Final Review Flashcards

Question

A 42-year-old bricklayer was diagnosed with acute bronchitis at an urgent care center 6–7 weeks ago. A chest radiograph was negative for pneumonia but revealed a solitary pulmonary nodule. No previous chest radiograph was available, so a follow-up chest radiograph was ordered for 4–6 weeks after the initial one. He is following up with you today to review those results. The patient’s bronchitis has since resolved, and he feels well. He has no significant past medical history and does not take any medications. He has no constitutional symptoms and a physical examination today is within normal limits. He has a 10-pack-year cigarette smoking history and quit 15 years ago. If a lesion is noted on the chest radiograph, which one of the following characteristics would be most suspicious for malignancy? (check one) A diameter of 5 mm Concentric calcifications Doubling in size in less than 1 month A nonsolid “ground glass” appearance Smooth borders

Answer 1

Characteristics that are more commonly associated with malignant lesions include a nonsolid “ground glass” appearance, a size >6 mm, noncalcified lesions, a lesion size or volume doubling time between 1 month and 1 year, and 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 2

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

Answer 3

D. Isoniazid for 9 months For children age 2–11 years, treatment with isoniazid, 10–20 mg/kg daily or 20–40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment regimen. The shorter 6-month treatment course is considered an acceptable option for adults, but it is not recommended for children. The use of rifampin alone or in combination with isoniazid is also an acceptable option for adults but not for children under the age of 12. > 5 mm for exposed > 10 for risk factors > 15 mm for no risks

Answer 4

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

Answer 5

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

Answer 6

ANSWER: B This patient has subclinical hyperthyroidism as evidenced by her low TSH level with normal free T4 and free T3 levels. Common causes of subclinical hyperthyroidism include Graves disease, autonomous functioning thyroid adenoma, and multinodular toxic goiter. Subclinical hyperthyroidism may progress to overt hyperthyroidism; this is more likely in patients with TSH levels <0.1 U/mL. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including atrial fibrillation, heart failure, and osteoporosis. For this reason it is important to assess for these conditions and consider treating the underlying thyroid condition, as well as the complication. The American Thyroid Association recommends treating patients with complications who are either over age 65 or have a TSH level <0.1 U/mL. Lipid and glucose abnormalities are not known to be related to subclinical hyperthyroidism. Calcium levels may be abnormal in hyperparathyroidism but not hyperthyroidism. Thyroid ultrasonography may be helpful to determine the cause of hyperthyroidism but is not used to help decide when to treat subclinical hyperthyroidism.

Answer 7

ANSWER: C Pediatric asthma is the most commonly encountered chronic illness, occurring in nearly one out of seven individuals. Short-acting -agonists in the form of metered-dose inhalers are clearly favored for acute exacerbations, as well as for intermittent asthma. Treatment for persistent asthma requires the use of inhaled corticosteroids, with short-acting -agonists used for exacerbations. For patients not well controlled with those options, either a long-acting -agonist or a leukotriene receptor antagonist may be added. While both cromolyn and nedocromil are fairly devoid of adverse effects, their use is limited because of a lack of efficacy in the prevention of acute asthma exacerbations.

Answer 8

Corynebacterium minutissimum infection, and use of an ultraviolet light would reveal a coral pink color. Pale blue fluorescence occurs with Pseudomonas infections, yellow with tinea infections, and totally white with vitiligo. A lime green fluorescence is not characteristic of a particular skin condition.

Answer 9

> 180 or > 110

Answer 10

NSWER: B Since many patients with diabetes mellitus are obese, the impact of medications on the patient’s weight is important to consider. Treatment with sulfonylureas, including glimepiride, is associated with weight gain. Empagliflozin, liraglutide, metformin, and sitagliptin are not associated with weight gain. In particular, the SGLT2 inhibitors such as empagliflozin and the GLP1 agonists such as liraglutide are associated with clinically significant weight loss.

Answer 11

ANSWER: E This patient has sarcoidosis that has been confirmed by a biopsy. He is symptomatic so treatment would be indicated. The recommended initial treatment for sarcoidosis is oral corticosteroids. Anti-infective agents are not appropriate treatment for sarcoidosis. Immunosuppressants are second- and third-line therapy for sarcoidosis and would not be recommended as first-line treatment.

Answer 12

ANSWER: D Enoxaparin is the most appropriate pharmacologic therapy for anticoagulation in patients who are pregnant. Aspirin is not used as treatment for deep vein thrombosis. Apixaban, warfarin, and heparin either have not been studied for use in pregnancy or there is data indicating potential fetal harm.

Answer 13

ANSWER: A Enoxaparin and other low molecular weight heparins are effective and are the preferred agents for acute and long-term anticoagulation in patients with an active malignancy (SOR B). Warfarin has been shown to be less effective in cancer patients and is not recommended to treat venous thromboembolic disease in this setting (SOR B). The novel oral anticoagulants including rivaroxaban have not been studied in the setting of malignancy and are not recommended.

Answer 14

ANSWER: B In a double-blind randomized trial, letrozole was associated with greater live-birth and ovulation rates compared to clomiphene (SOR A). A Cochrane review indicated that metformin does not increase fertility in patients diagnosed with polycystic ovary syndrome (PCOS). Spironolactone and finasteride are both used to treat PCOS in women who do not desire pregnancy.

Answer 15

D. Humoral hypercalcemia of malignancy

Answer 16

Amitryptyline

Answer 17

clindamycin

Answer 18

HIstamine H2 blockers (famotidine) PPI

Answer 19

azithromycin within 21 days of exposure

Answer 20

Dilation 0 closed 1 1-2 cm 2 3-4 cm 3 >= 5 cm Effacement 0 0-30% 1 40-50% 2 60-70% 3 >=80% Fetal station 0 -3 1 -2 2 -1,0 3 +1, +2 >5 = successful vaginal delivery

Answer 21

underweight 28-40 lb normal weight 25-35 over weight 15-25 obese 11-20

Answer 22

Aducanumab (aduhelm)

Answer 23

cardiovascualr disease cerbrovascular disease uncontrolled htn

Answer 24

change in blood pressure of 20 mm Hg or more systolic of 10 mm Hg or more diastolic

Answer 25

confusion for up to 24 hours due to impairment of venous drainage from hippocampus

Answer 26

ANSWER: A Clonidine (0.1–0.3 mg every 6–8 hours) is a useful adjunct to buprenorphine in the treatment of opioid use disorder to help increase the rates of abstinence and decrease stress-related opioid cravings (SOR C). Naloxone is an opioid antagonist used to treat overdoses. Nifedipine is a common antihypertensive like clonidine but it has no role in the treatment of opioid use disorder. Methadone and naltrexone are used to treat opioid use disorder but neither of these agents would be used simultaneously with buprenorphine.

Answer 27

ANSWER: D Early recognition and effective treatment of acute Bell’s palsy (idiopathic facial paralysis) has been shown to decrease the risk of chronic partial paralysis and pain. Corticosteroids have been shown in a meta-analysis to decrease chronic symptoms, but a Cochrane meta-analysis of 10 studies concluded that antiviral medication along with corticosteroids is significantly more effective than corticosteroids alone. The medications are most effective if started within 72 hours of symptom onset. The same analysis showed that antiviral medications alone were less effective than corticosteroids alone. This patient’s presentation is not consistent with stroke or another emergency. Because supranuclear input to the facial nerves comes from both cerebral hemispheres, strokes and other central pathologies affecting the facial nerves typically spare the forehead, which is not the case in this patient.

Answer 28

ANSWER: E In a patient presenting with obesity, hypertension, type 2 diabetes mellitus, and hirsutism, who also has thin skin and osteopenia, an elevated 24-hour collection showing high urinary free cortisol confirms the presence of Cushing syndrome. The dexamethasone suppression test, though still commonly used, no longer has a place in the diagnosis and treatment of patients with Cushing syndrome. Corticotropin-dependent and corticotropin-independent causes of Cushing syndrome can be separated by measuring plasma corticotropin. Plasma free cortisol measurements should be obtained only to determine the success or failure of transsphenoidal microadenomectomy or adrenalectomy. Inferior petrosal sinus sampling is used to confirm the source of corticotropin secretion before surgical intervention.

Answer 29

ANSWER: A This patient has a pituitary microadenoma. Microadenomas <10 mm in size that are secreting prolactin may be treated with a dopaminergic agent such as bromocriptine. This will lower the prolactin level and shrink the adenoma. Nonprolactin-secreting adenomas, especially those >10 mm in size (macroadenomas), require neurosurgical evaluation. >10 mm go to surgery!!

Answer 30

ANSWER: C This patient has clinically diagnosable acute bacterial prostatitis, and no further testing, including imaging, is required to establish the diagnosis. Culture of a midstream voided urine may aid in identifying the pathogen, but prostate massage should be avoided because it may increase the risk of bacteremia. A prostate biopsy is not indicated in the presence of acute infection, and a prostate-specific antigen level is not indicated because it is likely to be elevated in the presence of infection.

Answer 31

ANSWER: D Insulin therapy should be initiated in hospitalized patients with persistent hyperglycemia, starting at a threshold of 180 mg/dL. Once insulin therapy is started, a target glucose range of 140–180 mg/dL is recommended for the majority of hospitalized patients, regardless of whether they have a critical illness.

Answer 32

ANSWER: C Overt hyperthyroidism during pregnancy is associated with adverse effects to the mother and fetus, so treatment is required. Since methimazole is associated with birth defects when used in the first trimester, propylthiouracil is preferred. Methimazole should be considered after the first trimester because the risk of congenital anomalies is less than the risk of liver failure associated with propylthiouracil. Surgery and radioactive iodine should only be used if there is a clear indication, and radioactive iodine would not be appropriate during pregnancy.

Answer 33

ANSWER: B This patient has COPD and is in a risk category of A (low risk, fewer symptoms) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) combined assessment of COPD. As a result, either a short-acting anticholinergic or a short-acting 2-agonist should be selected as the initial pharmacologic management. Long-acting 2-agonists or long-acting anticholinergics are indicated for patients with a GOLD combined assessment category of B or worse. Long-acting inhaled corticosteroids are indicated for patients with a GOLD combined assessment category of C or worse. Due to its narrow therapeutic window, modest benefit, and need for monitoring, theophylline is not recommended as an initial agent and should be considered as an alternative only for patients with severe refractory symptoms.

Answer 34

ANSWER: D In a pediatric patient, blood pressure should be evaluated using comparisons based on age, sex, and height. Although this adolescent’s blood pressure is prehypertensive for an adult according to JNC 8 guidelines, it is stage 1 hypertension (between 95% and 99%) for her age, sex, and height. All pediatric patients with confirmed hypertension should have further evaluation to check for renal dysfunction as well as other cardiac risk factors. Additionally, renal ultrasonography is recommended to evaluate for renal disease and echocardiography to evaluate for end-organ damage that would affect treatment goals. Additional studies, such as plasma renin and catecholamine levels or renovascular imaging, may be indicated in children with abnormalities on initial evaluation that suggest secondary causes of hypertension. Pharmacologic therapy is usually recommended for pediatric patients with symptomatic hypertension, secondary hypertension, target organ damage, diabetes mellitus, or persistent hypertension in spite of nonpharmacologic treatment. A low-sodium diet may be helpful for decreasing blood pressure, and given this patient’s obesity, intensive counseling about lifestyle changes is appropriate.

Answer 35

ANSWER: D In men who are diagnosed with hypogonadism with symptoms of testosterone deficiency and unequivocally and consistently low serum testosterone concentrations, further evaluation with FSH and LH levels is advised as the initial workup to distinguish between primary and secondary hypogonadism. If secondary hypogonadism is indicated by low or inappropriately normal FSH and LH levels, prolactin and serum iron levels and measurement of total iron binding capacity are recommended to determine secondary causes of hypogonadism, with possible further evaluation to include other pituitary hormone levels and MRI of the pituitary. If primary hypogonadism is found, karyotyping may be indicated for Klinefelter’s syndrome.

Answer 36

ANSWER: B This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8 weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient presents with severe thyroid pain and systemic symptoms.

Answer 37

Mobitz type 1 cardiac monitoring - prolonging P Mobitz type 2 need pace maker - Same p wave

Answer 38

azithromycin

Answer 39

pityrasis rosea

Answer 40

myalgia, fatigue, loss of appetite, fever, and headache orchitiis

Answer 41

ANSWER: D Henoch-Schönlein purpura 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 arthralgias and arthritis, abdominal pain, and 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 presents with the classic triad of hemolytic anemia, thrombocytopenia, and kidney injury. Thrombotic thrombocytopenic purpura is rare in the pediatric age group.

Answer 42

ANSWER: A 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. The 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 43

ANSWER: A 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 44

ANSWER: C 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 -lactam antibiotic. Doxycycline could also be used in place of the macrolide.

Answer 45

ANSWER: C 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 46

ANSWER: B 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 47

anemia associated with lead toxicity

Answer 48

hemolytic anemia.

Answer 49

ANSWER: D 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 50

ANSWER: A 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 51

ANSWER: D 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 52

ANSWER: A 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 53

ANSWER: E 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 long-acting -agonists (LABAs) or 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.

Answer 54

ANSWER: B 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 55

For cushings

Answer 56

Lungs and liver

Answer 57

Lungs and kidneys

Answer 58

amphetamines

Answer 59

Levofloxacin

Answer 60

Sertraline

Answer 61

ANSWER: D This patient has a classic presentation for Lyme disease. Lyme disease is transmitted by a tick bite, but not all patients remember being bitten by a tick. The classic erythema migrans lesion appears a couple of weeks after the tick bite. The first-line treatment for Lyme disease is either amoxicillin or doxycycline. Macrolides can be used if patients have true allergies to -lactams and doxycycline, but they are less effective. This patient is not exhibiting the respiratory symptoms typically associated with adenovirus. Ehrlichiosis and Rocky Mountain spotted fever typically present with headaches and fevers but not with an erythema migrans rash. Although influenza should be considered in the differential diagnosis, it would not present with an erythema migrans rash.

Answer 62

Calcium gluconate

Answer 63

1) > 55 2) Isolated tenderness of patella 3) Tenderness at head of fibula 4) Inability to flex to 90 5) Inability to bear weight 4 steps

Answer 64

present in the desert regions of the U.S. southwest muscle and joint pain,

Answer 65

Mississippi and Ohio River valleys of the Midwest and the South. Muscle and joint pain

Answer 66

ANSWER: C The ACCOMPLISH trial demonstrated that an ACE inhibitor (ACEI) in combination with a calcium channel blocker (CCB) reduced both fatal and nonfatal cardiovascular events in patients with diabetes mellitus and hypertension. The benefit of an ACEI and a CCB for reducing cardiovascular events was greater than that of an ACEI and a thiazide diuretic. Evidence has shown that combination therapy for most patients should include a CCB, an ACEI or angiotensin receptor blocker (ARB), or a thiazide diuretic (SOR A). The American College of Cardiology/American Heart Association guidelines recommend against centrally acting medications such as -blockers for first-line therapy. Combining ACEIs and ARBs is not recommended, as the risk of side effects such as hyperkalemia outweighs the benefits. Loop diuretics are not considered first-line antihypertensive agents.

Answer 67

ANSWER: D Frostbite is a freezing injury that occurs when initial cooling causes vasoconstriction and localized ischemia. Continued cold exposure leads to ice crystal formation, which causes cellular lysis, electrolyte abnormalities, and microvascular occlusion. Rewarming creates an inflammatory response. Ibuprofen is the most appropriate agent for the treatment of frostbite until the wounds heal or surgery is performed (SOR C). Acetazolamide can cause frostbite at high altitudes. Amitriptyline is used to treat the pain of immersion foot (also called trench foot), which is a nonfreezing injury that happens when the foot is exposed to prolonged wet conditions above 0°C (32°F). Antibiotics are indicated if open or dirty wounds are present (SOR B). tPA has a role in treating patients with frostbite, but it is used only to decrease the risk of amputation when rewarming patients with grade 3, grade 4, or deep frostbite (SOR B).

Answer 68

Graves disease

Answer 69

positive anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody

Answer 70

Thiazides (chlorthalidone)

Answer 71

canker sores

Answer 72

500 mg IM (< 150 kg)

Answer 73

Fecal calprotectin in children rules out UC

Answer 74

Acute onset jaundice

Answer 75

Acamprosate and baclofen

Answer 76

Lifelong phlebotomy with goal to keep ferritin level around 50 ng per mL

Answer 77

Cilostazol Improved initial and absolute walking distances

Answer 78

Benign migratory glossitis associated with psoriasis

Answer 79

VTE include PE and DVT 3 months, then start aspirin Unprovoked VTE should continue anticoagulation indefinitely

Answer 80

Postpartum prophylaxis for 6 weeks

Answer 81

Doxycycline 100 mg 2x daily for 7 days

Answer 82

Antidepressant use and early indicator of Parkinson disease, Lewy body dementia and multiple system atrophy

Answer 83

Dopamine antagonists (metoclopramide (Reglan), prochlorperazine (Compazine), droperidol (Inapsine), and promethazine (Phenergan)) Antipsychotics Serotonergic antidepressants (SSRI)

Answer 84

Salmonella or Campylobacter infection

Answer 85

Corticosteroids

Answer 86

Maddrey Discriminant function tool (at least 32) Model for end stage liver disease (> 21)

Answer 87

Triamcinolone acetonide 0.1% cream

Answer 88

for at least 2 months

Answer 89

Radon exposure

Answer 90

Immunotherapy PD-L1 (programmed death ligand 1)

Answer 91

etoposide (etopopphos) plus cisplatin chemotherapy

Answer 92

2 unprovoked seizures occurring at least 24 hours apart

Answer 93

Wellbutrin Benadryl (diphenhydramine) Tramadol

Answer 94

emtricitabine and tenofovir alafenamide

Answer 95

Cefixime 800 mg

Answer 96

Diffuse large B cell lymphoma

Answer 97

Bullous pemphigoid

Answer 98

Kaposi sarcoma

Answer 99

Central slip injury, FOced flexion of extended finger at PIP joint

Answer 100

Jersey finger

Answer 101

Forced extension of partially flexed finger, inability to flex finger

Answer 102

Sudden blow to tip of extended finger, drooping or flexed posture at the DIP joint

Answer 103

biannual 50-75

Answer 104

Interstital lung disease

Answer 105

hydroxyurea

Answer 106

Low Complement levels

Answer 107

Autoimmune hepatitis

Answer 108

Systemic sclerosis

Answer 109

Psoratric arthritis

Answer 110

Procalcitonin

Answer 111

Addison's disease or adrenal insufficency Patches are vitiligo Get ACTH suppresion test (low morning cortisol)

Answer 112

Congenital adrenal hyperplasia

Answer 113

Initial test for cushing syndrome Dexamethasone confirms disorder

Answer 114

Trimethoprim/sulfame (Bactrim)

Answer 115

Corynebacteria Red brown amcules Erythromycin gel

Answer 116

Minoxidil 5% foam indefinitely

Answer 117

Gabapentin

Answer 118

Opioids SSRi

Answer 119

Decreased kidney function Skeletal disease Hypercalcemia

Answer 120

Oral trimethoprim/sulfamethoxazole (Bactrim)

Answer 121

Fasting glucose >= 126 2 hour >= 200 Random glucose >= 200

Answer 122

Hyperphosphatemia Hyperkalemia Hyperuricemia Calcium decreased due to binding with free phosphosus

Answer 123

Weakness of wrist extension

Answer 124

Median nerve

Answer 125

Musculocutanoeus nerve

Answer 126

ANSWER: C A hypertensive urgency is defined as a confirmed blood pressure >180/110–120 mm Hg without symptoms or signs of end-organ damage. Patients without symptoms in the setting of severe hypertension rarely have end-organ damage. The most common cause of hypertensive urgency in patients with known hypertension is nonadherence to the use of antihypertensive medications. When a significantly elevated blood pressure is measured, it should be repeated after 20–30 minutes of quiet rest. Blood pressures should be taken in both arms and a thigh to confirm elevation. One-third of patients with an initially elevated blood pressure will have significantly lower pressure after rest. Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral antihypertensives with close follow-up (SOR C). There is no standard workup for patients with hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis, EKG, and troponin to rule out end-organ damage. Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine is not recommended due to unpredictable blood pressure responses. Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.

