribed or over-the-counter medications. Starting an alpha-blocker while the catheter is in place should be considered, but initial treatment with an alpha-blocker without catheterization is not indicated. Suprapubic catheter placement should only be used when urethral catheterization is unsuccessful. Transurethral resection of the prostate may be necessary later but is not the initial treatment.

Answer 140

E) Corticosteroid injection (**REVIEW: 2018.127**) Carpal tunnel syndrome of mild to moderate severity can be treated nonsurgically. Patients with severe symptoms or nerve damage seen on electromyography should be referred for surgical therapy. Nonsurgical management options include splinting, physical therapy, therapeutic ultrasound, and corticosteroids (oral or injection). Oral prednisone, 20 mg daily, for 10–14 days improves symptoms and function compared with placebo, for up to 8 weeks, but oral corticosteroids are less effective than corticosteroid injections. In a 2013 double-blind, placebo-controlled, randomized clinical trial comparing methylprednisolone injection (40 mg and 80 mg) to saline injection, patients in the 80-mg injection group were less likely to have surgery at 12 months. While corticosteroid injections have the best evidence for delaying the need for surgery, night splints, physical therapy, and therapeutic ultrasound have some evidence of benefit. Splinting was found to be effective in a Cochrane review. It is low cost and safe and especially recommended in pregnancy-related disease. Limited evidence supports the use of physical therapy to treat carpal tunnel syndrome. Nerve glide exercises are simple hand and finger movements that are easy to learn, can be performed at home, and can be combined with other treatments such as splinting. Therapeutic ultrasound also has limited evidence of benefit. It requires an experienced therapist and requires multiple sessions, typically 5 days/week for 2–4 weeks.

Answer 141

B) Ibuprofen NSAIDs such as ibuprofen should be used as first-line treatment for the control of pleuritic pain (SOR B). NSAIDs do not have the analgesic potency of narcotics, but they do not cause respiratory suppression and do not change the patient’s sensorium. Corticosteroids should be reserved for patients who cannot take NSAIDs. Colchicine is used to treat pericarditis but not pleuritic pain.

Answer 142

C) Spironolactone (Aldactone) (**REVIEW: 2019.135, 2019.159** ) Patients with secondary hypertension frequently take several medications and are classified as having “resistant” hypertension. It is important to recognize that many antihypertensive medications can affect the results of the aldosterone/renin ratio. * An **aldosterone antagonist,** such as **spironolactone** or **eplerenone**, can **increase renin and aldosterone levels** and should be **discontinued 4–6 weeks** before obtaining a ratio. * Angiotensin receptor blockers and ACE inhibitors can increase renin levels. * Oral potassium supplements should be continued or started in patients with hypokalemia, since aldosterone biosynthesis is dependent on potassium. * Medications such as hydralazine, terazosin, and verapamil may be continued or started for blood pressure control because they do not affect aldosterone or renin levels.

Answer 143

D) Risperidone (Risperdal) Agitation and delirium are common end-of-life symptoms. It is important to assess for treatable causes, including constipation, urinary retention, uncontrolled pain, and adverse medication effects. The antipsychotic medication risperidone is effective for treating agitation and nausea at this stage, but dosing is much lower than when this medication is used for psychiatric disorders. * Benzodiazepines can provoke increased agitation and should be used with caution; however, they can be useful for treating significant end-of-life anxiety. * Generally, a longer-acting form such as lorazepam would be a better choice than short-acting alprazolam. * Amitriptyline and diphenhydramine can both cause urinary retention, potentially leading to delirium and agitation.

Answer 144

A) are not indicated at this time For patients who experience a seizure, the risk factors for recurrent seizures include two unprovoked seizures more than 24 hours apart, epileptiform abnormalities on an EEG, abnormal brain imaging results, severe head trauma, and a syndrome associated with epilepsy. In children who do not have any of these risk factors, antiepileptic drug therapy is not indicated after a first unprovoked seizure. When there are no risk factors there is no difference in 1- to 2-year seizure remission rates if antiepileptic drug therapy is started after a second seizure as opposed to starting it after the first seizure. If therapy is indicated, monotherapy should be the initial approach. The risk of adverse effects of drug therapy are as high as 50%. This includes subtle cognitive and behavioral effects in many cases.