Answer 127

ANSWER: A Carotid artery disease affects extracranial carotid arteries and is caused by atherosclerosis. This patient is asymptomatic and has no history of an ischemic stroke, neurologic symptoms referable to the carotid arteries such as amaurosis fugax, or TIA. He has risk factors for cardiovascular disease (age, male sex, hyperlipidemia), but the U.S. Preventive Services Task Force recommends against specific screening for asymptomatic carotid artery stenosis (D recommendation), which has a low prevalence in the general adult population. Stroke is a leading cause of disability and death in the United States, but asymptomatic carotid artery stenosis causes a relatively small proportion of strokes. Auscultation of the carotid arteries for bruits has been found to have poor accuracy for detecting carotid stenosis and is not a reasonable screening approach. Appropriate modalities for detecting carotid stenosis include carotid duplex ultrasonography, magnetic resonance angiography, and computed tomography, but these are not recommended for screening asymptomatic patients.

Answer 128

ANSWER: E Counseling by a diabetic educator or team of educators for medical nutrition therapy lowers hemoglobin A1c by 0.2–0.8 percentage points in patients with type 2 diabetes. While a healthy diabetic diet and regular exercise are important, simply reminding the patient of that fact is not likely to be as successful as comprehensive diabetic education. According to the Society of General Internal Medicine in the Choosing Wisely campaign, patients with type 2 diabetes who are not on insulin therapy should not check their blood glucose level daily. An additional medication will likely decrease the hemoglobin A1c, but this patient has expressed a desire to avoid additional medication, is near goal, and is not currently managing her diabetes with adequate lifestyle changes, so it would be appropriate to respect her wishes and pursue proven interventions that do not require medication.

Answer 129

ANSWER: D Impetigo may be caused by Streptococcus pyogenes or Staphylococcus aureus, but bullous impetigo is caused exclusively by S. aureus. Oral trimethoprim/sulfamethoxazole is an appropriate treatment for skin infections caused by S. aureus, including susceptible cases of methicillin-resistant S. aureus (MRSA). Topical mupirocin ointment is not practical in very widespread cases or in cases with large bullae. Neither azithromycin nor penicillin is a preferred treatment for impetigo, due to a high rate of treatment failure. Tetracycline should be avoided in children under 8 years of age due to a propensity to cause permanent staining of the teeth.

Answer 130

ANSWER: A Tumor lysis syndrome is a common complication of chemotherapy in hematologic malignancies, such as acute leukemia. Homeostasis is overwhelmed with phosphorus, potassium, calcium, and uric acid released into the bloodstream due to acute cell lysis. Hyperphosphatemia, hyperkalemia, and hyperuricemia are indicative of tumor lysis syndrome. Calcium levels are decreased due to binding with free phosphorus and a depletion of calcium in the bloodstream. Sodium electrolyte levels are not as likely to be affected.

Answer 131

ANSWER: A Hereditary hemochromatosis is a common inherited disorder of iron metabolism. Iron deposits in the liver may lead to chronic liver disease and hepatocellular cancer. Screening for hereditary hemochromatosis includes serum ferritin levels, a family history, and genetic testing. Chronic renal disease, encephalopathy, myelofibrosis, and Wilson disease (disorder of copper transport) do not result from iron overload.

Answer 132

ANSWER: D Upper respiratory tract infections are the most common acute illness in the United States. Symptoms are self-limited and can include nasal congestion, rhinorrhea, sore throat, cough, general malaise, and a low-grade fever. According to a Cochrane review of 10 trials without a meta-analysis, antitussives and expectorants are no more effective than placebo for cough. Intranasal ipratropium is the only medication that improves persistent cough related to upper respiratory infection in adults. Intranasal antibiotics, antihistamines, corticosteroids, and saline would not improve this patient’s cough.

Answer 133

ANSWER: D Celiac disease is a chronic malabsorptive disorder with an estimated worldwide prevalence of 1.4%. The preferred initial diagnostic test includes a serum IgA transglutaminase-2 (TG2) antibody level, which has a 98% sensitivity and 98% specificity for the diagnosis of celiac disease. False-negative serologic results may occur in patients with an IgA deficiency, which includes up to 3% of patients with celiac disease. Therefore, when a diagnosis of celiac disease is strongly suspected despite a negative IgA TG2 antibody test, a total IgA level should be obtained. Diagnostic confirmation for patients with positive serologic testing is accomplished with endoscopic mucosal biopsy. Dietary elimination of gluten, not an increase in gluten intake, prior to serologic testing may lead to false-negative results. Recent use of medications, including loperamide, would not be expected to interfere with the accuracy of serologic testing for celiac disease. Dermatitis herpetiformis is a widespread pruritic papulovesicular rash that occurs in less than 10% of patients with celiac disease, although is essentially pathognomonic for the condition, as nearly all patients with this rash have evidence of celiac disease on an intestinal biopsy. Iron deficiency anemia often occurs in patients with celiac disease due to poor iron absorption, although the presence of iron deficiency anemia does not decrease the sensitivity of serologic testing.

Answer 134

ANSWER: C Tuft fractures are the most common type of distal phalanx fracture. They rarely require orthopedic referral but often result in up to 6 months of hyperesthesia, pain, and numbness. Treatment involves splinting the affected digit for 2–4 weeks, followed by range of motion and strengthening exercises. Symptomatic treatment may also be involved, but splinting is needed. Taping digits would likely not provide enough stability for the second digit distal phalanx, which extends beyond the first digit. Patients with distal finger injuries need careful physical examination to evaluate for a nail bed injury, but in this case there is no evidence of nail bed damage or laceration.

Answer 135

ANSWER: A Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4 level. It is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST (Thyroid Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of randomized, controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle strength, fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A), and up to 60% of cases resolve within 5 years without intervention in older adults. Appropriate management of an elevated TSH level includes repeat testing in 1–3 months along with a free T4 level. If SCH is diagnosed, levels should be monitored yearly. Only 2%–4% of patients with SCH develop overt hypothyroidism.

Answer 136

ANSWER: C Lumbar spinal stenosis is a common cause of low back pain in older adults, with varying reports of prevalence but at least 10% in most studies. It is the most common reason for lumbar spinal surgery in the United States. Management of this condition is delayed due to the lack of strong evidence for definitively efficacious nonsurgical approaches, and by high rates of major complications with surgical approaches. Focused physical therapy has the best evidence for initial management. Given this patient’s cardiac and renal comorbidities, chronic use of oral NSAIDs is likely to cause significant harm. While some oral pain medications may be considered, pregabalin has not been found to be any more effective than placebo. Both orthopedic and neurosurgical subspecialists perform lumbar spinal surgeries across the United States. In this case, there is no indication for urgent or emergent surgical management. Given the high complication rate, elective surgical management should be considered only after more conservative options have been found ineffective.

Answer 137

ANSWER: C Sleeve gastrectomy is currently the most common bariatric procedure. The most common complication is development of GERD, which occurs in 20% of patients. Since this procedure does not produce a malabsorption component, complications such as cholelithiasis, dumping syndrome, and small bowel obstruction are not as likely as with other available procedures. A postoperative leak develops in <2% of cases. A sleeve gastrectomy involves removing the majority of the greater curvature of the stomach, which creates a tubular stomach. Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch both combine volume restriction and nutrient malabsorption.

Answer 138

ANSWER: E E-cigarette use has become quite popular among youth in the United States, with rates surpassing traditional cigarette use in 2014. Among teens who have never smoked, the odds of cigarette smoking are 3–6 times higher in those who have used e-cigarettes within the last year. Nicotine is highly addictive regardless of the source, and heavy metal toxicants are still present when using e-cigarettes, although less than with traditional cigarettes. E-cigarette use is associated with an increased risk of future marijuana use.

Answer 139

ANSWER: C A hypertensive urgency is defined as a confirmed blood pressure >180/110–120 mm Hg without symptoms or signs of end-organ damage. Patients without symptoms in the setting of severe hypertension rarely have end-organ damage. The most common cause of hypertensive urgency in patients with known hypertension is nonadherence to the use of antihypertensive medications. When a significantly elevated blood pressure is measured, it should be repeated after 20–30 minutes of quiet rest. Blood pressures should be taken in both arms and a thigh to confirm elevation. One-third of patients with an initially elevated blood pressure will have significantly lower pressure after rest. Patients who are asymptomatic with persistently elevated blood pressures can be safely treated with oral antihypertensives with close follow-up (SOR C). There is no standard workup for patients with hypertensive urgencies, but common practice includes obtaining a basic metabolic panel, CBC, urinalysis, EKG, and troponin to rule out end-organ damage. Oral medications to lower blood pressure in a patient with a hypertensive urgency are not indicated unless the patient is symptomatic. Symptoms such as headache or epistaxis warrant acute lowering of blood pressure. Preferred medications include clonidine, labetalol, and captopril, among others. Oral nifedipine is not recommended due to unpredictable blood pressure responses. Patients with physical or laboratory evidence of end-organ damage should be admitted to the intensive-care unit for intravenous treatment of blood pressure. Without symptoms of end-organ damage there is no need to transport patients to the emergency department, as hypertensive urgencies can be managed with outpatient care.

Answer 140

ANSWER: D This patient has seasonal affective disorder (SAD) that has recurred and is likely to continue to recur. Bupropion is the only medication beneficial for prevention of SAD. Light therapy and SSRIs are helpful for treating this disorder but do not prevent it. Exercise and cognitive-behavioral therapy are beneficial adjuncts to treatment but would not prevent recurrence.

Answer 141

ANSWER: E A history of an ischemic stroke within the past 3 months is an absolute contraindication to fibrinolytic therapy in patients with an ST-elevation myocardial infarction (STEMI), unless the stroke is diagnosed within 41⁄2 hours. Poorly controlled hypertension, dementia, peptic ulcer disease, and major surgery less than 3 weeks before the STEMI are relative contraindications that should be considered on an individual basis.

Answer 142

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

Answer 143

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

Answer 144

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

Answer 145

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

Answer 146

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

Answer 147

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

Answer 148

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

Answer 149

ANSWER: B This patient has subclinical hyperthyroidism as evidenced by her low TSH level with normal free T4 and free T3 levels. Common causes of subclinical hyperthyroidism include Graves disease, autonomous functioning thyroid adenoma, and multinodular toxic goiter. Subclinical hyperthyroidism may progress to overt hyperthyroidism; this is more likely in patients with TSH levels <0.1 U/mL. Even in the absence of overt hyperthyroidism these patients are at higher risk for several health conditions, including atrial fibrillation, heart failure, and osteoporosis. For this reason it is important to assess for these conditions and consider treating the underlying thyroid condition, as well as the complication. The American Thyroid Association recommends treating patients with complications who are either over age 65 or have a TSH level <0.1 U/mL. Lipid and glucose abnormalities are not known to be related to subclinical hyperthyroidism. Calcium levels may be abnormal in hyperparathyroidism but not hyperthyroidism. Thyroid ultrasonography may be helpful to determine the cause of hyperthyroidism but is not used to help decide when to treat subclinical hyperthyroidism.

Answer 150

ANSWER: B The only evidence-based treatment that confers significant benefits to children with autism is intensive behavioral interventions, which should be initiated before 3 years of age. Attention-deficit/hyperactivity disorder can be treated with cognitive-behavioral therapy (CBT) but medication is often required. CBT is as effective, if not more effective, than medication for treating anxiety, depression, and trauma-related disorders.

Answer 151

ANSWER: B Most orally administered immediate-release opioids such as morphine, oxycodone, and hydromorphone reach their peak effect at about 1 hour, at which time additional medication can be given if the patient is still in pain. Intravenous opioids reach their peak effect at about 10 minutes and intramuscular and subcutaneous opioids at about 20–30 minutes. Additional medication may therefore be given at those intervals if additional pain relief is required.

Answer 152

ANSWER: A The only proven therapy for pulmonary hypertension related to COPD is supplemental oxygen. Supplemental oxygen should be recommended when the PaO2 is <60 mm Hg, because it has been shown to improve mortality by lowering pulmonary arterial pressures. Treatments effective for pulmonary artery hypertension should not be used. Pulmonary vasodilators such as nifedipine, sildenafil, and bosentan may cause a ventilation-perfusion mismatch. Pulmonary endarterectomy may be indicated for pulmonary hypertension caused by chronic thromboembolic disease.

Answer 153

ANSWER: B Pain in the shoulder of a young athlete can be caused by many problems, including acromioclavicular strain, biceps tendinitis, glenohumeral instability, and rotator cuff pathology. Although rotator cuff pathologies are the most frequent cause of shoulder pain in adults, they are uncommon in children. Unique to children, however, is a repetitive use injury causing disruption at the proximal growth plate of the humerus. This condition is referred to as Little League shoulder and can be seen on plain radiographs as widening, demineralization, or sclerosis at the growth plate. If the radiograph is normal but suspicion for this condition is high, a bone scan or MRI can be ordered.

Answer 154

Yersinia pestis is an aerobic fermentative gram-negative rod. It causes a zoonotic infection with humans as the accidental host. The disease is spread by a bite from a flea vector, direct contact with infected tissue, or inhalation of infectious aerosols from a person with pulmonary plague. Plague occurs in two regions in the western United States. One region includes northern New Mexico, northern Arizona, and southern Colorado, and the other region includes California, southern Oregon, and far western Nevada. Escherichia coli is also an aerobic fermentative gram-negative rod but it generally causes symptoms of gastroenteritis, hemolytic-uremic syndrome, urinary tract infection, intra-abdominal infection, and meningitis. E. coli infection does not have a specific regional distribution. Listeria monocytogenes is a gram-positive rod and causes an influenza-like illness with or without gastroenteritis in adults. Infection occurs through ingestion of contaminated food products such as milk, cheese, processed meats, and raw vegetables. Outbreaks can occur in any geographic distribution. Coxiella burnetii is a gram-negative intracellular bacterium that causes Q fever. Human infections are associated with contact with infected cattle, sheep, goats, dogs, and cats. Brucella melitensis is a gram-negative coccobacilli that causes brucellosis. Humans are accidental hosts who can develop the disease from contact with tissues rich in erythritol, and from shedding of organisms in milk, urine, and birth products from goats and sheep.

Answer 155

ANSWER: E Because debilitating knee osteoarthritis is a frequent health concern in older adults, physicians should try to identify and possibly modify factors that increase the risk for this condition. Pooled data from many large studies has been sufficient to clearly identify several major risk factors for the development and progression of osteoarthritis of the knees. Overweight and obesity have consistently been found to approximately double the risk for developing knee osteoarthritis. Other factors that have been identified as risk factors include female sex, advancing age (50–75 years of age), and previous trauma. Smoking, inactivity, moderate physical activity, and socioeconomic status have not been shown to affect one’s risk for developing knee osteoarthritis. However, any of these factors in the extreme may be detrimental to joint health in general.

Answer 156

ANSWER: D A stress fracture in the proximal fifth metatarsal is particularly prone to nonunion and completion of the fracture. Because complete non–weight bearing or surgical intervention may be necessary with this high-risk fracture, MRI is indicated as the most sensitive test. Bone scans are sensitive but nonspecific. Most stress fractures of the metatarsals occur distally and can be managed with a hard shoe initially, with progressive activity as tolerated. NSAIDs are discouraged because of possible effects on fracture healing.

Answer 157

ANSWER: E Both typical and atypical antipsychotics increase the risk of mortality in patients with dementia. The FDA has a black box warning on these medications, including risperidone, about the increased risk of mortality in patients with dementia. Risperidone is not approved by the FDA for dementia-related psychosis. The typical antipsychotics are more commonly associated with extrapyramidal side effects. Diabetes mellitus and agranulocytosis are associated with the atypical antipsychotics, including risperidone. Periodic monitoring of serum glucose levels and CBCs is recommended.

Answer 158

ANSWER: B Since many patients with diabetes mellitus are obese, the impact of medications on the patient’s weight is important to consider. Treatment with sulfonylureas, including glimepiride, is associated with weight gain. Empagliflozin, liraglutide, metformin, and sitagliptin are not associated with weight gain. In particular, the SGLT2 inhibitors such as empagliflozin and the GLP1 agonists such as liraglutide are associated with clinically significant weight loss.

Answer 159

ANSWER: B Seborrheic dermatitis is commonly seen in the office setting and affects the scalp, eyebrows, nasolabial folds, and anterior chest. The affected skin appears as erythematous patches with white to yellow greasy scales. The etiology is not exactly known, but it is likely that the yeast Malassezia plays a role. Topical antifungals are effective and recommended as first-line agents. Topical low-potency corticosteroids are also effective alone or when used in combination with topical antifungals, but they should be used sparingly due to their adverse effects. The other agents listed have no role in the management of seborrheic dermatitis (SOR A).

Answer 160

ANSWER: A Mild asymptomatic elevations (<5 times the upper limit of normal) of ALT and AST are common in primary care. It is estimated that approximately 10% of the U.S. population has elevated transaminase levels. The most common causes of elevated transaminase levels are nonalcoholic fatty liver disease and alcoholic liver disease. The initial evaluation should include assessment for metabolic syndrome and insulin resistance. Waist circumference, blood pressure, a fasting lipid level, and a fasting glucose level or hemoglobin A1c should be obtained. A CBC with platelets and measurement of serum albumin, iron, total iron-binding capacity, and ferritin levels would also be indicated. Iron studies should be ordered to rule out hereditary hemochromatosis, which is an autosomal recessive disease that causes increased iron absorption in the intestines and release by tissue macrophages.

Answer 161

ANSWER: D Enoxaparin is the most appropriate pharmacologic therapy for anticoagulation in patients who are pregnant. Aspirin is not used as treatment for deep vein thrombosis. Apixaban, warfarin, and heparin either have not been studied for use in pregnancy or there is data indicating potential fetal harm.

Answer 162

ANSWER: D For patients with left ventricular systolic dysfunction, clinical trials have demonstrated that ACE inhibitors, -blockers, angiotensin receptor blockers, and aldosterone antagonists decrease hospitalizations and all-cause mortality. In African-American patients, all-cause mortality and hospitalizations have been reduced by hydralazine and isosorbide dinitrate.

Answer 163

ANSWER: E Perioperative management of chronic anticoagulation requires an assessment of the patient’s risk for thromboembolism and the risk of bleeding from the surgical procedure. High-risk patients include those with mechanical heart valves, a stroke or TIA within the past 3 months, venous thromboembolism within the past 3 months, or coronary stenting within the previous 12 months. High-risk patients require bridging therapy with low molecular weight heparin, while patients at low risk do not require bridging anticoagulation. For low-risk patients, it is recommended that warfarin be discontinued 5 days prior to surgery and restarted 12–24 hours postoperatively. This patient is at low risk for thromboembolism because her CHA2DS2-VASc score is 3. A patient with atrial fibrillation should receive bridging therapy with a CHA2DS2-VASc score 6. This patient’s surgery is associated with a high risk for bleeding, so it is preferable to stop her warfarin 5 days before the operation.

Answer 164

ANSWER: B In a double-blind randomized trial, letrozole was associated with greater live-birth and ovulation rates compared to clomiphene (SOR A). A Cochrane review indicated that metformin does not increase fertility in patients diagnosed with polycystic ovary syndrome (PCOS). Spironolactone and finasteride are both used to treat PCOS in women who do not desire pregnancy.

Answer 165

ANSWER: E This patient’s age, risk factors, red-flag symptoms, and other clinical findings indicate the need for endoscopy. The Leser-Trélat sign may be defined as the abrupt onset of multiple seborrheic keratoses, which is an unusual finding that often indicates an underlying malignancy, most commonly an adenocarcinoma of the stomach. CT is not an initial approach for diagnosing a suspected malignancy of the stomach or colon. Further skin evaluation and lifestyle changes, which are indicated, will not address the need for evaluation of weight loss and other abnormal symptoms and findings.