Answer 145

A) Therapeutic lifestyle changes with close follow-up in 2–3 weeks This patient has **stage 1 hypertension** based on his average blood pressure of 131/88 mm Hg after three measurements. He is asymptomatic so the initial recommendation is therapeutic lifestyle changes and close follow-up in 2–3 weeks (SOR C). If his blood pressure remains elevated, an evaluation for secondary hypertension would be appropriate. Medication would be appropriate for stage 1 hypertension with either evidence of end-organ disease or persistent hypertension after a trial of therapeutic lifestyle changes or progression to stage 2 hypertension (SOR C). Thiazide diuretics or ACE inhibitors would be appropriate choices for initial treatment. ß-Blockers are no longer considered first-line treatment for hypertension in adolescents or children. This patient would need blood pressure monitoring at every visit due to his elevated blood pressure.

Answer 146

E) A female infant with a first degree relative with developmental dysplasia of the hip Screening for developmental dysplasia of the hip (DDH) is somewhat controversial because the benefit of treatment remains somewhat unclear. Despite the widespread practice of screening for DDH, ethical newborn practices are difficult to determine. The American Academy of Family Physicians and the U.S. Preventive Services Task Force have found insufficient evidence to recommend routine screening for DDH. The American Academy of Pediatrics, however, recommends routine screening of all newborns with physical examination maneuvers, and targeted screening ultrasonography for infants who were breech in the third trimester, have a family history of DDH, or have a personal history of instability. Given this, decisions should be individualized. Additional risk factors include female sex, firstborn status, oligohydramnios, and a large-for-gestational-age infant.

Answer 147

B) Starting supplementation at 6 months of age if the primary water supply is fluoride deficient The U.S. Preventive Services Task Force recommends oral fluoride supplementation for the prevention of dental caries beginning at **age 6 months** for children whose primary water supply is fluoride deficient (B recommendation). Well water may be fluoridated naturally depending on the aquifer, but the water is highly variable and should be tested before deciding on the need for supplementation. Testing well water is also advisable because excessive fluoride may lead to fluorosis of the bones. Bottled water is variable, making it undependable as an adequate source of fluoride. Topical fluoride, in toothpaste or applications of fluoride varnish, is effective in preventing tooth decay in children and can be used in addition to properly fluoridated water. Twice-yearly application of fluoride varnish to primary teeth should begin when the first tooth comes in and repeated every 6 months thereafter in children (SOR B).

Answer 148

D) Naproxen Once the diagnosis of acute rheumatic fever is made, **NSAIDs** such as **aspirin** or **naproxen** should be administered (SOR B). The therapeutic response to NSAIDs is often remarkable. * Acetaminophen has not been shown to be a superior analgesic for acute rheumatic fever. * Gabapentin is not indicated, especially considering that the pain does not have a neuropathic etiology. * Opioids would not be considered first-line treatment because of their adverse effects and the dramatic response of NSAIDs alone.

Answer 149

C) An irreversible FEV1/FVC ratio \<65% A large cohort study indicated that the Global Initiative for **Chronic Obstructive Lung Disease criterion** (**FEV1/FVC ratio \<70%**) is more sensitive for COPD in individuals 65 years and older compared to the American Thoracic Society criteria (SOR C). COPD is present if the FEV1/FVC ratio is reduced to \<70% and is **irreversible** with bronchodilator therapy. A reversible response to bronchodilator therapy is more consistent with asthma.

Answer 150

C) A diuretic, ACE inhibitor, and ß-blocker until his symptoms and the abnormalities seen on the echocardiogram resolve (**REVIEW: 2018.155** ) Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, can develop following emotional distress and is characterized by the **abrupt onset of dysfunction of the left ventricle**. The clinical presentation and laboratory studies can mirror acute coronary syndrome and should be treated similarly. Once symptoms and cardiac abnormalities resolve, treatment is no longer indicated and may be withdrawn if there are no signs of coronary disease. Because this patient currently has cardiomyopathic abnormalities, a diuretic, ACE inhibitor, and ß-blocker are indicated. * Ambulatory cardiac monitors are not indicated for this patient with a known diagnosis of Takotsubo cardiomyopathy. * A pacemaker is not indicated in the absence of arrhythmias caused by conduction abnormalities.