Answer 166

ANSWER: D Penile lesions are usually easily diagnosed from clinical findings. Pearly penile papules are common and benign, and present as small, skin-colored, dome-shaped papules in a circular pattern around the coronal sulcus. Lichen nitidus is benign but uncommon. It presents as discrete, pinhead-sized hypopigmented papules that are asymptomatic. Papules are often found scattered all over the penis, as well as on the abdomen and upper extremities. Lichen sclerosus is more common and appears as hypopigmented lesions with the texture of cellophane. The lesions are usually located on the glans or prepuce. Atrophy, erosions, and bullae are common, and patients often present with itching, pain, bleeding, and possibly phimosis or obstructed voiding. Lichen sclerosus is associated with squamous cell cancer in a small percentage of cases. Carcinoma in situ is a premalignant condition that is more common in uncircumcised males over age 60. Lesions are typically beefy red, raised, irregular plaques and can be found on the glans, meatus, frenulum, coronal sulcus, and prepuce. Lesions can be ulcerated or crusted. Pruritus and pain are common. A biopsy is important for making the diagnosis. Angiokeratomas are lesions that are usually asymptomatic, circumscribed, red or bluish papules. They may appear solely on the glans of the penis, but are also found on the scrotum, abdomen, thighs, groin, and extremities. They may be misdiagnosed as pearly papules or carcinoma. Treatment is not necessary unless the lesions are bleeding or extensive. It is important to realize that angiokeratomas on the shaft of the penis, the suprapubic region, or the sacral region can be associated with Fabry disease. Patients with this finding should be promptly referred.

Answer 167

ANSWER: E The Surviving Sepsis Campaign recommends that patients with elevated serum lactate or hypotension receive isotonic intravenous fluids such as normal saline or lactated Ringer’s solution at an initial rate of 30 mL/kg in the first 3 hours using small boluses of approximately 500 mL. A serum lactate value >36 g/dL (4 mmol/L) is correlated with increased severity of illness and poorer outcomes even if hypotension is not yet present. Patients who are hypotensive or whose serum lactate level is >36 g/dL require intravenous fluids or colloid to expand their circulating volume and effectively restore perfusion pressure. The administration of 30 mL/kg of fluid is recommended as a fluid challenge, which should be started as early as possible in the course of septic shock.

Answer 168

ANSWER: A Clonidine (0.1–0.3 mg every 6–8 hours) is a useful adjunct to buprenorphine in the treatment of opioid use disorder to help increase the rates of abstinence and decrease stress-related opioid cravings (SOR C). Naloxone is an opioid antagonist used to treat overdoses. Nifedipine is a common antihypertensive like clonidine but it has no role in the treatment of opioid use disorder. Methadone and naltrexone are used to treat opioid use disorder but neither of these agents would be used simultaneously with buprenorphine.

Answer 169

ANSWER: B Both 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) are recommended for patients with chronic renal failure. Indications for PPSV23 alone in immunocompetent persons younger than 65 include chronic lung disease, diabetes mellitus, chronic heart disease, smoking, and alcoholism.

Answer 170

ANSWER: D Early recognition and effective treatment of acute Bell’s palsy (idiopathic facial paralysis) has been shown to decrease the risk of chronic partial paralysis and pain. Corticosteroids have been shown in a meta-analysis to decrease chronic symptoms, but a Cochrane meta-analysis of 10 studies concluded that antiviral medication along with corticosteroids is significantly more effective than corticosteroids alone. The medications are most effective if started within 72 hours of symptom onset. The same analysis showed that antiviral medications alone were less effective than corticosteroids alone. This patient’s presentation is not consistent with stroke or another emergency. Because supranuclear input to the facial nerves comes from both cerebral hemispheres, strokes and other central pathologies affecting the facial nerves typically spare the forehead, which is not the case in this patient.

Answer 171

ANSWER: E In a patient presenting with obesity, hypertension, type 2 diabetes mellitus, and hirsutism, who also has thin skin and osteopenia, an elevated 24-hour collection showing high urinary free cortisol confirms the presence of Cushing syndrome. The dexamethasone suppression test, though still commonly used, no longer has a place in the diagnosis and treatment of patients with Cushing syndrome. Corticotropin-dependent and corticotropin-independent causes of Cushing syndrome can be separated by measuring plasma corticotropin. Plasma free cortisol measurements should be obtained only to determine the success or failure of transsphenoidal microadenomectomy or adrenalectomy. Inferior petrosal sinus sampling is used to confirm the source of corticotropin secretion before surgical intervention.

Answer 172

ANSWER: A Second degree Mobitz type I (Wenckebach) heart block is characterized by an intermittent blockade of electrical impulses from the atria to the ventricles at the level of the atrioventricular node. This prevents generation of a QRS complex. It is characterized by progressive prolongation of the PR interval until a P wave is not followed by a QRS complex. P waves come at regular intervals so PP intervals are normal. Following the missed QRS complex, the PR interval returns to its baseline duration. A pacemaker is not recommended in patients with second degree Mobitz type I heart block who are asymptomatic. It is recommended in symptomatic patients, however, and is guided by electrophysiologic studies.

Answer 173

ANSWER: B The Baby-Friendly Hospital Initiative is a global program established by UNICEF and WHO to promote healthy infant feeding and mother-baby bonding. The primary objective is to educate the public on the benefits of breastfeeding and encourage, promote, and facilitate breastfeeding as outlined in the UNICEF/WHO Ten Steps to Successful Breastfeeding chart. These steps promote breastfeeding to the public and provide guidelines for hospitals and birthing centers for the successful initiation and continuation of breastfeeding. Baby-friendly facilities must have a written breastfeeding policy that is routinely communicated to all health care staff, and all health care staff must be trained in the skills necessary to implement this policy. All pregnant women should be informed about the benefits and management of breastfeeding. Mothers should be helped to initiate breastfeeding within an hour after birth and shown how to breastfeed and to maintain lactation, even if they are separated from their infants. Breastfeeding infants should not be given food other than breast milk, unless medically indicated. If mothers choose to give formula after appropriate education, they should be instructed in proper preparation and use. Rooming in should be practiced, allowing mothers and infants to remain together 24 hours a day. Mothers should be encouraged to breastfeed on demand. Breastfeeding infants should not be given pacifiers or artificial nipples. Mothers should be referred to breastfeeding support groups on discharge from the hospital. In addition, the hospital must comply with the International Code of Marketing of Breast Milk Substitutes, which requires that formula companies cannot give free gifts to staff or mothers, that breast milk substitutes are not marketed in the maternity unit, and that breast milk supplements and infant feeding supplies are purchased at fair market price.

Answer 174

ANSWER: D The American Heart Association and the American College of Cardiology have decreased the number of indications for antibiotic prophylaxis prior to dental procedures. Currently antibiotics are indicated for prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease or a repaired congenital defect with a residual shunt, and a cardiac transplant with valve regurgitation due to a structurally abnormal valve. Amoxicillin, 2 g, is the antibiotic prophylaxis of choice.

Answer 175

ANSWER: E Amniotic fluid volume is regulated in part by fetal swallowing, inspiration, and urination. Some malformations of the urinary tract, including renal agenesis and persistent obstruction from posterior urethral valves, lead to oliguria or anuria, and are associated with marked oligohydramnios. Anencephaly, esophageal atresia, heart failure, and maternal -thalassemia are associated with polyhydramnios. Anencephaly is probably the most common cause of polyhydramnios, via transudation from the exposed meninges; swallowing difficulties and excessive urination may also be contributing factors. Esophageal atresia is almost always associated with polyhydramnios due to an inability to swallow. Intrauterine heart failure, whether due to dysrhythmias, structural defects, or severe anemia, often leads to fetal hydrops, which is associated with polyhydramnios. -Thalassemia, relatively common in Asians, can also cause fetal hydrops and polyhydramnios.

Answer 176

ANSWER: E Clindamycin or a combination of trimethoprim/sulfamethoxazole (or doxycycline or minocycline) plus cephalexin (or dicloxacillin or amoxicillin/clavulanate) should provide adequate coverage for Streptococcus and methicillin-resistant Staphylococcus aureus (MRSA) for mild to moderate cellulitis. Doxycycline plus trimethoprim/sulfamethoxazole would provide inadequate coverage for streptococcal bacteria. Cephalexin plus dicloxacillin would provide inadequate coverage for MRSA. The primary indication for ciprofloxacin is treatment of infections with gram-negative rods. Fosfomycin is indicated only for urinary tract infections. Neither is typically used in the treatment of cellulitis

Answer 177

ANSWER: B In many normally developing infants there may be imperfect coordination of eye movements and alignment during the early days and weeks of life, but proper coordination should be achieved by age 4–6 months. Persistent deviation of an eye in an infant requires evaluation.

Answer 178

ANSWER: C This patient has clinically diagnosable acute bacterial prostatitis, and no further testing, including imaging, is required to establish the diagnosis. Culture of a midstream voided urine may aid in identifying the pathogen, but prostate massage should be avoided because it may increase the risk of bacteremia. A prostate biopsy is not indicated in the presence of acute infection, and a prostate-specific antigen level is not indicated because it is likely to be elevated in the presence of infection.

Answer 179

ANSWER: D Insulin therapy should be initiated in hospitalized patients with persistent hyperglycemia, starting at a threshold of 180 mg/dL. Once insulin therapy is started, a target glucose range of 140–180 mg/dL is recommended for the majority of hospitalized patients, regardless of whether they have a critical illness.

Answer 180

ANSWER: D The most common cause of hypercalcemia is hyperparathyroidism. This is seldom symptomatic and is often discovered through routine blood testing. Hypercalcemia due to cancer can be caused by secretion of the parathyroid hormone–related protein and by osteoclastic bone resorption. Other causes of hypercalcemia include thiazide diuretics, lithium, vitamin D intoxication, hyperthyroidism, milk alkali syndrome from excessive calcium antacid ingestion, adrenal insufficiency, and lymphoma.

Answer 181

ANSWER: D The mainstay of therapy for acute respiratory syncytial virus bronchiolitis is supportive care, and maintaining hydration is important. Infants with respiratory rates >60/min may have poor feeding secondary to difficulty breathing and oral rehydration may increase the risk of aspiration. In these cases, nasogastric or intravenous fluids should be administered. Oxygen saturation of 90% or more on room air is sufficient for infants with bronchiolitis, and using supplemental oxygen to maintain higher oxygen saturations only prolongs hospitalization because of an assumed need for oxygen. Bronchodilators should not be administered to infants with bronchiolitis, because they have not been shown to have any effect on the need for hospitalization, oxygen saturation, or disease resolution. In addition, there is no evidence to support the use of epinephrine or corticosteroids in the inpatient setting.

Answer 182

ANSWER: C Although behavioral interventions are the mainstay of treatment for insomnia, they often need to be supplemented by pharmacologic therapy. When both doxepin and extended-release melatonin fail to provide benefit, a member of the Z-drug class should be tried next. Among the Z-drugs only eszopiclone provides an early peak onset and a long half-life, with a 1-hour approximate time to peak and a 6-hour half-life. While zaleplon has an equally short time to peak of 1 hour, it also has a 1 hour half-life. Antihistamines, including diphenhydramine and doxylamine, as well as atypical antipsychotics such as olanzapine, are not indicated unless used primarily to treat another condition.

Answer 183

ANSWER: C Overt hyperthyroidism during pregnancy is associated with adverse effects to the mother and fetus, so treatment is required. Since methimazole is associated with birth defects when used in the first trimester, propylthiouracil is preferred. Methimazole should be considered after the first trimester because the risk of congenital anomalies is less than the risk of liver failure associated with propylthiouracil. Surgery and radioactive iodine should only be used if there is a clear indication, and radioactive iodine would not be appropriate during pregnancy.

Answer 184

ANSWER: B This patient has COPD and is in a risk category of A (low risk, fewer symptoms) based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) combined assessment of COPD. As a result, either a short-acting anticholinergic or a short-acting 2-agonist should be selected as the initial pharmacologic management. Long-acting 2-agonists or long-acting anticholinergics are indicated for patients with a GOLD combined assessment category of B or worse. Long-acting inhaled corticosteroids are indicated for patients with a GOLD combined assessment category of C or worse. Due to its narrow therapeutic window, modest benefit, and need for monitoring, theophylline is not recommended as an initial agent and should be considered as an alternative only for patients with severe refractory symptoms.

Answer 185

ANSWER: B Using a procalcitonin-guided therapy algorithm reduces antibiotic use by 3.47 days without increasing either morbidity or mortality in adults with acute respiratory infections. If the procalcitonin level is <0.10 mg/dL, a bacterial infection is highly unlikely and it is strongly recommended that antibiotics not be prescribed. If the procalcitonin level is 0.10–0.24 mg/dL a bacterial infection is still unlikely and it is recommended that antibiotics not be used. If the level is 0.25–0.50 mg/dL a bacterial infection is likely and antibiotics are recommended. It is strongly recommended that antibiotics be given if the level is >0.50 mg/dL, because a bacterial infection is very likely.

Answer 186

ANSWER: D Penile enlargement in an 8-year-old male is a sign of precocious puberty. Isolated sparse pubic and axillary hair growth and axillary odor is referred to as premature adrenarche, and represents high levels of dehydroepiandrosterone rather than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty. The isolated findings of premature adrenarche are generally considered benign. An 8-year-old with breast buds and a 10-year-old with menarche are within the normal range of expected pubertal development. Penile enlargement typically represents full activation of the hypothalamic-pituitary-gonadal axis and warrants endocrinologic evaluation in boys younger than 9 years of age.

Answer 187

ANSWER: A The 2015 American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults 65 years of age states that donepezil use should be avoided in patients with syncope, due to an increased risk of bradycardia (Moderate Evidence Level; Strong Strength of Recommendation). Donepezil is a cholinesterase inhibitor. Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes. This can cause bradycardia or heart block in patients with or without underlying cardiac conduction abnormalities. Syncope has been reported with these medications. 83 Memantine is an N-methyl-D-aspartate receptor antagonist and is not associated with bradycardia. Escitalopram, lisinopril, and zolpidem are also not associated with bradycardia.

Answer 188

ANSWER: D In a pediatric patient, blood pressure should be evaluated using comparisons based on age, sex, and height. Although this adolescent’s blood pressure is prehypertensive for an adult according to JNC 8 guidelines, it is stage 1 hypertension (between 95% and 99%) for her age, sex, and height. All pediatric patients with confirmed hypertension should have further evaluation to check for renal dysfunction as well as other cardiac risk factors. Additionally, renal ultrasonography is recommended to evaluate for renal disease and echocardiography to evaluate for end-organ damage that would affect treatment goals. Additional studies, such as plasma renin and catecholamine levels or renovascular imaging, may be indicated in children with abnormalities on initial evaluation that suggest secondary causes of hypertension. Pharmacologic therapy is usually recommended for pediatric patients with symptomatic hypertension, secondary hypertension, target organ damage, diabetes mellitus, or persistent hypertension in spite of nonpharmacologic treatment. A low-sodium diet may be helpful for decreasing blood pressure, and given this patient’s obesity, intensive counseling about lifestyle changes is appropriate.

Answer 189

ANSWER: C The Lachman test is the most accurate test for an anterior cruciate ligament (ACL) tear (SOR A). Accurate testing can lead to appropriate referral and treatment for ACL tears, and early detection can lead to better outcomes. The Lachman test has higher validity based on a sensitivity of 68% for partial ruptures and 96% for complete ruptures. The other two commonly used tests are the anterior drawer test, which has a sensitivity of 38% and a specificity of 81%, and the pivot shift test, which is more technically difficult than the other two tests and has a sensitivity ranging from 24% to 85%. The pivot shift test is effective if done correctly but should not be used alone to diagnose an ACL tear (SOR A). 85 The lever sign test is a newer test that holds promise for detecting ACL tears and is easily performed in the office. However, sensitivity and specificity reports vary (SOR B). The McMurray test is used to detect meniscal tears.

Answer 190

ANSWER: C This patient most likely has peroneal tendinopathy, which is a degeneration of the peroneal tendon that involves pain or tenderness in the lateral calcaneus below the ankle along the path to the base of the fifth metatarsal. Initial treatment options include activity modification, decreasing pressure to the affected area, anti-inflammatory or analgesic medications, and eccentric exercises. Calcaneal apophysitis, or Sever's disease, is a common growth-related injury that typically affects adolescents between 8 and 12 years of age. Symptoms often present after a growth spurt or starting a new high-impact sport or activity, and common examination findings include tight heel cords and a positive calcaneal squeeze test. A calcaneal stress fracture, which most commonly occurs immediately inferior and posterior to the posterior facet of the subtalar joint, involves pain that intensifies with activity and often worsens to include pain at rest. It typically follows an increase in weight-bearing activity or a switch to running or walking on a hard surface. Plantar fasciitis is characterized by sharp, shooting pain in the arch and medial aspect of the foot that often is worse upon arising and taking the first few steps of the morning. Examination of the foot reveals tenderness at the site and pain with dorsiflexion of the toes. Tarsal tunnel syndrome involves entrapment of the posterior tibial nerve and causes a burning, tingling, or shooting pain and numbness that radiates into the plantar aspect of the foot, often into the toes. The pain associated with tarsal tunnel syndrome typically worsens with activity and is relieved with rest.

Answer 191

ANSWER: C Exenatide is a GLP-1 receptor agonist that is not associated with hypoglycemia and can also assist with weight loss, which would be helpful in this patient with obesity. All of the other listed medications, including both types of insulin, sulfonylureas, and meglitinides, can be associated with hypoglycemia. Since this patient’s hemoglobin A1c is only moderately elevated at 8.4%, exenatide is reasonable, although it can be an expensive option. If her hemoglobin A1c was severely elevated, insulin would be indicated, with close monitoring for hypoglycemia.

Answer 192

ANSWER: B Polypharmacy, which is defined as regular use of five or more medications, increases the risk of adverse medical outcomes. Patients who take five or more medications can find it difficult to understand and adhere to the complicated regimens. Risk factors for polypharmacy include having multiple medical conditions that are managed by multiple specialist or subspecialist physicians, residing in a long-term care facility, having poorly updated medical records, and using automated refill services. Inappropriate prescribing of drugs that are not discontinued after their usual effective or recommended period is known as legacy prescribing and can contribute to inappropriate polypharmacy. According to the Choosing Wisely campaign, any prescriptions beyond a threshold of five medications should trigger a thorough review of the patient’s complete regimen, including over-the-counter medications and dietary supplements, to determine if any of the medications can be discontinued. Tools such as the Beers criteria list and the Medication Appropriateness Index can be used to identify potentially inappropriate medication use, but no single tool or strategy has been determined to be superior. If discontinuation of particular high-risk medications is not possible because of medical conditions, then dose reductions should be considered.

Answer 193

ANSWER: B This patient has peripheral artery disease (PAD) of the right arm. PAD of the upper extremities is characterized by pain with exertion and can cause gangrene and ulceration. It is more common in patients who have had lower extremity occlusive disease. A blood pressure differential of 15 mm Hg between arms suggests stenosis and warrants further testing. Initial testing in symptomatic patients includes arterial duplex ultrasonography of the upper extremities. CT angiography and MR angiography may be appropriate to clarify the diagnosis or plan intervention. Neither radiography nor physical therapy would be appropriate.

Answer 194

ANSWER: A This patient has mild inflammatory acne as indicated by her combination of comedones and pustules. She does not have extensive skin involvement and should benefit from the use of a topical agent. Topical retinoids, including adapalene, tretinoin, tazarotene, and trifarotene, are appropriate for the treatment of mild to moderate acne as single agents, although they may be more effective when combined with a topical antibiotic or benzoyl peroxide. Topical antibiotics can lead to bacterial resistance and should not be used as monotherapy. Oral antibiotics are appropriate for the treatment of moderate to severe acne that has failed to respond to topical treatment. Oral isotretinoin is reserved for the treatment of severe nodular acne.

Answer 195

ANSWER: B Common variable immunodeficiency (CVID) is the only immunodeficiency condition listed that can present later in life, while severe combined immunodeficiency, DiGeorge syndrome, and Wiskott-Aldrich syndrome typically present prior to 6 months of age. CVID is a condition of impaired humoral immunity and thus should be considered in a patient this age in the setting of recurrent bacterial infections such as sinusitis or pneumonia. The blunted response to a vaccination challenge implies impaired IgG antibody response, which differentiates CVID from a selective IgA deficiency. Because severe combined immunodeficiency is associated with significant abnormalities of both T-cell and B-cell function, it presents very early in life with multiple severe, opportunistic infections, and failure to thrive. DiGeorge syndrome is associated with multiple other physical abnormalities such as cardiac malformations and dysmorphic facial features. Wiskott-Aldrich syndrome is linked to the X chromosome (primarily affecting males) and associated with eczema and thrombocytopenia.

Answer 196

ANSWER: B About half of pregnant women experience nausea and vomiting during pregnancy, which increases the risk of dehydration, poor weight gain, and impaired fetal growth. Pregnancy-related nausea and vomiting often begins by 4 weeks estimated gestation and typically resolves by the end of 12 weeks estimated gestation. When treating common causes of nausea and vomiting during pregnancy, lifestyle modifications such as frequent small meals and avoidance of high-protein or fatty foods are considered the safest intervention and first-line therapy. If these conservative measures are not effective, other well established low-risk therapies can be added in a stepwise fashion. These options include vitamin B6 (pyridoxine), over-the-counter antihistamines such as doxylamine, and natural ginger (<1500 mg daily). In addition, combination doxylamine/pyridoxine is approved by the FDA for the prevention of nausea and vomiting in pregnancy. Prescription antiemetics such as metoclopramide or trimethobenzamide are reserved for severe or refractory cases. Vitamin A, vitamin B12, vitamin C, and vitamin E are not appropriate for the treatment of pregnancy-related nausea and vomiting.

Answer 197

ANSWER: A The U.S. Preventive Services Task Force and the American Academy of Family Physicians concluded that evidence is insufficient for vitamin D testing and for vitamin D supplementation in asymptomatic adults. Vitamin D supplementation does not reduce the risk of cancer, depression, diabetes mellitus, or fractures.

Answer 198

ANSWER: E This patient has symptomatic New York Heart Association class II heart failure, and an escalation in therapy is warranted. Both -blockers and aldosterone antagonists have been shown to reduce mortality in patients with symptomatic heart failure (SOR A). Management of associated cardiovascular disease such as hyperlipidemia and hypertension is important to prevent disease progression, but of the medications listed (aspirin, atorvastatin, furosemide, hydrochlorothiazide, and spironolactone) spironolactone is the best choice to reduce heart failure–related mortality.

Answer 199

ANSWER: B Chronic kidney disease (CKD) is one of the most common chronic disease states encountered by family physicians, affecting 15% of the total U.S. adult population, and substantially impacting health care costs as well as morbidity and mortality. In the United States, diabetes mellitus and hypertension are the most common causes. CKD is defined by abnormal kidney structure or function lasting greater than 3 months, with associated implications for health. Diagnostic criteria include a persistent glomerular filtration rate <60 mL/min/1.73 m2, albuminuria, urine sediment abnormalities, renal imaging abnormalities, and serum acid-base or electrolyte abnormalities.

Answer 200

ANSWER: A Gastroparesis is a complication of diabetes mellitus, and presents with nausea, vomiting, early satiety, bloating, postprandial fullness, and/or upper abdominal pain. Gastric emptying scintigraphy with a solid meal is the first-line study for confirming the diagnosis. Hepatobiliary scintigraphy (HIDA) is used to evaluate biliary dyskinesia and is not indicated in this patient. An upper gastrointestinal radiographic series, abdominal ultrasonography, and CT of the abdomen can help to rule out obstructive pathology, biliary tract disease, and other gastrointestinal conditions but would not confirm the diagnosis. The patient should also undergo esophagogastroduodenoscopy to exclude obstruction.

Answer 201

ANSWER: A The U.S. Preventive Services Task Force (USPSTF) has found adequate evidence that questionnaires and other clinical prediction tools to identify asymptomatic children with elevated blood lead levels are inaccurate. The USPSTF went on to conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children 5 years of age and younger. Although children living in older housing with lead-based paint are at higher risk of elevated blood lead levels than those living in housing built after 1978, the USPSTF does not recommend routine screening in asymptomatic children based on this risk factor.

Answer 202

Diabetes adn hypothyroidism

Answer 203

ANSWER: E The 2020 American College of Rheumatology guideline for the management of gout generated numerous recommendations, including the management of concurrent medications in patients with gout. In such patients, losartan is the preferred antihypertensive agent when possible (SOR C). Hydrochlorothiazide should typically be changed to another agent, such as losartan, when feasible in patients with gout (SOR C). Both hydrochlorothiazide and losartan are known to have effects on the serum urate concentrations, with hydrochlorothiazide causing an increase and losartan causing a decrease. The American College of Rheumatology guideline does not recommend for or against the use of atenolol, hydralazine, and lisinopril as antihypertensive treatment in patients with gout.

Answer 204

ANSWER: C Family physicians are often required to manage dyspnea and evaluate common office spirometry results. The American Thoracic Society recommends full pulmonary function testing when office spirometry suggests a restrictive pattern, which is the case with this patient’s normal FEV1/FVC ratio and decreased FVC. Full laboratory pulmonary function testing gives further information about gas exchange and lung volumes, which allows a more definitive diagnosis.

Answer 205

ANSWER: E Immunoassay drug screenings can be performed at the point of care and are relatively inexpensive. Typical immunoassays can detect nonsynthetic opioids such as morphine and codeine, as well as illicit substances such as amphetamines, cannabinoids, cocaine, and phencyclidine. However, these immunoassays do not reliably detect synthetic or semisynthetic opioids such as oxycodone, oxymorphone, methadone, buprenorphine, and fentanyl, as well as many benzodiazepines. Confirmatory testing is needed in situations with an unexpected negative result in order to distinguish a false negative from a true negative.

Answer 206

ANSWER: B SARS-CoV-2 is a respiratory coronavirus that is responsible for COVID-19. Knowledge of the natural history of the viral infection will inform testing strategies and many other aspects of counseling of patients. The incubation period measures the time from exposure to symptom onset. The typical incubation period for COVID-19 is approximately 4–5 days, though it can range from 1–14 days.

Answer 207

ANSWER: D All patients between 40 and 75 years of age with diabetes mellitus and an LDL-cholesterol level 70 mg/dL should begin taking a moderate-intensity statin. It is not necessary to calculate a 10-year risk for atherosclerotic cardiovascular disease because the results do not alter the recommendation. This patient’s hemoglobin A1c is <7%, which is acceptable, and she does not need additional hypoglycemic medications. She has no diabetes-specific risk-enhancing conditions such as a long duration of illness, chronic kidney disease, retinopathy, neuropathy, or an ankle-brachial index <0.9. Older age and risk-enhancing conditions may require increasing the statin to high-intensity dosages. A DPP-4 inhibitor, an SGLT2 inhibitor, and a low-intensity statin would not be appropriate for this patient at this time.

Answer 208

ANSWER: B The U.S. Preventive Services Task Force (USPSTF) recommends prescribing low-dose aspirin after 12 weeks gestation for asymptomatic women at high risk for preeclampsia. Women at high risk include those with a history of preeclampsia, chronic hypertension, multiple pregnancy, type 1 or 2 diabetes, renal disease, autoimmune disease, or any combination of these. Many women become iron deficient in pregnancy but not all will require additional iron supplementation beyond what is available in the prenatal vitamin. The USPSTF found insufficient evidence to recommend for or against routine iron supplementation for pregnant women. Additional folic acid is recommended for women with increased risk for neural tube defects (NTDs), and while obesity increases the risk for NTD it is not an indication alone for a higher dosage of folic acid than the levels found in prenatal vitamins. In pregnant patients with chronic hypertension, treatment with antihypertensive medications is recommended only when the blood pressure is >150/100 mm Hg, because aggressive blood pressure lowering may result in placental hypoperfusion.

Answer 209

ANSWER: B For patients with mild asthma, recent evidence has shown that an inhaled corticosteroid (ICS)/long-acting -agonist (LABA), such as budesonide/formoterol, as needed was as effective at preventing exacerbations as a daily maintenance ICS plus a short-acting -agonist (SABA) at one-fifth of the total corticosteroid dose. In addition, it was more effective at preventing exacerbations than continued use of a SABA alone as needed. A daily maintenance ICS inhaler plus either a LABA or a leukotriene receptor antagonist are management strategies for persistent asthma.

Answer 210

ANSWER: C This patient presents with classic biliary symptoms and normal right upper quadrant ultrasonography, liver enzymes, and pancreatic enzymes. Abdominal ultrasonography was negative for gallstones. The next most appropriate test is hepatobiliary scintigraphy, also known as a hepatobiliary iminodiacetic acid (HIDA) scan. While a normal HIDA scan does not exclude a diagnosis of functional gallbladder disease (also referred to as acalculous cholecystitis, biliary dyskinesia, and biliary dysmotility), an abnormal study identifies patients for whom cholecystectomy is strongly recommended. Plain radiography of the abdomen and CT of the abdomen are helpful to evaluate for other etiologies of abdominal pain but are not the most appropriate next step for a patient with classic biliary symptoms and a normal laboratory workup. Magnetic resonance cholangiopancreatography (MRCP) is reserved for suspected choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive test also used for choledocholithiasis and in conjunction with sphincterotomy and stone extraction.

Answer 211

NSWER: C The American Academy of Pediatrics (AAP) recommends formal screening for maternal depression with the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire–2 (PHQ-2) at the 1-, 2-, 4-, and 6-month well child visits. The AAP recommends screening for autism at 18 months, but the U.S. Preventive Services Task Force (USPSTF) finds insufficient evidence to recommend screening unless there are parental concerns. The AAP recommends screening for iron deficiency at 12 months, but the USPSTF finds insufficient evidence for screening at this time. Otoacoustic emissions (OAE) testing is performed during the newborn screening and is not recommended at 6 months of age.

Answer 212

ANSWER: E This patient presents with a symptomatic fibroid. Although she does not express a desire to maintain fertility, she prefers uterine preservation. The Agency for Healthcare Research and Quality Effective Health Care Program review found consistent evidence that uterine artery embolization and occlusion is effective for reducing fibroid size, with lasting effects up to 5 years and moderate evidence for reducing bleeding and improving quality of life. Expectant management is an appropriate option only for patients who have asymptomatic fibroids. GnRH agonists are effective for providing symptom relief and reducing fibroid size, but their use results in a hypoestrogenized state and should not be continued long term for a sustained effect in premenopausal women. Treatment with a selective estrogen receptor modulator such as raloxifene does not affect fibroid size or bleeding patterns. There is limited data regarding the efficacy of a levonorgestrel-releasing IUD for the treatment of uterine fibroids.

Answer 213

ANSWER: A Although use of chronic indwelling urethral catheters should be avoided whenever possible, there are still some patients that will require one. Prevention of catheter-associated urinary tract infections (CAUTIs) is important. The most important measure to prevent CAUTIs is routine cleaning of the meatal surface with soap and water while bathing or showering. Use of specific periurethral antiseptics or instillation of antiseptics into the drainage bag does not reduce rates of CAUTI. Daily oral antibiotics are not indicated to prevent CAUTIs. Catheters and drainage bags should only be changed when clinically indicated, such as when there is an infection or obstruction.

Answer 214

ANSWER: C Decisions regarding the management of burn wounds depend on first identifying the depth of the burn. Superficial burns are red, painful, and blanching, and they do not blister. Superficial partial-thickness burns blister and blanch with pressure. Deep partial-thickness burns blister, but do not blanch with pressure. Full-thickness burns extend through the entire dermis and into the underlying tissues, and they are dry and leathery. Patients with deep partial-thickness or full-thickness burns should be evaluated by a burn specialist.

Answer 215

Red painful and blanching, do not blister

Answer 216

blister and blanch with pressure

Answer 217

blister but DO NOT blanch

Answer 218

Extend entire dermis into underlying tissue

Answer 219

ANSWER: C Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that is not acquired in a hospital, long-term care facility, or other health care setting, and it is a significant cause of morbidity and mortality in adults. This patient has CAP in the presence of a significant comorbidity (diabetes mellitus). After CAP is diagnosed the first decision to make is whether hospitalization is needed. In all patients with CAP, mortality and severity prediction scores should be used to determine inpatient versus outpatient care (SOR A). This patient has a CURB-65 score of 1 (age 65 years), so she can be treated as an outpatient. For outpatients with comorbidities, amoxicillin/clavulanate is a possible treatment option, but it should be paired with a macrolide. Macrolides such as azithromycin are the treatment of choice for previously healthy outpatients with no history of antibiotic use within the past 3 months. Azithromycin monotherapy, amoxicillin plus metronidazole, azithromycin plus levofloxacin, or clindamycin plus doxycycline would not be appropriate treatment strategies for this patient with a significant comorbidity.

Answer 220

ANSWER: C This patient has a compression fracture of the distal radius, also known as a buckle fracture. There is no cortical disruption and these are inherently stable fractures. Radiography or ultrasonography may be used as the initial imaging study if a buckle fracture is suspected. Treatment consists of short arm immobilization, which is most easily performed with a removable splint or wrist brace. The Choosing Wisely campaign states that these fractures do not require repeat imaging if there is no longer any tenderness or pain with palpation after 4 weeks of splinting, and the patient can return to full activity as tolerated. These fractures do not require referral to an orthopedist and can be managed in the office.

Answer 221

ANSWER: D Fibrates reduce the likelihood and recurrence of pancreatitis due to severe hypertriglyceridemia when triglyceride levels are 500 mg/dL, measured in a fasting or nonfasting state (SOR A). This patient’s risk of atherosclerotic cardiovascular disease is <7.5% and his LDL-cholesterol level is within normal range, so initiating a statin or ezetimibe is not indicated. Colesevelam may be used to reduce LDL-cholesterol and glucose levels but is not considered a first-line treatment. Omega-3-acid ethyl esters will reduce the triglyceride levels but this patient has severe hypertriglyceridemia, so fibrate therapy is recommended to prevent recurrent pancreatitis.

Answer 222

ANSWER: D The U.S. Preventive Services Task Force (USPSTF) recommends counseling interventions to prevent perinatal depression in patients who are at risk. This patient has risk factors for perinatal depression, including young age, single motherhood, and a history of depression. Other risk factors include low socioeconomic status and depressive symptoms. The USPSTF found that the benefits of counseling interventions outweigh the harms. The USPSTF could not find evidence that exercise, amitriptyline, or sertraline were beneficial.

Answer 223

ANSWER: B Antiretroviral therapy (ART) should be prescribed at the time of diagnosis of HIV infection unless the patient has expressed a desire to not initiate treatment. ART should not be delayed until the CD4 cell count drops to a predetermined level or until an AIDS-defining illness occurs. It is recommended to initiate prophylaxis for Pneumocystis pneumonia when the CD4 cell count drops below 200 cells/ L.

Answer 224

ANSWER: C This patient presents with typical symptoms of digitalis toxicity, which is common in elderly patients and may occur when the serum level is in the suggested therapeutic range. When drug toxicity is suspected the first step in management would be to discontinue or reduce the dosage of the suspected agent. In this case the addition of verapamil will increase the serum level of digoxin, which will reach a new steady-state level in several days. Therefore, the side effects may not occur for several days while the level is increasing. Because this patient has a good response to verapamil, it is not advisable to stop it, as the digitalis toxicity should be reversed by a dosage reduction. A therapeutic trial of an H2-blocker, an upper gastrointestinal contrast study, or imaging to look for a central nervous system abnormality would not be appropriate at this time.

Answer 225

ANSWER: A In 2020 the American College of Physicians and the American Academy of Family Physicians published a guideline regarding the treatment of acute pain from musculoskeletal injuries (non–low back related). This systematic review found good evidence to support the recommendation that topical NSAIDs be used as first-line therapy to reduce pain and improve physical function. Topical NSAIDs were the only intervention that improved multiple outcomes and were not associated with a statistically significant increase in the risk for adverse events. Oral NSAIDs and acetaminophen were recommended as second-line therapies, as they were found to be effective for pain relief but were associated with an increased risk for adverse events. Topical menthol gel was not found to be effective as monotherapy but may be considered when combined with a topical NSAID. The guideline specifically recommends avoidance of opioids, including tramadol, noting a prevalence of 6% for prolonged opioid use resulting from an initial prescription. Nonpharmacologic approaches with evidence of benefit include specific acupressure and use of a transcutaneous electrical nerve stimulation (TENS) unit.

Answer 226

ANSWER: C Using the Jones criteria for diagnosis, this patient has acute rheumatic fever, with two major criteria (carditis and polyarthritis) and two minor criteria (fever and positive erythrocyte sedimentation rate). NSAIDs such as naproxen can provide significant relief and should be administered as soon as acute rheumatic fever is diagnosed (SOR B). Hydroxychloroquine is not FDA approved for the treatment of acute rheumatic fever and would not be appropriate. Treatment with corticosteroids, intravenous immunoglobulins, and plasmapheresis is not considered appropriate for acute rheumatic fever but may be indicated for management of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

Answer 227

ANSWER: A Women experience subjective cognitive difficulties during their menopausal transition. This may include retrieving numbers or words, losing one’s train of thought, forgetting appointments, and forgetting the purpose of behavior such as entering a room. Clinical studies of these women showed intact cognitive test performance. The treatment consists of patient education and reassurance, since studies have shown that 62% of women report subjective cognitive problems during their menopausal transition. Imaging and referral to a neurologist are not indicated, and there are no trials that support the use of hormone therapy.

Answer 228

ANSWER: A Trigeminal neuralgia is a clinically diagnosed condition that is characterized by brief, sudden, unilateral pain in the distribution of one of the three branches of the trigeminal nerve. The pain, which is often triggered by minimal stimulus, is paroxysmal with episodes of remission that can last for months. First-line treatment for the condition is carbamazepine or oxcarbazepine (SOR C). Other suggested treatments include lamotrigine, baclofen, and surgical treatments, including microvascular decompression. There is a paucity of good evidence for treatments other than carbamazepine. Valacyclovir would be an appropriate treatment for herpes zoster, which can also cause unilateral electrical shock–like pain in the face. However, patients with herpes zoster typically would have developed the characteristic lesions by 10 days. In addition, the pain is rarely paroxysmal in nature with herpes zoster. Short-term corticosteroids are not recommended for trigeminal neuralgia and there is minimal evidence of their effectiveness for herpes zoster. Sumatriptan is an appropriate treatment for migraines that are also unilateral but are associated with photophobia, phonophobia, nausea, and persistent severe pain. High-flow oxygen is used to relieve cluster headaches that occur in the orbital, temporal, or supraorbital areas and persist for 15–180 minutes. Cluster headaches are accompanied by tearing and nasal discharge.

Answer 229

ANSWER: C COPD is currently the third leading cause of death in the United States and is commonly treated by primary care providers. In patients on monotherapy with a long-acting bronchodilator such as a long-acting muscarinic agonist (LAMA) or long-acting -agonist (LABA) who have continued dyspnea, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend escalating therapy to two bronchodilators. This patient has persistent dyspnea and is being treated with a single agent, a LAMA, so his regimen needs to be escalated to include a LABA such as salmeterol. Once the symptoms are stabilized, treatment can be de-escalated to a single agent. For patients with frequent COPD exacerbations or with a diagnosis of asthma and COPD, the guidelines recommend adding an inhaled corticosteroid (ICS) such as fluticasone to a LABA, LAMA, or both. Triple therapy with a LABA, a LAMA, and an ICS is not indicated at this time as the patient has not yet been treated with a combination of a LAMA and LABA and has not had any recent exacerbations. The addition of azithromycin may be considered in patients who are already on triple therapy with a LABA, a LAMA, and an ICS and still having exacerbations. Monotherapy with an ICS is not indicated in COPD and has been shown to increase the risk of developing pneumonia.

Answer 230

ANSWER: E This patient has several risk factors for a significant problem such as esophageal cancer, including age over 50, weight loss, and progressive symptoms. Esophagogastroduodenoscopy (EGD) is needed without delay. This approach would allow biopsy of any lesions seen and therapeutic dilatation if a benign-appearing stricture is noted. Biopsies are also needed to diagnose eosinophilic esophagitis. If the EGD does not identify a problem, further workup should then proceed. CT may identify a source of extrinsic pressure. Barium esophagography may detect mild narrowing or esophageal webs missed on EGD. Esophageal motility disorders may be diagnosed with esophageal manometry. Waiting 8 weeks to see if his symptoms improve with regular use of a proton pump inhibitor would not be appropriate in this patient with symptoms that are worrisome for esophageal cancer.