Answer 151

D) \>75 years of age Studies have documented an increased rate of metered-dose inhaler (MDI) use errors in certain patient subgroups that could adversely affect the efficacy of treatment. For patients over the age of 15, the ability to demonstrate correct MDI use drops significantly with increasing age. One large study of MDI technique, after a minimum of 3 months of prescribed use, confirmed error frequencies of 61% in patients 15–30 years of age, 70% in patients 30–60 years of age, 77% in patients 60–75 years of age, and 86% in patients \>75 years of age. Other patient characteristics also affect MDI error rates. A higher level of education and a diagnosis of asthma rather than COPD are both associated with fewer errors, whereas the frequency of errors is higher for females and lower-income patients. Disease severity and the presence of comorbidities has also been found to affect MDI use. The error rate is lower for patients who have had prior training, and the rate of proper usage relates directly to the duration of the training session.

Answer 152

A) Administration of dexamethasone, 0.6 mg/kg orally in a single dose (**REVIEW: 2018.131** ) This patient has mild **croup** based on the clinical findings. * **A single dose of dexamethasone** is recommended in all cases of croup (SOR A). Hospitalization is not necessary if the child is stable. Racemic epinephrine, which has been shown to reduce symptoms at 30 minutes but not at 2 hours or 6 hours, is recommended for the treatment of moderate to severe croup when patients are being observed in a medical setting such as the emergency department or hospital (SOR A). Amoxicillin and albuterol are not indicated in the management of croup.

Answer 153

D) Doxycycline, 100 mg twice daily for 10 days This patient has **early Lyme** disease as evidenced by * erythema migrans, * fever, * myalgias, and * arthralgias. The treatment of early Lyme disease is **doxycycline for 7–21 days**. * Single-dose doxycycline is used for prophylaxis to prevent Lyme disease after a tick bite in an area where Lyme disease is endemic. * Longer treatment periods are required for Lyme arthritis and patients may require intravenous antibiotics. * With this patient’s clinical presentation, antibiotic treatment would be recommended and serologic testing is not needed. In clinical scenarios where diagnostic testing is needed, testing for early Lyme disease should be performed with a two-tier test starting with an enzyme immunoassay and, if positive, confirmed with a Western blot.

Answer 154

B) Fifth grade It is recommended that all printed patient education information be written at or below a fifth- to sixth-grade reading level. This aligns with universal health literacy precautions in which easy-to-understand concepts and terms are used for all patients instead of focusing on those with low literacy. These literacy precautions are recommended by professional organizations such as the American Medical Association and the Agency for Healthcare Research and Quality.

Answer 155

B) 12 months Multiple reports have associated iron deficiency with impaired neurodevelopment and it is therefore essential to ensure adequate iron intake. Based on expert opinion, the American Academy of Pediatrics recommends measuring a child’s **hemoglobin level at 12 months** of age.

Answer 156

E) Excision This patient has tried first-line treatment for hemorrhoids with increased fiber intake but has returned with symptoms of a thrombosed external hemorrhoid. Office-based surgical excision of the thrombosed external hemorrhoid within 2–3 days of symptom onset may provide significant symptomatic relief (SOR B) and result in a lower risk of recurrence. While conservative treatment with topical therapies such as corticosteroids may be helpful, symptomatic relief is prolonged with excision of the thrombosed hemorrhoid. * Bioflavonoids are used outside the United States for symptomatic treatment of hemorrhoids but evidence is lacking and they are not approved by the FDA for this use. * Oral antibiotic therapy has no role in the treatment of thrombosed external hemorrhoids but may be beneficial in treating an abscess, which would present with a gradual onset of pain and a fluctuant rectal mass. * Rubber band ligation is an appropriate treatment for grades I–III internal hemorrhoids (SOR A).

Answer 157

B) Increase prednisone to 15 mg daily and continue fludrocortisone at the current dosage Patients with chronic adrenal insufficiency, either primary or secondary, _may not be able to mount a stress response to infection or surgical procedures_. Common practice during minor infections is to **increase the corticosteroid** supplementation (SOR C). Fludrocortisone should be continued, but stress dosing is not necessary.

Answer 158

D) Levofloxacin The FDA issued a warning that **systemic** **fluoroquinolones** can **increase** the occurrence of **aortic dissections** or **ruptures**. Drugs in this group should be avoided in patients with an existing aortic aneurysm or in patients at increased risk for developing an aortic aneurysm unless there are no other treatment options available. Patients at increased risk include those with * peripheral vascular disease, * hypertension, * Marfan syndrome, or * Ehlers-Danlos syndrome. Similarly, the use of systemic fluoroquinolones should be avoided in the elderly. Aztreonam, ceftriaxone, and doxycycline are not associated with this side effect (SOR A).

Answer 159

C) Nodular basal cell carcinoma This patient has a nodular basal cell carcinoma, which has a pearly papular appearance with telangiectasia. Basal cell carcinoma is the most common cutaneous malignancy. The incidence increases with age and occurs most commonly in skin types 1 and 2. The tumors occur most frequently on the face, scalp, ears, and neck, and less frequently on the torso and extremities. While locally destructive, basal cell carcinoma rarely metastasizes. The skin becomes slightly rough with actinic keratosis, and a slight scale forms gradually. Sebaceous hyperplasia begins as elevated papules that eventually become dome-shaped and umbilicated. It consists of small tumors made up of sebaceous glands. Fibrous papule of the face is a variant of angiofibroma. It is usually 1–5 mm in diameter and most often appears on the nose. Seborrheic keratoses are benign skin neoplasms that are tan or black, well circumscribed, and have a stuck-on appearance.

Answer 160

B) coccidioidomycosis Knowledge of endemic fungi capable of causing infection in otherwise healthy patients can be very helpful in ensuring an appropriate evaluation. * **Coccidioidomycosis** is a common infection in the **southwestern** United States. In addition to the symptoms in this patient, coccidioidomycosis can also present with a rash such as **erythema nodosum**. **Histoplasmosis** is most common in the **Midwest** and with low-level exposure symptoms are usually mild or absent. * **Blastomycosis** is also present in the **Midwest**, as well as in the **Atlantic** and southeastern states. Symptoms include an abrupt onset of fever, chills, pleuritic chest pain, arthralgias, and myalgias. The cough is initially nonproductive but frequently becomes purulent. **Cryptococcosis** and **mucormycosis** are more **opportunistic** infections occurring in **immunocompromised** hosts.

Answer 161

B) RBC casts (**REVIEW: 2018.160** ) This is a classic presentation for acute **post-streptococcal glomerulonephritis** (APSGN), with the onset of gross hematuria associated with hypertension and systemic edema. This is most commonly seen in school-age children, usually 1–2 weeks after an episode of pharyngitis or 3–4 weeks after an episode of impetigo, caused by so-called **nephritogenic strains** of **Group A ß-hemolytic Streptococcus**. The hematuria is caused by **immune complex–mediated** glomerular injury. The classic finding on microscopic urinalysis for acute glomerulonephritis is the presence of RBC casts. * **Bacteriuria** may be seen in both upper and lower **urinary tract infections**, but may also be a spurious finding, especially with the combined presence of epithelial cells. * **WBC casts** are seen with acute **pyelonephritis**. * The presence of urinary **eosinophils** indicates acute **interstitial** **nephritis**. * **Calcium oxalate** makes up the most common type of **kidney stones**. Antibiotics prescribed for antecedent pharyngitis do not prevent APSGN. Treatment is supportive, controlling blood pressure and edema with a thiazide or a loop diuretic. The prognosis for resolution and full recovery of the vast majority of patients with APSGN is excellent, especially in the pediatric age group.

Answer 162

A) Padding, ice, and elevation (**REVIEW: 2018.118** ) This patient has **olecranon bursitis**, which is a **superficial bursitis** caused by chronic microtraumas to the affected area. The initial management for this condition includes conservative measures such as padding, elevation, icing, and analgesics (SOR B). If significant pain is associated with the swelling, or a decrease in range of motion is present due to severe swelling, aspiration should be offered. This is not indicated in this particular case and should be avoided to reduce the risk of septic bursitis. Septic bursitis would require empiric antibiotics to cover common skin organisms (SOR B). Aspiration should be performed if infection is suspected and the aspirate should be sent for a cell count, Gram stain, culture, glucose measurement, and crystal analysis (SOR C). Plain radiographs are indicated only if there is acute trauma and concern that a fracture may be present. If recurrent superficial bursitis occurs, a referral for surgery is indicated.

Answer 163

A) Metoclopramide (Reglan) Diabetic gastroparesis is a delay in the emptying of food from the upper gastrointestinal tract in the absence of a mechanical obstruction of the stomach or duodenum. **Metoclopramide is the only prokinetic agent that has been studied specifically for long-term use in gastroparesis** and is considered **first-line therapy** (SOR B). It is among the **only FDA-approved medications** for gastroparesis. * Nortriptyline is a prokinetic agent but has not been shown to be more effective than placebo for decreasing gastroparesis symptoms. * Proton pump inhibitors such as omeprazole, histamine H2-receptor antagonists such as ranitidine, and **ondansetron** **delay gastric emptying** and should be withheld in patients with gastroparesis whenever possible.