Answer 231

ANSWER: D In men who are diagnosed with hypogonadism with symptoms of testosterone deficiency and unequivocally and consistently low serum testosterone concentrations, further evaluation with FSH and LH levels is advised as the initial workup to distinguish between primary and secondary hypogonadism. If secondary hypogonadism is indicated by low or inappropriately normal FSH and LH levels, prolactin and serum iron levels and measurement of total iron binding capacity are recommended to determine secondary causes of hypogonadism, with possible further evaluation to include other pituitary hormone levels and MRI of the pituitary. If primary hypogonadism is found, karyotyping may be indicated for Klinefelter’s syndrome.

Answer 232

ANSWER: E Psychogenic tremor is characterized by an abrupt onset, spontaneous remission, changing characteristics, and extinction with distraction. Cerebellar tremor is an intention tremor with ipsilateral involvement on the side of the lesion. Neurologic testing will reveal past-pointing on finger-to-nose testing. CT or MRI of the head is the diagnostic test of choice. Parkinsonian tremor is noted at rest, is asymmetric, and decreases with voluntary movement. Bradykinesia, rigidity, and postural instability are generally noted. For atypical presentations a single-photon emission CT or positron emission tomography may help with the diagnosis. One of the treatment options is carbidopa/levodopa. Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head, voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no specific diagnostic test but the tremor is treated with propranolol or primidone. Enhanced physiologic tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of caffeine use or anxiety.

Answer 233

ANSWER: B This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8 weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient presents with severe thyroid pain and systemic symptoms.

Answer 234

ANSWER: B High-intensity statin therapy is recommended for patients younger than 75 years of age with known coronary artery disease. For those who are intolerant of high-intensity statins, a trial of a moderate-intensity statin is appropriate. There is evidence to support ezetimibe plus a statin in patients with acute coronary syndrome or chronic kidney disease. Omega-3 fatty acids, fibrates, and niacin should not be prescribed for primary or secondary prevention of atherosclerotic cardiovascular disease because they do not affect patient-oriented outcomes. PCSK9 inhibitors such as evolocumab are injectable monoclonal antibodies that lower LDL-cholesterol levels significantly and have produced some promising results, but more studies are needed to determine when this would be cost effective.

Answer 235

ANSWER: E This patient has classic pityriasis rosea. This is generally a benign disease except in pregnancy. The epidemiology and clinical course suggest an infectious etiology. Pregnant women are more susceptible to pityriasis rosea because of decreased immunity. Pityriasis rosea is associated with an increased rate of spontaneous abortion in the first 15 weeks of gestation. It is not associated with an increased risk for a small-for-gestational-age newborn, congenital cataracts, or multiple birth defects.

Answer 236

ANSWER: C Sarcoidosis has numerous extrapulmonary manifestations. Because inflammation of the eye can result in permanent impairment and is often asymptomatic, patients require yearly eye examinations as well as additional monitoring with disease flares. Although skin involvement is common it is usually readily apparent and rarely has serious sequelae. Cardiac sarcoidosis can potentially lead to progressive heart failure and sudden death, but evaluation is needed only in patients who are symptomatic. Similarly, evaluation for neurologic involvement is needed only in patients who are symptomatic.

Answer 237

ANSWER: C 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 238

ANSWER: A The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of two of four cardinal symptoms, which include nasal drainage, nasal obstruction, facial pain or pressure, and hyposmia or anosmia, along with 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 239

ANSWER: D 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 240

ANSWER: B To mitigate the risk of opioid harm, it is essential to understand morphine milligram equivalents (MME). The evidence shows that the risk 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 241

ANSWER: A 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 242

ANSWER: A 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 243

ANSWER: C 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.

Answer 244

ANSWER: A 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 bone mineral density T-score –2.5 at either the spine or the femoral neck and are either male and 50 years of age or 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 245

ANSWER: C 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 246

ANSWER: C 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.

Answer 247

ANSWER: B 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 248

ANSWER: A 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 249

ANSWER: A 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 250

ANSWER: B HPV vaccine is currently recommended for males and females at age 11. 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 251

ANSWER: A 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 252

ANSWER: E 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 253

ANSWER: B 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 254

ANSWER: B 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 255

ANSWER: A The TSH reference range is lower during pregnancy because of the cross-reactivity of the -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 256

ANSWER: C 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 257

ANSWER: A 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. The 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 258

ANSWER: E Multiple studies have determined that parenteral antiemetics have benefits for the treatment of acute 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 259

ANSWER: E 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 260

ANSWER: B 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 261

ANSWER: A 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 262

ANSWER: D 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 263

ANSWER: D 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 264

ANSWER: C 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 265

ANSWER: B 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 266

Item 137 ANSWER: A 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 267

ANSWER: A 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 268

ANSWER: D 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 269

ANSWER: E 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: pain with passive extension, tenderness with palpation of the tendon sheath, flexed position of the involved finger, and 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 270

ANSWER: D 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 271

ANSWER: D 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 272

ANSWER: B 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. 55 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 273

ANSWER: C 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 274

ANSWER: E 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 275

ANSWER: E 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 276

ANSWER: B 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 277

ANSWER: E 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 278

ANSWER: B This is a classic presentation for acute poststreptococcal 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 -hemolytic Streptococcus. The hematuria is caused by immune complex–mediated glomerular injury. 66 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. The classic finding on microscopic urinalysis for acute glomerulonephritis is the presence of RBC casts. 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 279

ANSWER: D 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 280

ANSWER: D 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 281

ANSWER: D 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.

Answer 282

ANSWER: E For patients with gender dysphoria or gender incongruence who desire hormone treatment, the treatment goal is to suppress endogenous sex hormone production and maintain sex hormone levels in the normal range for their affirmed gender. For a female-to-male transgender patient this is most easily accomplished with testosterone. When testosterone levels are maintained in the normal genetic male range, gonadotropins and ovarian hormone production is suppressed, which accomplishes both goals for hormonal treatment without the need for additional gonadotropin suppression from medications such as leuprolide. Clomiphene can increase serum testosterone levels, but only in the presence of a functioning testicle. Letrozole is an estrogen receptor antagonist, but it would not increase serum testosterone levels. Spironolactone has androgen receptor blocking effects and would not accomplish either of the hormone treatment goals.

Answer 283

ANSWER: D According to American Cancer Society guidelines for cervical cancer screening, Papanicolaou (Pap) testing should begin at age 21 irrespective of sexual activity and should be continued every 3 years until age 29. The preferred screening strategy beginning at age 30 is Pap testing with HPV co-testing, which should be continued every 5 years until age 65. Cervical screening may be discontinued at that time if the patient’s last two tests have been negative and the patient was tested within the previous 5 years.

Answer 284

ANSWER: D This patient presents with symptoms of chronic insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) and brief behavioral therapy for insomnia (BBT-I) are effective nonpharmacologic treatments for chronic insomnia. Modified CBT-I and BBT-I can be administered by a primary care physician. The basic principles include stimulus control (sleep hygiene) and sleep restriction. Reducing time in bed increases sleep efficiency. In this case, 6 hours of time in bed would improve the patient’s sleep efficiency and a bedtime of 12:30 a.m. would accomplish this goal. Generally, reduced time in bed is accomplished by postponing bedtime rather than getting up earlier. Naps generally do not improve sleep efficiency. While getting out of bed is recommended after being in bed for 30 minutes without falling asleep, or being awake for 30 minutes after being asleep, staying up for a prescribed period of time is not recommended.

Answer 285

ANSWER: A This patient has symptoms of acute simple cystitis and does not have any symptoms that would suggest a complicated urinary tract infection or vaginal infection. In these cases treatment with oral antibiotic therapy may be prescribed without further evaluation (SOR B). Simple cystitis is a clinical diagnosis and a urinalysis and urine culture are not necessary. The patient does not have any symptoms that warrant evaluation with abdominal radiographs or pelvic ultrasonography.

Answer 286

ANSWER: E Heparin-induced thrombocytopenia (HIT) is an immune-mediated process that occurs in approximately 1 in 5000 hospitalized patients. Patients are at highest risk 7–10 days after exposure to unfractionated heparin, and the risk is particularly high after cardiac surgery, which is associated with an estimated rate of 1%–3%. In contrast to other causes of thrombocytopenia, HIT places patients at a paradoxically increased risk of thrombotic complications, with clotting events occurring in roughly 50% of confirmed cases of HIT. Lower-extremity deep vein thrombosis and pulmonary embolism are the most common thrombotic complications, followed by arterial thromboses, stroke, and myocardial infarction, in descending order of frequency. Thromboses often occur concurrently with the development of thrombocytopenia or shortly thereafter. The risk of HIT can be determined with the 4T scoring system, which evaluates the acuity of thrombocytopenia, timing of onset, presence of thrombosis, and alternative causes of thrombocytopenia. Patients with an intermediate or high pretest probability should be managed with prompt discontinuation of heparin and initiation of full-dose anticoagulation with a non-heparin anticoagulant, such as argatroban, danaparoid, fondaparinux, or bivalirudin, pending results of further HIT diagnostic evaluation. Anaphylaxis, disseminated intravascular coagulation, hemorrhage, and sepsis are all less common complications of HIT compared to thrombotic events.

Answer 287

ANSWER: B The appropriate classification of heart failure is important for monitoring the disease. The most common currently used system is the New York Heart Association (NYHA) functional classification. In this system, class I is defined as heart disease in a patient with no symptoms and no limitations of physical activity. Patients with class II heart failure have mild symptoms with normal physical activity. Class III heart failure refers to significant limitations of activity, including symptoms with less than normal activities. Patients with class IV heart failure have symptoms at rest and are unable to carry on activity without discomfort.

Answer 288

ANSWER: D The most appropriate management of a recurrent Bartholin gland abscess would be marsupialization, which has a 0% recurrence rate at 6 months. Local anesthesia can be used in the office to effectively treat Bartholin gland abscesses and sedation is not required (SOR A). If the Bartholin gland abscess is >5 cm, referral to a gynecologist is recommended. Expectant management, fine-needle aspiration, or incision and drainage would likely lead to recurrence.

Answer 289

ANSWER: C Crohn’s disease may present insidiously with diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and fatigue. Red-flag symptoms include perianal lesions, a first degree relative with inflammatory bowel disease, weight loss of 5% of the patient’s usual weight, abdominal pain for more than 3 months, nocturnal diarrhea, fever, the absence of abdominal pain for 30–45 minutes after eating, and the absence of rectal urgency. This patient exhibits symptoms consistent with Crohn’s disease. While anemia is also common in celiac disease, rectal bleeding is not. Chronic pancreatitis does not generally present with improved pain after eating. Irritable bowel syndrome is not associated with fever, rectal bleeding, anemia, or perianal fistulas. Ulcerative colitis is not associated with perianal lesions.

Answer 290

ANSWER: A Among the available U-100 insulin products, the one with the longest duration of action is ultralong-acting degludec, which lasts 42 hours. The duration of action of rapid-acting lispro is 3–6.5 hours, short-acting regular is 5–8 hours, intermediate-acting isophane is 12–16 hours, and long-acting glargine is 11–24 hours.

Answer 291

ANSWER: D This patient has a classic presentation for Lyme disease. Lyme disease is transmitted by a tick bite, but not all patients remember being bitten by a tick. The classic erythema migrans lesion appears a couple of weeks after the tick bite. The first-line treatment for Lyme disease is either amoxicillin or doxycycline. Macrolides can be used if patients have true allergies to -lactams and doxycycline, but they are less effective. This patient is not exhibiting the respiratory symptoms typically associated with adenovirus. Ehrlichiosis and Rocky Mountain spotted fever typically present with headaches and fevers but not with an erythema migrans rash. Although influenza should be considered in the differential diagnosis, it would not present with an erythema migrans rash.

Answer 292

ANSWER: A Oral iron supplements, including ferrous fumarate, ferrous gluconate, and ferrous sulfate, are generally ineffective when used by hemodialysis patients and are only modestly effective when used by patients with non–dialysis-dependent chronic kidney disease. The one exception is ferric citrate, which is highly efficacious in all patients with chronic kidney disease. Intravenous iron preparations such as iron dextran are similarly effective in both groups and are considered the gold standard for the treatment of iron deficiency in patients on chronic hemodialysis.

Answer 293

ANSWER: B The Welcome to Medicare preventive visit, also known as an Initial Preventive Physical Examination (IPPE), is a one-time service that can be provided within the first year of a patient’s enrollment in Medicare Part B. Medicare Part B covers provider visits and outpatient services such as laboratory testing. Beneficiaries are automatically enrolled in Part A when they apply to Medicare, which provides coverage for hospital-based and hospice care. Because Part A does not typically carry a monthly premium, some working older adults who continue to have insurance through their employer may opt to obtain Part A only, and wait on Part B coverage, which does have a monthly premium. Medicare Part D is prescription drug coverage.

Answer 294

ANSWER: A The Choosing Wisely campaign recommends checking only carcinoembryonic antigen (CEA) levels following curative treatment for colorectal cancer (SOR C). No routine laboratory studies such as a CBC or liver function tests should be ordered for follow-up.

Answer 295

ANSWER: D Smoking during pregnancy increases the risk for fetal growth restriction. The U.S. Preventive Services Task Force identified evidence that tobacco cessation increases infant birth weight and decreases the risk for preterm delivery. There is no evidence that tobacco cessation in pregnant women decreases the risk for cesarean delivery, the risk for preeclampsia, or the need for epidural anesthesia.

Answer 296

ANSWER: C Delayed puberty in girls is defined as the absence of breast development by age 13. Typically, menarche starts 2.5 years after the onset of breast development, with an average age of 12.5 years (normal range 9–15 years). In girls with otherwise normal sexual development, the absence of menarche by 15 years of age should prompt an evaluation for primary amenorrhea.

Answer 297

ANSWER: C The ACCOMPLISH trial demonstrated that an ACE inhibitor (ACEI) in combination with a calcium channel blocker (CCB) reduced both fatal and nonfatal cardiovascular events in patients with diabetes mellitus and hypertension. The benefit of an ACEI and a CCB for reducing cardiovascular events was greater than that of an ACEI and a thiazide diuretic. Evidence has shown that combination therapy for most patients should include a CCB, an ACEI or angiotensin receptor blocker (ARB), or a thiazide diuretic (SOR A). The American College of Cardiology/American Heart Association guidelines recommend against centrally acting medications such as -blockers for first-line therapy. Combining ACEIs and ARBs is not recommended, as the risk of side effects such as hyperkalemia outweighs the benefits. Loop diuretics are not considered first-line antihypertensive agents.

Answer 298

ANSWER: D Frostbite is a freezing injury that occurs when initial cooling causes vasoconstriction and localized ischemia. Continued cold exposure leads to ice crystal formation, which causes cellular lysis, electrolyte abnormalities, and microvascular occlusion. Rewarming creates an inflammatory response. Ibuprofen is the most appropriate agent for the treatment of frostbite until the wounds heal or surgery is performed (SOR C). Acetazolamide can cause frostbite at high altitudes. Amitriptyline is used to treat the pain of immersion foot (also called trench foot), which is a nonfreezing injury that happens when the foot is exposed to prolonged wet conditions above 0°C (32°F). Antibiotics are indicated if open or dirty wounds are present (SOR B). tPA has a role in treating patients with frostbite, but it is used only to decrease the risk of amputation when rewarming patients with grade 3, grade 4, or deep frostbite (SOR B).

Answer 299

ANSWER: B This patient has subclinical hyperthyroidism caused by Graves disease. A positive anti–thyrotropin-receptor (thyroid-stimulating immunoglobulin) antibody result is virtually diagnostic of Graves disease. Central hypothyroidism is associated with a low TSH level and low T3 and T4 levels. Iodine deficiency is associated with goiter and hypothyroidism. Nodular thyroid disease is unlikely given the imaging results. Treatment of this patient’s mild Graves disease is probably indicated, given her age and cardiac symptoms.

Answer 300

ANSWER: E Cardiac resynchronization therapy is strongly recommended for patients with symptomatic heart failure, an ejection fraction <35%, and a left bundle branch block with a QRS interval >150 msec. Amiodarone is an antiarrhythmic and would not be indicated for this patient. Ivabradine, a sinoatrial node modulator, is used in patients with symptomatic heart failure as an add-on therapy to decrease the heart rate. It is indicated in patients with a heart rate >70 beats/min despite -blockade. Sacubitril/valsartan is contraindicated in patients with a history of angioedema. Sinoatrial node ablation is indicated for some patients with sinus node dysfunction.

Answer 301

ANSWER: B Hypercalcemia is a commonly encountered laboratory abnormality. It is important for family physicians to be aware of common medications that can cause elevated calcium levels. Of the options listed, lithium is the only medication that can cause high calcium levels. In addition, thiazide diuretics, excluding aldosterone receptor antagonists such as spironolactone, often cause elevated calcium levels. Hypercalcemia is not a side effect of alendronate, omeprazole, sertraline, or spironolactone.

Answer 302

ANSWER: E Recommendations for the treatment of back pain often include ice, targeted exercises, oral analgesics, and spinal manipulation. Although there is some evidence that certain modalities are better than placebo, there is very little evidence to show that one modality is superior to another in relieving back pain or shortening the course of the pain. There is some evidence that spinal manipulation is superior to sham manipulation.

Answer 303

ANSWER: E Scaphoid fractures have a high risk for nonunion because the blood supply arises distally from branches of the radial artery. The proximal pole of the scaphoid is entirely dependent on this distal blood supply. To improve healing and decrease the risk of nonunion and avascular necrosis, displaced fractures should be treated with surgical fixation. Nondisplaced fractures of the distal third of the scaphoid may be treated with a short arm thumb spica cast for 4–6 weeks. Middle and proximal fractures should be treated with a long arm thumb spica cast for 6 weeks, followed by a short arm thumb spica cast.

Answer 304

ANSWER: D This patient most likely has benign idiopathic hirsutism. It is estimated that approximately 50% of women with mild hirsutism have idiopathic hirsutism. In the absence of other worrisome findings on the history or examination, such as a rapid onset, virilization, or a high degree of hirsutism, the most appropriate next step is a trial of pharmacologic therapy, using oral contraceptive pills as the first-line agent if the patient does not desire pregnancy. A minimum 6-month trial is needed because of the length of the hair growth cycle. An early morning total testosterone level, a full hormonal workup, and transvaginal ultrasonography would be appropriate if there were other signs and symptoms of hyperandrogenism on the history or examination.

Answer 305

ANSWER: B This patient has a hypertensive urgency, defined as symptomatic acute severe hypertension without evidence of acute end-organ injury. Hypertensive urgencies may be managed in the ambulatory setting. Emergent intravenous treatment at the hospital is not indicated. This patient should be treated with an oral agent with a fairly rapid onset of action, such as clonidine, labetalol, captopril, or prazosin. Topical nitroglycerin is also an option. Nifedipine may cause unpredictable blood pressure reduction and should be avoided. The patient may be discharged to resume his usual medications after his symptoms have improved and his blood pressure is below 160–180/110 mm Hg, with follow-up within a week.

Answer 306

ANSWER: D Current U.S. Preventive Services Task Force guidelines for breast cancer screening recommend biennial screening mammography for women ages 50–75 (B recommendation). Biennial screening mammography can be considered for women age 40–49 after discussing the risks and benefits with the patient (C recommendation).

Answer 307

ANSWER: A Idiopathic pulmonary fibrosis occurs most often in male former smokers over the age of 60. For patients with newly diagnosed interstitial lung disease (ILD) with suspected idiopathic pulmonary fibrosis, the American Thoracic Society recommends taking a detailed history of medication use and environmental exposures over the patient’s lifetime. In an observational study of 1084 patients, 47% were identified as having hypersensitivity pneumonitis on a detailed assessment of new-onset ILD with an unknown cause. Laboratory testing for connective tissue disease is also recommended. Antibiotics would be appropriate to treat a bacterial infection. Furosemide is used to treat heart failure. An inhaled short-acting -agonist and pulmonary rehabilitation would not be appropriate at this time.

Answer 308

ANSWER: D After treatment for a Helicobacter pylori infection it is essential to document clearance of the infection. This is typically done with a stool antigen test or a urea breath test performed 1 month after the completion of antibiotic therapy. If the patient is taking a proton pump inhibitor it should be discontinued prior to the test. H. pylori IgG or IgM levels and gastric biopsies are not appropriate for documenting clearance of H. pylori infection.

Answer 309

ANSWER: D The clinical findings on examination, including symmetric polyarthritis, thrombocytopenia, positive antinuclear antibodies (ANAs), and pleural effusion, meet the American College of Rheumatology criteria for a diagnosis of systemic lupus erythematosus (SLE). The rash and the patient’s neuropsychiatric history may also factor into the diagnosis, but they are not described specifically in this case. A positive ANA is sensitive but not specific for SLE. Although additional laboratory testing may not be needed to confirm SLE in this case due to classic clinical findings, low complement levels help confirm SLE and may be helpful because the ANA is only mildly elevated. 49 Elevated anticyclic citrullinated peptide antibodies help confirm a diagnosis of rheumatoid arthritis. Anti–smooth muscle antibodies are used to confirm autoimmune hepatitis, which can also cause an elevated ANA. Anti-centromere antibodies, a subset of ANAs, are more closely associated with systemic sclerosis. A positive HLA-B27 test is associated with the seronegative spondyloarthropathies, such as psoriatic arthritis.

Answer 310

ANSWER: B This clinical case is consistent with Addison’s disease, or adrenal insufficiency. This case is most likely the result of autoimmune disease, given the concurrent vitiligo, but it may also be idiopathic or secondary to cancers such as lymphoma or infections such as tuberculosis. Adrenal insufficiency is suggested by a low morning cortisol level, but the test of choice to confirm this diagnosis is the ACTH stimulation test. 17-Hydroxyprogesterone deficiency causes congenital adrenal hyperplasia, which typically presents in childhood. This test is part of newborn screening in the United States. Acquired 17-hydroxyprogesterone deficiency can present in adulthood as adrenal insufficiency but a low 17-hydroxyprogesterone level does not confirm adrenal insufficiency. Late night salivary cortisol is an initial test for corticosteroid excess (Cushing syndrome) and the dexamethasone suppression test is used to confirm that disorder. Renin and aldosterone levels can be helpful to characterize mineralocorticoid deficiency but they are not diagnostic.

Answer 311

ANSWER: B The CDC recommends that all adults 18 years of age or older receive a one-time screening for hepatitis C virus (HCV). Persons with risk factors for HCV exposure should be screened periodically, based on risk level. If the anti-HCV antibody screen is positive, then a qualitative HCV RNA test is the next step (SOR C). Prior to initiating treatment, a quantitative HCV RNA and genotype testing is necessary (SOR A). In addition, assessing the degree of fibrosis will provide information regarding the urgency of treatment. Percutaneous liver biopsy is generally the preferred evaluation after obtaining quantitative and genotype results, all of which can guide treatment decisions.

Answer 312

ANSWER: A Four widely recognized principles of medical ethics include respect for autonomy, beneficence, nonmaleficence, and justice. Respect for patient autonomy is central to medical ethics and to the doctor-patient relationship. Physicians should involve patients in health care decisions commensurate with the patient’s capacity to understand and make decisions. Even when a condition affects a patient’s decision-making capacity, the patient may be able to participate in some aspects of the decision-making process. Competence (or incompetence) is a legal term, which can be used to refer to a patient being granted autonomy or not. Harm and safety are not ethical principles, but are related to the principle of nonmaleficence, or “do no harm.” The principle of justice addresses the question of who ought to receive the benefits of an intervention and/or bear its burdens. An injustice occurs when a person who is entitled to a benefit is denied without good reason or when some burden is imposed unduly.

Answer 313

ANSWER: A Hundreds of thousands of Americans have undergone bariatric surgery, and family physicians are often asked to provide long-term postoperative management. Many bariatric surgery procedures create a small stomach pouch. Dietary compliance is essential to minimize feeding intolerance symptoms such as postprandial nausea, emesis, and diarrhea. Post bariatric surgery diet recommendations typically include the following: Ref: * * * * Avoid fluid 15 minutes before and after meals. Fluids with meals will move food more quickly through the pouch and decrease the feeling of fullness. Avoid carbonated beverages entirely. Eat three small protein-rich meals and one or two snacks daily. Lower fat diets are not typically recommended. Whole grains and fibrous vegetables often exacerbate symptoms so there is no need to increase these foods.

Answer 314

ANSWER: E A systematic review found that arthroscopic procedures for degenerative meniscal tears in middle-aged adults with little or no arthritis do not significantly improve long-term pain or function compared to conservative management consisting of physical therapy and a standardized exercise program. No studies have compared conservative management to intra-articular injections of corticosteroids or hylan GF 20 for managing degenerative meniscal tears, either alone or when combined with conservative management.

Answer 315

ANSWER: E Trimethoprim/sulfamethoxazole is one of the antimicrobials most likely to increase the INR of a patient taking warfarin. If trimethoprim/sulfamethoxazole is used in a patient on warfarin, reducing the warfarin dosage by 25%–40% is recommended, with close monitoring of the INR. The patient’s INR should be checked within 3–5 days of starting or stopping any antimicrobial. 55 First generation cephalosporins such as cephalexin, fourth generation cephalosporins, clindamycin, and penicillin G have a lower likelihood of affecting the INR. Rifampin decreases the INR and the warfarin dosage should be increased if rifampin is started. Other antimicrobials that significantly affect the INR include metronidazole and fluconazole. Azithromycin, ciprofloxacin, clarithromycin, and levofloxacin may impact the INR with a variable patient-specific effect.

Answer 316

ANSWER: C Early and consistent dental care in infants has been shown to reduce the rate of early childhood caries. The American Academy of Pediatric Dentistry recommends the use of low-fluoride toothpaste for tooth cleaning, starting with newly erupted teeth. According to the CDC, dental caries is one of the most prevalent chronic conditions among children in the United States. Dental caries can start soon after eruption of the first teeth. Brushing an infant’s teeth twice daily with a “smear” of fluoridated toothpaste is recommended. Fluoridated toothpaste has been found to be safe and effective for infants’ teeth. The use of fluoride in toothpaste is more effective for the prevention of caries than wiping or brushing the teeth with water. A daily fluoride supplement is not appropriate for this patient because the family’s local water source already contains fluoride. Topical sealants are intended for molar teeth, not incisors.

Answer 317

ANSWER: D Erythrasma is a superficial infection caused by Corynebacterium minutissimum. It presents as small, red-brown macules that may coalesce into larger patches with sharp borders. It fluoresces coral red on Wood’s lamp examination. Cutaneous erythrasma is treated with erythromycin (topical, twice daily until the rash resolves, or oral, 250 mg four times daily for 2 weeks). Topical clindamycin, Whitfield ointment, and antibiotic soaps may also be beneficial. Triamcinolone cream, hydrocortisone cream, nystatin cream, and oral antifungals are not effective treatments for this bacterial infection.

Answer 318

ANSWER: E Hyperthyroidism is a common condition with a generally favorable prognosis. However, it is important to remember that life-threatening complications such as thyrotoxicosis, also known as thyroid storm, can occur. Symptoms of thyroid storm include fever, central nervous system dysfunction, gastrointestinal or liver dysfunction, and cardiovascular complications such as tachycardia and heart failure. The diagnosis is made using the Burch-Wartofsky Point Scale, which produces a total score based on the presence or absence of various diagnostic criteria. In this case, the patient has a score of 45, which is highly suggestive of thyroid storm. This acute, life-threatening condition typically requires care in an intensive-care unit. It would therefore be inappropriate to start treatment with an agent such as methimazole prior to hospitalization. While a thyroid receptor antibody test may be useful in identifying the cause of the condition it should not delay hospitalization. A radioactive iodine uptake test is also useful for identifying the underlying cause of hyperthyroidism but should be avoided until the thyroid storm has resolved. This patient requires hospitalization, so a referral to endocrinology would not be most appropriate at this time.

Answer 319

ANSWER: B This patient presents with his first recurrence of Clostridioides (Clostridium) difficile infection, which was previously treated with vancomycin. Initial episodes can be treated with vancomycin (strong recommendation, high quality of evidence), fidaxomicin (strong recommendation, high quality of evidence), or metronidazole if the other two treatments are unavailable (weak recommendation, high quality of evidence). However, fidaxomicin is recommended for recurrent infection if vancomycin was prescribed for the initial episode (weak recommendation, moderate quality of evidence). If available, a prolonged tapered course of vancomycin could be used if a 10-day course was prescribed initially (weak recommendation, low quality of evidence). Vancomycin is only recommended for a first recurrent episode if metronidazole was used initially (weak recommendation, low quality of evidence). Metronidazole is not recommended for recurrent episodes. Probiotic administration is not recommended due to insufficient data. Fecal microbiota transplantation is only recommended for a second or subsequent recurrent infection (strong recommendation, moderate quality of evidence).

Answer 320

ANSWER: D Opioid use may cause numerous adverse reactions, including drowsiness, pruritus, nausea, and constipation. In addition to these well known side effects, chronic opioid use can lead to hypogonadism through inhibition of gonadotropin-releasing hormone and an increase in prolactin. A recently published study found that long-term opioid users were nearly twice as likely to be diagnosed with hypogonadism as short-term opioid users. Given the large number of opioid users in the United States, prescribers should be aware of this adverse effect and screen for hypogonadism when appropriate. None of the other medications in this patient’s regimen, including acetaminophen, cyclobenzaprine, meloxicam, and pregabalin, are the likely cause of his decreased libido.

Answer 321

ANSWER: E This patient’s symptoms are consistent with bicipital tendinitis, which causes pain with abduction and external rotation of the arm, and tenderness of the bicipital groove with palpation. Resisted supination of the hand with the elbow flexed to 90° is the Yergason test, and anterior shoulder pain with this maneuver is consistent with bicipital tendinitis. Anterior shoulder pain with cross adduction of the arm is more consistent with acromioclavicular arthritis. Axial compression of the slightly flexed neck is the Spurling test for cervical radiculopathy. Extension of the elbow would activate the triceps, and internal rotation of the shoulder with the elbow flexed would result in less activation of the biceps than resisted supination. Ref: Churgay CA: Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician 2009;80(5):470-476. 2) Jameson JL, Fauci AS, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, ed 20. McGraw-Hill, 2018, p 2647.

Answer 322

ANSWER: C In randomized, controlled trials, gabapentin has demonstrated benefit for treating a refractory chronic cough after 4 weeks of treatment (SOR C). Chronic cough may be due to a hypersensitivity of the cough reflex, either centrally or peripherally. Cyclobenzaprine, duloxetine, lorazepam, and propranolol have not proven to be beneficial in reducing or eliminating chronic cough.

Answer 323

ANSWER: A Glucocorticoid use is the most common cause of secondary osteoporosis. Glucocorticoids increase bone resorption early, so addressing the issue at the start of treatment is vital in preventing fractures. The use of glucocorticoids is associated with an increased risk of fracture in the first 6 months. A bone density test should be performed shortly after starting corticosteroid treatment (SOR C). The fracture risk can then be calculated using the FRAX assessment tool. If the risk of major osteoporotic fracture is sufficiently elevated, then treatment is recommended. One caveat is that the FRAX score should be adjusted upward if the prednisone dosage is >7.5 mg daily. Calcium alone has not been shown to reduce the risk of fracture in osteoporosis. Calcium and vitamin D together have been shown to prevent decreases in bone mineral density with low-dose prednisone use but the effect with high doses is unknown. If a patient has an increased fracture risk, oral bisphosphonates should be started. It is not recommended that they be used empirically to reduce the risk of fracture.

Answer 324

Transgender describes persons whose experienced or expressed gender differs from their sex assigned at birth. In the United States approximately 150,000 youth and 1.4 million adults identify as transgender, though many believe these numbers underestimate the actual prevalence. Transgender men who take testosterone may experience increased muscle mass and decreased fat mass, male pattern baldness, increased sexual desire, clitoromegaly, decreased fertility, deepening of the voice, cessation of menses, acne, and a significant increase in body hair, particularly on the face, chest, and abdomen. Risks of testosterone therapy include more atherogenic lipid profiles, an increase in blood pressure, and erythrocytosis (rather than anemia). Severe liver dysfunction is unusual at therapeutic dosages but is a concern at dosages above the recommended therapeutic range. Testosterone therapy has not been associated with cervical cancer, kidney disease, or venous thromboembolism (VTE). Estrogen-based therapies for male-to-female transgender patients do carry an increased risk for VTE. It is not clear whether increased blood pressure and dyslipidemia in these patients translates into an increase in cardiovascular events. Even so, when identified, treatment such as antihypertensive drugs and statins to address these risk factors is recommended as for any other patient.

Answer 325

ANSWER: D Excess thyroid hormone intake would cause a low TSH level with a high free T4 level. Other possibilities include an hCG-secreting tumor and the thyrotoxic phase of subacute thyroiditis. An elevated TSH level would be seen with thyroid-hormone resistance or a thyrotropin-secreting pituitary tumor. Graves disease causes a homogeneous increased thyroid uptake on radionuclide scanning, whereas a hot nodule would be expected with toxic nodular goiter.

Answer 326

ANSWER: B Hallux rigidus affects as many as 50% of women and 40% of men by the age of 70. It is usually due to osteoarthritis of the metatarsophalangeal (MTP) joint and presents as decreased range of motion, swelling, and pain. With progression of the condition, flare-ups become more frequent and more severe, and it can be mistaken for gout. Initial treatment is restriction of motion across the MTP joint. A stiffening shoe insert does relieve pain and most patients see improvement without surgery. Custom orthotics, rigid inserts, or hard-soled shoes are options that are more effective than NSAIDs. Corticosteroid injections, preferably administered with ultrasound guidance, and surgery are reserved for those who fail to respond to more conservative measures. Stretching and strengthening exercises are recommended for plantar fasciitis more so than for hallux rigidus.

Answer 327

ANSWER: C Pediatric type 1 diabetes is recognized as a high-risk condition for the future development of cardiovascular disease. Current guidelines recommend initiating a statin, in addition to education regarding a healthy diet and physical activity, for pediatric patients in this high-risk category with an LDL-cholesterol level >100 mg/dL. Statins such as atorvastatin are recommended for first-line treatment according to multiple studies that demonstrate their efficacy and benefits in reduction of cardiovascular morbidity and mortality, along with long-term studies demonstrating their safety. Fish oil supplements, ezetimibe, and gemfibrozil would not be appropriate recommendations for this patient at this time.

Answer 328

ANSWER: D The leading cause of mortality among people aged 45–64 years is malignancy. The U.S. Preventive Services Task Force generally recommends a focus on cancer screening in this age group. Accidents are the third most common cause of mortality in people 45–64 years of age, but they are the leading cause of mortality among people 15–44 years of age, and preventive recommendations reflect interventions to prevent accidents. Diabetes mellitus is the sixth most common cause of mortality in people 45–54 years of age, and the fifth most common cause in people 55–64 years of age. Heart disease is the second most common cause of mortality in people 45–64 years of age, but it is the leading cause of mortality in people 65 years of age and older. Suicide is the fourth most common cause of mortality in adults 45–54 years of age, and the eighth most common cause in adults 55–64 years of age.

Answer 329

ANSWER: C Acute respiratory distress syndrome (ARDS) will often present similarly to pneumonia and heart failure with dyspnea, hypoxemia, and tachypnea. ARDS typically does not respond to supplemental oxygen or diuretic therapy. Patients decompensate quickly and usually require mechanical ventilation. Chest radiographic findings include bilateral airspace opacities but not a localized infiltrate as with pneumonia, venous congestion or cardiac enlargement as with heart failure, or a flattened diaphragm (associated with COPD).

Answer 330

ANSWER: E This patient’s laboratory studies are consistent with a past natural hepatitis B virus (HBV) infection and she is now immune. If she had never been infected her anti-HBc and anti-HBs would both be negative. If she had an acute infection the HBsAg, anti-HBc IgM, and HBV nucleic acid test (NAT) would have all been positive along with the total anti-HBc. If she had a chronic infection the HBsAg and HBV NAT would be positive in addition to the total anti-HBc. Furthermore, the anti-HBs would be negative in both acute and chronic infection since its presence is associated with recovery from infection. If her anti-HBc screening test were a false positive the anti-HBs would be negative.

Answer 331

ANSWER: B After confirming low testosterone with two morning laboratory tests, the next step is to attempt to determine the cause of the low testosterone. Checking LH and FSH levels is recommended to evaluate for primary hypogonadism. If primary hypogonadism is present, chromosomal studies should be considered. Before initiating testosterone therapy, checking the patient’s PSA level and performing a digital rectal examination are recommended, but in this case the initial workup is not yet complete. It is crucial to discuss the risks and benefits of treatment, and as with all medications, it is recommended to start with the lowest dose needed. However, starting treatment in this case is premature. Evidence for testosterone replacement therapy is not as robust as desired and it does carry risks, but as long as there are no contraindications it can be initiated after a discussion of the risks and benefits.

Answer 332

ANSWER: B Office spirometry can be very helpful in the development of a differential diagnosis. The differential can be narrowed with the use of office spirometry, as many conditions create either an obstructive or restrictive pattern. Of the options listed, only cystic fibrosis can cause an obstructive pattern. Other causes of an obstructive pattern include asthma, COPD, 1-antitrypsin deficiency, and bronchiectasis, among others. Common diseases or conditions causing restrictive patterns include adverse reactions to nitrofurantoin, methotrexate, and amiodarone. Chest wall conditions such as kyphosis, scoliosis, and morbid obesity can also cause restrictive patterns. Interstitial lung disease, including idiopathic pulmonary fibrosis, sarcoidosis, and asbestosis, also causes a restrictive pattern (SOR A).

Answer 333

ANSWER: B Adjustable orthotic shoes in infants who are not yet walking can be effective for the treatment of metatarsus adductus (SOR B). These orthotics can be adjusted to apply an abduction force on the forefoot while maintaining the heel in a neutral position. Night splints, braces, and physical therapy are not indicated or proven to correct this deformity. Surgery has high complication rates and is rarely indicated to treat metatarsus adductus.

Answer 334

ANSWER: E Because patients with an acute ischemic stroke may require the increased perfusion pressure to limit ischemia, antihypertensive therapy should not be given during the first 48–72 hours as long as they are not candidates for, or recipients of, reperfusion therapy with alteplase or thrombectomy; do not have a comorbid condition requiring acute blood pressure lowering; and do not have a blood pressure >220/120 mm Hg.

Answer 335

ANSWER: B In all patients found to have a thyroid nodule, the first steps in evaluation should be measuring the TSH level and performing thyroid ultrasonography. If the TSH level is low, then a radionuclide scan is indicated. If the scan indicates hyperfunctioning of the nodule, then fine-needle aspiration is not necessary and radioactive iodine ablation is generally the treatment of choice. With normal to high TSH levels, the need for a biopsy and for follow-up surveillance depends on the findings on ultrasonography. Measuring antithyroid antibodies in a patient with a thyroid nodule is not part of the routine workup.

Answer 336

ANSWER: C This patient has anorexia nervosa, likely a combination of the restrictive subtype and the binge-eating and purging subtype, given the dental findings on examination. This condition is difficult to treat and carries significant risk of mortality, with an estimated aggregate mortality of 5.6% per decade. Coexisting psychiatric conditions are common, with major depression, anxiety disorders, obsessive-compulsive disorder, and trauma-related disorders predominating. Medical complications include disorders of the esophagus and stomach related to repeated vomiting; cardiovascular conditions associated with bradycardia, orthostatic hypotension, and arrhythmias; renal disease due to chronic dehydration and electrolyte abnormalities; and osteoporosis and bone marrow abnormalities. Treatment may be provided in inpatient or outpatient settings, depending on the severity of disease. Psychotherapy is the foundation of treatment and parental involvement is key for children and adolescents. Parents or guardians typically have a high level of distress around their child’s condition and family therapy helps provide consistent support for treatment goals set by the care team. Other types of one-on-one therapy may be appropriate to augment family therapy and for adolescents with specific comorbidities. Psychotropic drugs have not been consistently and clearly shown to add benefit to psychotherapy, although they are often prescribed.