Answer 164

E) One prescription in the patient’s name and three blank prescriptions Expedited partner therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed with Chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner. When patients have been diagnosed with gonorrhea or Chlamydia, EPT has been shown to reduce the overall burden of disease in a given population when the partners cannot be linked to care. In this case, as the partners’ identities are unknown, it is impossible for the clinician to examine them or even contact them, so four prescriptions should be written, one with the patient’s name and the other three for EPT. The CDC states that EPT is particularly effective in treating the female partners of infected males. The CDC considers having the partners visit a health care provider to be the optimal course of treatment but this is not often practically feasible due to a lack of resources or social factors. Although conventional practice is to treat only the patient, this does not provide timely treatment for the patient’s partners. A prescription written to “EPT” can be filled at the pharmacy without the individual’s name or date of birth. Kentucky and South Carolina are the only states that do not allow this practice. A prescription with three refills would be unethical, as presumably the physician would be advising the patient to distribute medications that had been prescribed to only the patient. Blank prescriptions would require the partners to reveal their identities, which may lead to a reluctance to fill the prescriptions.

Answer 165

A) Number needed to treat A basic understanding of statistics is essential to evaluate clinical evidence. The number needed to treat, which represents the number of patients that must be treated to result in one positive outcome, is one of the most intuitive statistical concepts in explaining the power or relative lack thereof of an intervention. * Relative risk reduction in particular can be misleading, since a seemingly large relative risk reduction may result in a very small absolute risk reduction if the prevalence of the disorder in question is low. * Specificity indicates the ability of a test to accurately identify a condition but does not indicate the effectiveness of an intervention. * A 95% confidence interval relates to statistical variation and the relationship of an outcome to chance. * P-value deals with statistical significance but not magnitude of the effect.

Answer 166

B) lithium This patient is experiencing a **manic** or **hypomanic episode**. Therapeutic options include * **lithium**, * anticonvulsants such as **divalproex**, and * antipsychotic medications such as **olanzapine**. Benzodiazepines such as lorazepam may be of minimal benefit. SSRIs such as sertraline can aggravate mania. Bupropion would help treat an associated depression and trazodone could possibly help the patient sleep, but these medications are ineffective for treating a manic/hypomanic episode.

Answer 167

B) Polycystic ovary syndrome The most common cause of hirsutism in premenopausal women is polycystic ovary syndrome, which accounts for 75%–80% of cases. The second most common cause is idiopathic hirsutism, which accounts for 5%–20% of cases. Other causes are rare, but should be considered when evaluating new cases of hirsutism.

Answer 168

C) 48 hours after the initial antibiotic order For patients started on **empiric** antibiotic therapy at hospital admission, the CDC recommends an **antibiotic time-out 48 hours after the initial order** to determine if it can be stopped or needs to be changed. The dose, route, and duration should also be reviewed. The rationale is that antibiotics are often ordered empirically at the time of admission, while cultures and other studies are also being ordered. The original empiric order should be reassessed, incorporating the results of these studies while considering the evolving clinical status of the patient. Studies show this reassessment with antibiotic modification does not reliably occur.

Answer 169

D) Doxycycline plus ceftriaxone This patient presents with **acute epididymitis**. Typical symptoms develop gradually over **1–2 days** with posterior scrotal pain and swelling. Additional symptoms may include fever, hematuria, dysuria, and urinary frequency. The pain may radiate to the lower abdomen. Physical examination findings may include tenderness of the epididymis and testis along with swelling of the scrotum. **Elevation of the scrotum may decrease the pain** (**Prehn sign**). Typical ultrasound findings include hyperemia, swelling, and increased blood flow to the epididymis. With testicular torsion the pain is often sudden in onset and severe, with associated nausea and vomiting and no other urologic symptoms. A physical examination often demonstrates a high-riding testis that may lie transversely in the scrotum. The cremasteric reflex may be absent. Ultrasound findings would demonstrate decreased or absent blood flow with testicular torsion. In sexually active adults \<35 years of age, gonorrhea and Chlamydia are the most common causative organisms of acute epididymitis. Ceftriaxone, 250 mg intramuscularly or intravenously once, with oral doxycycline, 100 mg twice daily for 10 days, would be the appropriate treatment for acute epididymitis (SOR C). In men over the age of 35 or those with a history of recent urinary tract surgery or instrumentation, enteric organisms are the most likely cause and monotherapy with oral levofloxacin or ofloxacin for 10 days would be the recommended treatment.