Answer 337

ANSWER: D This patient has abnormal uterine bleeding characterized by an increased frequency and volume of vaginal bleeding. Due to the increased risk of endometrial cancer, current guidelines recommend that all women >45 years of age presenting with abnormal uterine bleeding undergo endometrial sampling. Irregular menses can occur during the perimenopausal period but this patient’s increased frequency and volume of vaginal bleeding combined with her age warrant further evaluation. In a patient with an up-to-date Papanicolaou smear and normal-appearing cervix, HPV testing would have no role in the evaluation. Transvaginal ultrasonography is recommended if a bimanual examination is abnormal or if symptoms persist despite treatment. CT is rarely indicated if imaging is necessary, because transvaginal ultrasonography is preferred.

Answer 338

ANSWER: E Acute Charcot neuropathy is a commonly missed diagnosis, and the diagnosis is delayed in up to 25% of cases. The diagnosis should be considered in patients over age 40 with neuropathy and obesity who present with unilateral foot swelling. There may be associated erythema and warmth, and pain may be absent. In a patient with suspected acute Charcot neuropathy, bilateral weight-bearing radiographs are recommended to detect fractures of the midfoot. Acute Charcot neuropathy is frequently painless, and its consequences can be severe, so it would be inappropriate to counsel a patient that lack of pain means the absence of serious disease. Charcot neuropathy is commonly misdiagnosed as cellulitis. In this patient’s presentation, cellulitis is not a clear diagnosis, and Charcot neuropathy needs to be considered before initiating treatment for cellulitis. Compression stockings and leg elevation are appropriate for peripheral edema when other causes of edema have been evaluated and addressed, but in this case the swelling is lower on the leg than what compression stockings would usually treat, and further evaluation is required prior to treatment. There is no evidence for ankle sprain or instability in this patient, so an ankle brace would not be appropriate.

Answer 339

ANSWER: A The American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) guideline recommends use of a validated clinical prediction rule, preferably the Pneumonia Severity Index (PSI), to determine the need for hospitalization in adults diagnosed with community-acquired pneumonia (CAP) (strong recommendation). The yield of blood cultures is around 2% (outpatients) to 9% (inpatients) in adults with non-severe CAP. A sputum culture and a Gram stain of respiratory secretions are recommended in patients classified as having severe CAP, or in those with strong risk factors for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa. Randomized trials have failed to show a benefit for urinary antigen testing for Streptococcus pneumoniae and Legionella. ATS/IDSA guidelines recommend empiric antibiotic therapy for adults with clinically suspected and radiographically confirmed CAP regardless of the initial serum procalcitonin level (strong recommendation). Coverage for MRSA is not recommended in patients without risk factors for MRSA pneumonia.

Answer 340

ANSWER: C Direct oral anticoagulants such as apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban are first-line agents for prevention of stroke in patients with nonvalvular atrial fibrillation with a CHA2DS2-VASc score 2 in men or 3 in women. For patients with atrial fibrillation without valvular heart disease, forgoing antithrombotic therapy is only appropriate in patients with a CHA2DS2-VASc score of 0 in men and 1 in women. Aspirin should not be considered a substitute for anticoagulation but may be suggested for patients with an unprovoked deep vein thrombosis or pulmonary embolism who do not wish to receive lifelong anticoagulation. Low molecular weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism, although direct anticoagulants may be appropriate in some situations. If a patient has moderate to severe mitral stenosis or a mechanical valve, then vitamin K antagonists are the preferred agent.

Answer 341

LMWH (enoxaparin)

Answer 342

Moderate to severe mitral stenosis or mechanical valve

Answer 343

Apixaban (eliquis) Betrixaban Dabigatran Edoxaban Ribaroxaban (xarelto)

Answer 344

ANSWER: B In 2018, 1 in 10 infants born in the United States were preterm, with significant racial and ethnic differences noted. Breastfed infants born before 37 weeks gestation should receive iron supplementation at 2 mg/kg/day after 1 month of life. This infant does have some physiologic reflux but since this infant appears asymptomatic, the parents should be counseled on behavioral techniques to reduce spitting up, as there is no clear long-term benefit to antireflux medication. This infant’s growth and development are normal so there is no indication for caloric fortification of breast milk, which is more appropriate for small-for-gestational-age infants or those born below the 10th percentile. There is no specific recommendation for micronutrient supplementation other than iron and vitamin D, so there is no indication to initiate vitamin E supplementation. This child should be screened for developmental delay at each office visit, but there is currently no evidence of delay so referral to early intervention is not indicated.

Answer 345

ANSWER: D The evidence suggests that this patient did not have syphilis prior to this lone contact and a diagnosis of syphilis cannot be confirmed by examination or testing at this point. He should be treated presumptively for early syphilis, even though the serologic test result is negative, because he had sexual contact within the past 90 days with a person who was diagnosed with secondary syphilis. The same is true for individuals exposed to sex partners diagnosed with primary or early latent syphilis during the same time period. When the contact occurred more than 90 days before confirmation of a negative serologic test result, no treatment is necessary. The recommended treatment for individuals such as this patient and for those with primary or secondary syphilis is a single dose of penicillin G benzathine, 2.4 million units. For patients with a penicillin allergy, oral treatment with doxycycline, 100 mg twice daily; tetracycline, 500 mg four times daily; or azithromycin, 2 g as a single dose, has been effective as an alternate treatment option but should only be used when penicillin is contraindicated and should be followed by close monitoring of serologic tests.

Answer 346

ANSWER: D The likely etiology of this patient’s lesion is neuropathy, most likely due to poorly controlled diabetes mellitus. Peripheral neuropathy can predispose patients to abnormal gait patterns and/or unrecognized trauma. These deep ulcers usually present over a bony prominence and are surrounded by a callus (SOR A). 64 Ulcers of arterial origin are due to tissue ischemia and are most typically deep but on the anterior leg, distal dorsal foot, and toes, and have a dry, fibrous base with poor granulation tissue. Tendons can be exposed. Venous ulcers are due to venous hypertension and chronic venous insufficiency. These ulcers are shallow and exudative with good granulation tissue in the base. Common locations are over bony prominences such as the medial malleolus. Infectious lesions would typically have erythema and extensive exudation. Pressure ulcers occur on areas of high pressure in patients with limited mobility, especially on the sacrum, heels, and hips.

Answer 347

ANSWER: C Iron deficiency anemia is the most common cause of koilonychia, which is also known as spoon nail because it appears as a central depression in the nail that curves outward away from the nailbed, giving the nail the appearance of a spoon. If iron deficiency anemia is the cause of koilonychia, the nail will return to a normal appearance when the anemia is corrected. Chronic pulmonary disease is associated with clubbing of the nails. Hyperthyroidism can result in onycholysis and brown discoloration of the nail plate. Onychomycosis causes onycholysis, hyperkeratosis, and yellow streaks. Psoriasis typically causes pitted nails, although patients can also have some hyperkeratosis and onycholysis.

Answer 348

ANSWER: D Pharmacologic treatment should be initiated in patients with gestational diabetes mellitus (GDM) when nutrition and exercise therapy are not adequate to meet goals. Accepted goals are fasting blood glucose levels <95 mg/dL, 1-hour postprandial glucose levels <140 mg/dL, and 2-hour glucose levels <120 mg/dL. Although oral antidiabetic medications are being used more frequently in GDM, insulin is the preferred treatment recommended by the American Diabetes Association and the American College of Obstetricians and Gynecologists. Oral medication may be initiated in patients who refuse insulin or are unable to comply with insulin management. This recommendation is made predominantly because metformin has not shown superiority and there is a lack of long-term outcome studies in the offspring exposed to metformin. Glyburide has not shown outcomes equivalent to those of metformin or insulin.

Answer 349

ANSWER: B This patient presents with trigger finger, which has a lifetime prevalence of 2%–3% in the adult population, with higher prevalence rates in patients with diabetes mellitus. There are several options for conservative treatment that are appropriate prior to consideration of surgical release. Splinting, which is a first-line treatment, has been shown to be effective. Single-joint orthoses at either the metacarpophalangeal or the proximal interphalangeal joint can be effective (SOR B). The duration of splinting can range from 6 weeks to 3 months. A retrospective case series analysis of trigger finger managed by observation only found that trigger finger resolved spontaneously in 52% of patients, with the majority resolving within 1 year. Corticosteroid injections are generally effective but efficacy depends on the severity of the condition and on the number of fingers involved. They are more effective than NSAID injections (SOR B). Surgical release is considered the most effective treatment but not the most cost-effective. A series of three corticosteroid injections could result in savings of up to $72,000 in one study.

Answer 350

ANSWER: D Several medications can be secondary causes of hypertriglyceridemia, including -blockers, with the exception of carvedilol. Others include oral estrogens, glucocorticoids, bile acid sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, and thiazides. Calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers are not associated with hypertriglyceridemia.

Answer 351

Mild: dexamethasone Moderate-severe: nebulized epinephrine

Answer 352

ANSWER: A The defined age at which a woman loses natural fertility is not known. The median age for menopause in the United States is approximately 51 years of age, but it can normally occur anytime between 40 and 60 years of age. The American College of Obstetricians and Gynecologists and the North American Menopause Society both currently recommend that women continue contraceptive use until menopause or age 50–55 years. For women on hormonal contraception no current laboratory test can confirm the menopausal state. Natural pregnancy is uncommon for women over 44 years of age, but the risks associated with pregnancy beyond that age may exceed the risks associated with use of combined oral contraceptives (COCs) in women who do not have certain chronic conditions. For this group, increased risks for developing breast cancer in women over 40 years of age and stroke for women over 45 years of age who continue to use COCs has been shown to be nonsignificant in recent studies (level of evidence 2). It is not clear that the increased risk for myocardial infarction or thromboembolism associated with the use of COCs is any higher above baseline for women over the age of 45 years than for younger women.

Answer 353

C) A negative serum antinuclear antibody The diagnosis of systemic lupus erythematosus (SLE) can be difficult and is often not established for months or even years, due to the significant overlap of symptoms with many other conditions. The American College of Rheumatology has established 11 diagnostic criteria, at least 4 of which must be met over time, to establish a diagnosis of SLE. The vast majority (>95%) of patients with SLE have a positive antinuclear antibody (ANA) test, thus it is sensitive as an initial test in a patient for whom there is clinical suspicion for SLE. However, testing for other immunologic subgroup ANA markers should be performed in a patient with a positive ANA. If one or more of those are positive, then the likelihood of SLE is higher. The majority of patients with a positive ANA do not have SLE but a negative ANA is very unlikely in a patient who has SLE. The typical malar rash of SLE is one of the 11 clinical criteria but is only present in approximately 30% of patients with SLE. Up to 80% of patients may have some form of cutaneous involvement over the course of the disease but hair loss is not specifically a feature of SLE. Other potentially helpful but nonspecific findings in SLE include proteinuria and RBC cellular casts, both of which are indicators of nephritis, but their absence does not rule it out. The subgroup markers (anti-dsDNA, anti-SmDNA, complement C3, C4, CH50) should only be obtained in patients suspected of having SLE who have a positive ANA. Myalgias or arthralgias and synovitis in two or more joints (not limited to large or small joints) is another one of the clinical diagnostic criteria.

Answer 354

ANSWER: D According to the International Classification of Headache Disorders, this patient meets criteria for the diagnosis of migraine without aura. Many medications have been studied for the prevention of migraine. Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine prevention by consistent, good-quality evidence. One of these medications should be offered as first-line treatment. Studies of fluoxetine have demonstrated inconsistent results. Gabapentin has been evaluated in six randomized, controlled trials with mixed results. Three studies have been conducted with ACE inhibitors and angiotensin receptor blockers for migraine prevention, with just one study showing some benefit. Verapamil has previously been considered effective, but on reevaluation of previous studies, the supporting data for verapamil is insufficient to prove efficacy.

Answer 355

ANSWER: C Alendronate decreases the risk of osteoporosis-related hip and vertebral fractures in postmenopausal women. The risk for atypical subtrochanteric fractures increases significantly with duration of treatment. The American College of Physicians evidence-based guideline recommends a maximum treatment duration of 5 years with alendronate. Continuation of treatment beyond 5 years should be reassessed at that point and determined based upon an individualized discussion of risks and benefits.

Answer 356

ANSWER: D This patient has signs and symptoms of pulmonary hypertension. Diagnostic tests, particularly echocardiography, can confirm this diagnosis. It is important to determine the etiology since addressing the underlying condition is the preferred treatment for most cases of non-severe pulmonary hypertension. Left heart disease, including both preserved and reduced systolic function, is the most common cause of pulmonary hypertension, while chronic thromboembolism, COPD, and sleep-disordered breathing are other possible but less common causes. Idiopathic pulmonary arterial hypertension is a rare cause.

Answer 357

ANSWER: A The threshold for transfusing platelets to prevent spontaneous bleeding in the setting of hypoproliferative thrombocytopeniainmostadultsis<10,000/ L(SORA).Aplateletcount<20,000/ Listhethreshold for use of elective central venous catheter placement. For elective diagnostic lumbar puncture, major elective non-neuraxial surgery, and interventional procedures, the threshold is a platelet count <50,000/ L. For neuraxial surgery a threshold <100,000/ L is recommended.

Answer 358

ANSWER: E Primary amenorrhea is the lifelong absence of menses. If menarche has not occurred by age 15, or no menses have occurred 3 years after the development of breast buds, an evaluation is recommended. The patient’s history should include a review of eating and exercise habits, sexual activity, changes in body weight, perfectionistic tendencies, substance abuse, chronic illness, and timing of breast and pubic hair development. A family history of late growth spurts or late menses may indicate constitutional delay, which manifests as short stature that continues on the same percentile until puberty, when there is a delayed growth spurt to achieve normal height. A physical examination should note trends in height, weight, and BMI. An evaluation should be performed to look for signs of virilization, which would indicate androgen excess found in congenital adrenal hyperplasia, polycystic ovary syndrome, Cushing syndrome, or adrenal tumors. Laboratory testing is usually initiated with a pregnancy test and prolactin, LH, FSH, and TSH levels. Primary ovarian insufficiency is associated with low estradiol levels and high levels of LH and FSH. Generally, the LH/FSH ratio is <1. Patients with congenital adrenal hyperplasia will have low estrogen, LH, and FSH levels. Virilization is generally noted in congenital adrenal hyperplasia, and a 17-hydroxyprogesterone level should be obtained to assess for this condition. Functional hypothalamic amenorrhea will also cause low levels of LH, FSH, and TSH. While polycystic ovary syndrome is associated with low estrogen, LH, and FSH levels, prolactin may be elevated. A pituitary adenoma will cause the prolactin level to be elevated.

Answer 359

ANSWER: B This patient presents with dyspepsia but does not have any alarm symptoms such as weight loss, blood in the stools, or difficulty swallowing. An important cause of dyspepsia is gastric infection with Helicobacter pylori. In patients younger than 55 years of age with no alarm symptoms, a test-and-treat strategy is effective and safe, with esophagogastroduodenoscopy reserved for patients not meeting these criteria (SOR A). Lifestyle interventions and proton pump inhibitor therapy are more effective for GERD. A barium swallow would not be appropriate for this patient at this time.

Answer 360

ANSWER: C Apophysitis is a traction injury at the bony site of the tendon attachment. It most often occurs in children or adolescents who are rapidly growing. Rapid growth results in bone lengthening, which occurs more rapidly than lengthening of the associated muscle and tendons. Osgood-Schlatter disease is one type of apophysitis affecting the patellar tendon attachment at the proximal tibia. Anterior cruciate ligament tears will present with joint laxity and meniscal tears with joint line tenderness. Anterior cruciate ligament and medial meniscus tears are usually associated with trauma, especially in younger patients. A patellar sleeve fracture results from a similar type of apophysitis (Larsen-Johansson disease), which affects the patellar tendon attachment at the lower pole of the patella. It most often occurs in athletic children between the ages of 10 and 12. Patellofemoral pain syndrome may present with a similar history, but the pain is generally felt under the patella and localized tenderness over the tibial tuberosity is not present.

Answer 361

ANSWER: A Hirsutism affects 5%–15% of women and can adversely affect quality of life. It is caused by increased androgen production. Most cases are caused by benign conditions. Polycystic ovary syndrome (PCOS) accounts for 70% of cases with another 25% attributable to idiopathic hyperandrogenism and idiopathic hirsutism. First-line therapy for hirsutism in women who do not desire pregnancy and for whom cosmetic treatments are not effective is combined oral contraceptives (SOR B), which decrease androgen production in the ovaries by decreasing LH levels. Flutamide is an antiandrogen treatment that has been found to be effective but should be avoided due to potential hepatotoxicity. Leuprolide can be used in patients who do not respond to combined oral contraceptives and antiandrogen treatments. However, there are serious side effects with its use, including bone loss and hypoestrogenism. Metformin is not effective for the treatment of hirsutism (SOR B). While this patient likely has PCOS, the anti-insulin medications will not affect excess hair growth. Antiandrogen treatments such as spironolactone and finasteride are second-line therapies that can be added to the combined oral contraceptives if there is no improvement after the first 6 months (SOR A).

Answer 362

targets individuals who may be at risk to devleop a medical condition and intervenes to prevent onset of condition - Vaccines - antismoking - education safe sex

Answer 363

targets individuals who have developed an asymptomatic disease and institutes treatmetn to prevent complications Pap Screening HTN Screening DM and Hyperlipidemia

Answer 364

targets individuals with a known disease with a goal of limiting or preventing future complications screening DM patients for microalbumineuria

Answer 365

Back up is not needed The Centers for Disease Control and Prevention (CDC) provides specific recommendations for backup contraception after IUD insertion. According to the CDC guidelines, this patient does not need to use backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts, the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

Answer 366

Hyponatremia Elderly patients, especially those taking hydrochlorothiazide, are at risk for developing hyponatremia while taking carbamazepine. Carbamazepine is one of the medications that can cause the syndrome of inappropriate antidiuretic hormone secretion, as it interferes with the ability to dilute the urine. It does not lead to the other derangements listed (SOR A).

Answer 367

Oral corticosteroids are not indicated in the treatment of plaque psoriasis. All of the other options are indicated only if topical treatments fail. Of the options listed, the combination of a topical corticosteroid and topical calcipotriene is considered the most appropriate for this patient. Another option would be to add topical tazarotene to the topical corticosteroid. However, when tazarotene is used as monotherapy it often fails to clear plaques and increases the incidence of skin irritation.

Answer 368

The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay. Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.

Answer 369

All patients 65 and older should be given either PCV20 once or PCV 15 followed by PPSV23 at least one year later If immunocompromised can do 8 week later

Answer 370

Primary hyepraldosteronism Check aldosterone/renin ratio

Answer 371

Erythema nodosum

Answer 372

cutaneous rash caused by prolonged heat exposure

Answer 373

associated with parvovirus B19 Slapped cheek appearance

Answer 374

expanding, erythematous, annular rash with or without central clearing and is often associated with tick exposure (Lyme disease).

Answer 375

Erythema multiforme consists of raised, annular, target-like lesions with central erythema and is usually associated with herpes simplex virus type 1.