Answer 170

E) Sacroiliac joint dysfunction The cause of hip pain is generally determined from the patient’s history and physical examination. A positive **flexion**, **abduction**, **external rotation** (**FABER**) test that produces pain at the **sacroiliac joint**, **lumbar spine**, and **posterior hip** is associated with sacroiliac joint dysfunction. * The log roll test involves passive supine internal and external rotation of the hip. When this test is positive for pain it is associated with piriformis syndrome. * While femoroacetabular impingement may be associated with a positive FABER test, it would produce pain in the groin. * Greater trochanteric pain syndrome results in lateral hip pain rather than posterior pain. * Osteoarthritis is usually associated with a limited range of motion and groin pain.

Answer 171

B) Exposure to respiratory syncytial virus Immunologic profiles of patients with asthma are influenced by environmental exposures. Those who are exposed to **respiratory syncytial virus (RSV)** as an infant have an increased risk, whereas those who are exposed to a high microbial environment have a lower risk than those without such exposure. Otitis media and lactose intolerance are not known to be associated with asthma risk.

Answer 172

E) Bariatric surgery (**REVIEW: 2018.177** ) This patient presents with morbid obesity complicated by several obesity-related conditions. Bariatric surgery has been shown to result in greater weight loss compared to nonsurgical interventions (SOR A). It has also been shown to be highly effective in treating obesity-related comorbid conditions such as diabetes mellitus (SOR A). Patients with a **BMI \>40 kg/m²** should be referred for consideration of bariatric surgery (SOR B). While worksite intervention, exercise therapy, behavioral therapy, and pharmacotherapy are appropriate treatments for obesity, these interventions are all less effective than bariatric surgery.

Answer 173

E) Supraclavicular In primary care practice the annual incidence of unexplained lymphadenopathy is only 0.6%. Only 1.1% of these cases are related to malignancy. This percentage increases with age. Supraclavicular adenopathy is associated with a high risk of intra-abdominal malignancy in both adults and children, with studies finding 34%–50% of these patients having a malignancy. Lymphadenopathy in the other locations listed is associated with a lower risk of malignancy.

Answer 174

A) No further testing This asymptomatic patient is at low risk for a major adverse cardiac event (\<1%) and requires no further testing prior to undergoing a low-risk, nonurgent surgical intervention. A routine preoperative EKG does not provide any benefit for asymptomatic patients undergoing low-risk surgical procedures (level of evidence 2). A preoperative EKG may be considered for asymptomatic patients without known coronary artery disease who are undergoing intermediate and high-risk surgeries (SOR B). A preoperative EKG is reasonable for patients who have known heart disease, peripheral artery disease, or cerebrovascular disease who are undergoing intermediate and high-risk surgeries (SOR B). Exercise stress testing for noncardiac surgery is not useful for patients at low risk but may be helpful for patients with an elevated risk and unknown functional capacity (SOR B). Routine chest radiography has no role in the preoperative evaluation. Routine preoperative echocardiography to assess left ventricular function is not recommended in asymptomatic patients (SOR B). It is reasonable for patients with dyspnea of unknown etiology and patients with worsening heart failure symptoms to undergo preoperative evaluation of left ventricular function (SOR C). Preoperative echocardiography is recommended for patients with known or suspected moderate- or high-degree valvular heart disease (SOR C).

Answer 175

D) allowing adequate time to deliver the diagnosis in a private setting with limited interruptions Physicians should respect the patient’s individual preferences for receiving bad news and allow adequate time to deliver the diagnosis in a private setting with limited interruptions. After delivering the news it is best to avoid extensive treatment details and making estimates of the patient’s survival, and to focus instead on patient-directed questions and providing empathy. Patients should be allowed to have as few or as many family members and friends present as they desire at the time of communication, and this often varies depending on the patient’s cultural background.

Answer 176

D) Doxycycline (**REVIEW: 2018.185** ) This patient has a history of symptoms consistent with **acute bacterial rhinosinusitis** that have persisted for 10 days, warranting empiric antibiotic therapy (SOR B). * **Doxycycline** is an appropriate alternative to amoxicillin/clavulanate for a patient with a history of a reaction to penicillin. Macrolides and trimethoprim/sulfamethoxazole are not recommended as empiric therapy because of high rates of resistance.

ABFM ITE 2019 Flashcards

(200 cards)