Answer 376

ANSWER: E Primary prevention of variceal hemorrhage is an important consideration in the management of patients with cirrhosis. Although this patient's varices were diagnosed incidentally, patients with cirrhosis and clinically significant portal hypertension should be screened for varices every 2–3 years with esophagogastroduodenoscopy (EGD). EGD can be deferred in patients with platelet counts <150,000/mm3 and transient elastography with liver stiffness <20 kPa. Once esophageal varices are identified, the criteria for initiating prophylaxis to prevent variceal hemorrhage is based on the risk of bleeding. Findings associated with a high risk of bleeding include small varices in patients with decompensated cirrhosis, small varices with red wale signs (thinning of the variceal wall), and medium to large varices. Patients with small varices not meeting these criteria have a low risk of hemorrhage and do not require prophylaxis. They should be rescreened with EGD every 1–2 years. For patients requiring treatment due to high-risk features, options for primary prophylaxis of hemorrhage include nonselective -blockers such as propranolol or endoscopic variceal ligation. Treatment decisions are based on patient preference, other potential contraindications, and local resources. The need for repeat endoscopy in these cases will depend on the clinical circumstances. If nonselective -blockers are used, they should be continued indefinitely. Octreotide is only given intravenously for acute hemorrhage. There is no evidence that omeprazole slows the progression of esophageal varices. Wale sign: thinning of the variceal wall

Answer 377

ANSWER: A Amiodarone-induced thyrotoxicosis (AIT) is a less common cause of hyperthyroidism and can be particularly difficult to accurately diagnose and treat. AIT type 1 is a form of iodine-induced thyrotoxicosis caused by the high iodine content in amiodarone. AIT type 2 is a form of amiodarone-induced thyroiditis. Digoxin, flecainide, metoprolol, and valsartan do not cause hyperthyroidism.

Answer 378

ANSWER: B Hormone therapy is not required for all transgender patients, but those who receive treatment generally report improved quality of life, higher self-esteem, and decreased anxiety. Feminizing and masculinizing hormone therapies, including the use of estrogen and/or androgen therapies such as testosterone, are partially irreversible. Thus, it is important to make a reasonable, educated decision and use informed consent prior to treatment. Patients who receive masculinizing therapy are at increased risk for erythrocytosis and those who receive feminizing hormone therapy often experience reduced muscle mass and fat redistribution.

Answer 379

ANSWER: A This patient has signs and symptoms consistent with polycystic ovary syndrome (PCOS). The Rotterdam 2003 criteria are the most widely used diagnostic criteria for PCOS, endorsed by multiple national and international professional societies. These criteria require the presence of two out of the following three features: oligomenorrhea, hyperandrogenism, and the presence of polycystic ovaries on ultrasonography. When the first two of these criteria are clearly met, ultrasonography to establish the presence of polycystic ovaries is not required. Therefore, a diagnosis is already warranted for this patient and additional evaluation is not needed. When patients require imaging, pelvic ultrasonography is the preferred modality rather than CT. While this patient has evidence of insulin resistance, as is common for patients with PCOS, a C-peptide test is not indicated. Dexamethasone suppression testing is not indicated because this patient does not have any other clinical signs and symptoms that would be consistent with Cushing syndrome.

Answer 380

ANSWER: D Unconjugated hyperbilirubinemia can be defined as an elevated indirect bilirubin level. While unconjugated hyperbilirubinemia is most commonly seen in hemolysis, another common cause is Gilbert syndrome, which stems from a genetic defect that affects how the liver processes bilirubin. Alcoholic liver disease, biliary tract disease, fatty liver disease, and Wilson disease do not lead to unconjugated hyperbilirubinemia.

Answer 381

ANSWER: A This patient’s clinical picture is most consistent with chronic autoimmune thyroiditis, traditionally known as Hashimoto thyroiditis. This diagnosis is suggested by her neck fullness and symptoms of hypothyroidism. Additionally, a nontender goiter that feels like pebbles on examination is classically reported with chronic autoimmune thyroiditis. Graves disease typically presents with symptoms of hyperthyroidism and, in many patients, orbitopathy (eye bulging). A patient with lymphadenitis typically shows symptoms of a causative infection. Lymphadenitis tends to rapidly enlarge the lymph nodes, which are also typically painful and tender. Lymphoma more commonly presents with fevers, night sweats, unintentional weight loss, itchy skin, and dyspnea. This patient lacks a discrete thyroid nodule, which makes thyroid cancer less likely. Thyroid nodules are more frequently painful, while the neck fullness in chronic autoimmune thyroiditis is usually painless and nontender.

Answer 382

ANSWER: A Most bacteriologic treatment failures for group A Streptococcus (GAS) represent a GAS carrier state. This patient had clinical improvement followed by a second illness with typical features of a viral infection. Oral azithromycin, oral ciprofloxacin, intramuscular benzathine penicillin, and intramuscular ceftriaxone are not appropriate for the treatment of viral infections in a patient who is a pharyngeal GAS carrier.

Answer 383

ANSWER: A Because of their vasoconstricting properties, triptan medications are contraindicated in patients with established coronary artery disease, cerebrovascular disease, or peripheral vascular disease; patients with uncontrolled or multiple cardiovascular risk factors; and patients with certain high-risk migraine syndromes, including basilar and hemiplegic migraines. Triptan use for the treatment of migraine headaches would not be contraindicated with a history of depression with psychotic features, poorly controlled diabetes mellitus, hypertension requiring two medications, or stage 4 chronic kidney disease.

Answer 384

ANSWER: C In addition to bisphosphonates, calcium, and vitamin D, zinc supplementation is recommended to improve bone density in patients with thalassemia and osteoporosis (SOR C). Though hydroxyurea is an indicated therapy to minimize the frequency of blood transfusions needed in transfusion-dependent thalassemia, it does not improve bone density (SOR C). Vitamin C supplementation does not improve bone health in patients with thalassemia and osteoporosis. Deferoxamine infusions are indicated when ferritin levels are >1000 ng/mL in patients with transfusion-dependent thalassemia to reduce iron overload (SOR C). Luspatercept reduced transfusion burden by 33% in a phase 3, randomized study but is not indicated to improve bone density.

Answer 385

ANSWER: E Hyperkalemia is a known side effect of ACE inhibitors and angiotensin receptor blockers such as olmesartan. The risk of hyperkalemia is increased with chronic kidney disease, diabetes mellitus, moderately severe to severe heart failure, NSAID use, and older adults. Chlorthalidone and hydrochlorothiazide can cause hypokalemia, while amlodipine and metoprolol have no significant effect on potassium levels.

Answer 386

ACE inhibitors/ ARBS

Answer 387

Hhydrchlorothiazide and chlorthalidone

Answer 388

ANSWER: B The patient has hidradenitis suppurativa, a chronic folliculitis affecting intertriginous areas in the axillae and the groin that may also occur around the anus and nipples. Treatment depends on severity and ranges from topical to systemic antibiotics. Hidradenitis suppurativa is associated with obesity, diabetes mellitus, Crohn’s disease, arthritis and spondyloarthropathy, metabolic syndrome, polycystic ovary syndrome, pyoderma gangrenosum, and trisomy 21. There are three stages: stage I is single or multiple abscesses without sinus tracts or scarring, stage II is abscess recurrence with sinus tracts and scarring and widely separated lesions, and stage III is diffuse abscesses with interconnecting sinus tracts. Amyotrophic lateral sclerosis has no typical skin manifestation. Dermatitis herpetiformis is associated with celiac disease and has clusters of pruritic lesions. Systemic lupus erythematosus has cutaneous manifestations of a malar rash and may involve subcutaneous lesions without scarring. Hidradenitis suppurativa is not associated with trauma.

Answer 389

Crohns disease

Answer 390

ANSWER: D Biologic therapy for asthma targets type 2 inflammation pathways. According to the 2019 Global Initiative for Asthma (GINA) guidelines, diagnosis and management of severe asthma includes determination of the asthma phenotype to assess for type 2 inflammation. Type 2 asthma includes allergic and eosinophilic asthma. Non–type 2 asthma is driven by neutrophils and is associated with smoking and obesity. Type 2 inflammation is diagnosed by elevated eosinophils in the blood or sputum, elevated fractional exhaled nitric oxide, or a need for oral corticosteroid maintenance therapy. Biologic therapy may be considered in patients with severe type 2 inflammatory asthma who continue to have significant symptoms despite adherence to optimal therapy, including high-dose inhaled corticosteroids and a long-acting -agonist.

Answer 391

ANSWER: E This patient has a low serum TSH level in the presence of normal free T4 and total or free T3 levels, which is consistent with subclinical hyperthyroidism. The etiology of overt and subclinical hyperthyroidism should be determined by clinical symptoms, biochemical markers, and, if indicated, diagnostic studies such as a radioactive iodine uptake (RAIU) scan. A scan that shows multiple areas of increased and suppressed uptake is consistent with toxic multinodular goiter. There is no RAIU with exogenous ingestion of thyroid hormone, painless thyroiditis, and recent excess iodine intake. Graves disease causes diffuse RAIU. It is important to determine the etiology of subclinical hyperthyroidism in order to treat it appropriately. In patients who have TSH levels that are persistently <0.1 U/mL, the American Thyroid Association has a strong recommendation with moderate-quality evidence for treating patients 65 years of age and older; persons with cardiac risk factors, heart disease, or osteoporosis; postmenopausal women not on estrogens or bisphosphonates; and those with hyperthyroid symptoms.

Answer 392

ANSWER: B Tumor lysis syndrome is considered the most common oncologic emergency. It is caused by the rapid release of intracellular material from lysis of the malignant cells. The breakdown of nucleic acids releases large amounts of uric acid and leads to acute kidney failure, which limits clearance of potassium, phosphorus, and uric acid. This leads to hyperuricemia, secondary hypocalcemia, hyperkalemia, and hyperphosphatemia. It can result in acute renal failure, arrhythmia, seizure, and sudden death. While tumor lysis syndrome has been reported with many cancer types, it is more common with acute leukemia and high-grade lymphomas. Patients with this condition generally present within 7 days of cancer treatment, including chemotherapy, radiation, or biologic therapies. It can also occur spontaneously. An LDH elevation related to a high cell turnover rate prior to cancer treatment may indicate an increased risk of tumor lysis syndrome. Hypercalcemia, hypokalemia, hypophosphatemia, and low LDH would not be expected laboratory findings in patients with tumor lysis syndrome.

Answer 393

Limits clearance of potassium, phosphorus and uric acid Hyperuricemia Secondary hypocalcemia Hyperkalemia Hyperphosphatemia

Answer 394

ANSWER: A In the setting of acute symptoms, cardiac stress testing is indicated when there is an intermediate probability of acute coronary syndrome. Cardiac stress testing is also indicated in a preoperative assessment when surgery is at least a moderate risk and the patient cannot reach 4 METs of exertion (climbing a single flight of stairs) without cardiac symptoms. Cardiac stress testing is contraindicated after a recent stroke or TIA and in patients with severe symptomatic aortic stenosis. It is not indicated in asymptomatic patients with no history of revascularization.

Answer 395

ANSWER: A Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. In patients on statin therapy, concurrent use of other medications that are also metabolized by this system, including amiodarone, calcium channel blockers such as amlodipine, certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy. In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9), and this patient’s other medications are metabolized by different mechanisms (empagliflozin) or not significantly metabolized (hydrochlorothiazide and metformin).

Answer 396

ANSWER: E Although it is considered an appetite stimulant, megestrol is not recommended in older adults due to potential harmful side effects and a lack of evidence supporting improved outcomes for the treatment of cachexia in the geriatric population, according to the American Geriatrics Society’s Choosing Wisely recommendation. Acetaminophen is not considered a contributor to weight loss. Though loop diuretics, spironolactone, ACE inhibitors, calcium channel blockers, and propranolol may contribute to weight loss due to their adverse effects, hydrochlorothiazide and angiotensin receptor blockers such as losartan are less likely to contribute to weight loss and the patient’s hypertension is currently controlled on this regimen. The patient’s hypothyroidism is currently stable, so changes to the levothyroxine dosage are unnecessary.

Answer 397

ANSWER: C Crisis planning is recommended for patients presenting with suicidal ideation (SOR B). By identifying social support, local resources, and counseling services, suicidal ideation and days spent in the hospital can be reduced. Direct inquiry about suicide is recommended to better evaluate and treat suicidal patients with more favorable outcomes (SOR B). Though calling 911 may be appropriate for transportation for inpatient therapy if involuntary treatment is recommended, further assessment is needed in this case. Suicide prevention contracts do not effectively prevent suicide (SOR B). Psychogenic medications should not be withheld when treating a patient with suicidal ideation. Evidence has shown that the combination of pharmacotherapy and psychotherapy is most effective (SOR C).

Answer 398

ANSWER: C In March 2020, the FDA upgraded its warning label for montelukast to a boxed warning (black box warning) based on the trends for all neuropsychiatric adverse events, including suicidality, associated with montelukast use reported in the FDA Adverse Event Reporting System database from the date of FDA approval in February 1998 through May 2019 (SOR B). The boxed warning does not indicate an increased risk of delirium, myocardial infarction, or venous thromboembolism.

Answer 399

ANSWER: E This is a typical history for a fixed drug eruption (FDE), which is an immunologic reaction that recurs upon re-exposure to the offending drug. It is most likely related to T-lymphocytes at the dermal-epidermal junction. Sulfonamides and anticonvulsants are the most frequently cited medications, but tetracycline and penicillins have also been reported to cause FDE. FDE is not caused by bacteria. Erythema multiforme does not present as an isolated, recurrent macule and generally has central clearing. Nummular eczema is a coin-shaped, very pruritic patch but does not fit this clinical scenario. Shiga toxin–producing Escherichia coli are rarely found in extra-intestinal sites.

Answer 400

ANSWER: B This patient presents with erosive osteoarthritis that involves the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints with sparing of the metacarpophalangeal (MCP) joints. The primary goals for treating osteoarthritis are to control symptoms such as pain and stiffness and optimize function in order to preserve quality of life. Topical or oral NSAIDs are the most appropriate pharmacotherapy for osteoarthritis of the hand. Colchicine and methotrexate have not been studied for the treatment of osteoarthritis and their use for this condition is not recommended. Colchicine is indicated for the treatment of gout, which is usually pauciarticular and asymmetrical, and methotrexate is effective for rheumatoid arthritis. Conventional synthetic and biologic disease-modifying medications such as hydroxychloroquine and infliximab have not been shown to be effective in the treatment of osteoarthritis. These medications are appropriate for the treatment of systemic lupus erythematosus and rheumatoid arthritis, which have examination findings that involve the MCP and PIP joints but spare the DIP joints.

Answer 401

ANSWER: D Clozapine is a highly effective antipsychotic medication, but its use is limited due to its association with severe drug-induced neutropenia, also referred to as agranulocytosis. Patients must be enrolled in the national Clozapine Risk Evaluation and Mitigation Strategy (REMS) program to receive treatment, and all prescribers and pharmacies must be certified by this program in order to dispense clozapine. The patient’s absolute neutrophil count must be submitted at least every 30 days, or more frequently as determined by stability in treatment. A signed patient consent form should be obtained but is not a part of the Clozapine REMS monitoring system. Monitoring serum clozapine levels and creatinine levels may be appropriate but is not part of the Clozapine REMS program. Family physicians can prescribe clozapine if registered and certified in the Clozapine REMS program, which includes passing a brief knowledge assessment, but specialty training in psychiatry is not required.

Answer 402

ANSWER: C This patient has diarrhea-predominant irritable bowel syndrome (IBS-D) and may benefit from validation of her symptoms and a clear diagnosis that has several substantiated treatment options. A 2021 clinical guideline from the American College of Gastroenterology (ACG) is based on a systematic review performed by a committee of experts in this field. Based on this review, soluble fiber (but not insoluble fiber) has good evidence for the alleviation of global IBS symptoms and is recommended strongly as a first-line intervention. In contrast, a gluten-free diet has not been shown to be beneficial for IBS. A diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has low-quality evidence supporting its benefit but merits a trial in patients who do not have an adequate response to fiber supplementation. The ACG has not commented on prebiotics as a treatment for IBS. A 2018 systematic review concluded that while there are small individual studies suggesting benefit for prebiotics (and probiotics) there is inadequate long-term consistent evidence to support their routine use. Probiotics have mixed and low-quality evidence for benefit in IBS. Because of the inconsistent data the ACG recommends against their use.

Answer 403

ANSWER: E This patient’s pretest probability for pulmonary embolism is high given his multiple risk factors, signs, and symptoms. The presence of a new onset of right bundle branch block in a patient presenting with a sudden onset of shortness of breath and chest pain, especially in the setting of active cancer, should raise suspicion of pulmonary embolism. Other EKG abnormalities include tachycardia or bradycardia, an S1Q3T3 pattern, atrial fibrillation, and T-wave inversions in the anterior leads. Patients with cancers of the pancreas and stomach have the highest risk of developing venous thromboembolism (VTE) and should receive pharmacologic VTE prophylaxis during hospitalizations. In the absence of renal failure, a computed tomography pulmonary angiogram (CTPA) is the most appropriate diagnostic study and would be preferred over a ventilation-perfusion (V/Q) scan. A D-dimer level has a high negative predictive value in the diagnosis of pulmonary embolism; however, it has low specificity, and therefore a high rate of false positives, in patients with active cancer. An elevated troponin level can occur in the setting of pulmonary embolism and is nondiagnostic. Their principal value is in the diagnosis of acute myocardial infarction (SOR A). Doppler ultrasonography of the lower extremities helps identify and locate peripheral deep vein thrombosis and helps support but not confirm the diagnosis of pulmonary embolism. A V/Q scan is a reasonable option when CTPA is contraindicated.

Answer 404

ANSWER: A Osteochondrosis refers to degenerative changes in the epiphyseal ossification areas of growing bones. Legg-Calvé-Perthes disease is a type of osteochondrosis that affects the femoral head. Patients with Legg-Calvé-Perthes disease should be referred to an orthopedist and instructed to avoid all weight-bearing activities until reossification occurs. Osteochondrosis should be differentiated from apophysitis because the etiologies and management strategies differ. Apophysitis is a traction injury to the cartilage and bony attachments of tendons in growing children. Osgood-Schlatter disease, Sever’s disease, and Sinding-Larsen-Johansson syndrome are apophysitis disorders that affect the anterior tibial tubercle, posterior heel, and inferior patellar pole, respectively. Treatment of apophysitis involves stretching, activity modification, icing, and limited use of NSAIDs.

Answer 405

ANSWER: A This patient has psoriasis that is characterized by plaques on her extensor extremities and limited bleeding with removal of the scales (Auspitz sign). First-line treatment for localized plaques is topical corticosteroid therapy, such as clobetasol propionate lotion. Antifungals such as selenium sulfide lotion and terbinafine cream are used to treat dermatophytosis infections including tinea pedis and tinea versicolor. Permethrin cream is indicated for treatment of scabies and lice. Loratadine, an oral antihistamine, is used to treat urticaria.

Answer 406

ANSWER: E This patient has vocal cord dysfunction, sometimes called paradoxical vocal fold motion, a condition in which the vocal cords close during inspiration when they should be open. It is not entirely understood why this occurs but it is associated with other conditions including asthma, GERD, and anxiety disorders. It typically causes sudden, severe shortness of breath and often has a trigger such as exercise, gastroesophageal reflux, inhalation of an irritant, or stress. Symptoms may include chest or throat tightness, inspiratory stridor, and wheezing predominantly over the upper airway. In less severe situations the voice may be impacted, and patients sometimes also describe a chronic cough that occurs separately from more acute symptoms. Vocal cord dysfunction is confirmed by direct visualization of the vocal cords during inspiration via nasolaryngoscopy. Pulmonary function tests are often performed as part of the assessment for shortness of breath and, if performed while the patient is experiencing symptoms, will show a flattened inspiratory flow loop. Treatment is primarily focused on therapeutic breathing maneuvers and vocal cord relaxation techniques. A speech therapist may assist in instructing patients in these techniques. Associated conditions should also be treated to help prevent vocal cord dysfunction. A sleep study, chest radiography, chest CT, and esophagogastroduodenoscopy would not confirm a diagnosis of vocal cord dysfunction.

Answer 407

Temp > 104 F assoc with neurologic conditions ( Headache, confusion, altered mental status, irritability, seizure)

Answer 408

May have neurologic symptoms but are at a lower heat than heat stroke 101- 104

Answer 409

Like heatstoke has temp > 104 but no neurologic symptoms. Instead kidney, muscle or liver injury may be present

Answer 410

Concern for pagets disease of bone. Get xray of skull, pelvis and tibia

Answer 411

ANSWER: B The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°–7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis. The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°.

Answer 412

ANSWER: E Obstructive sleep apnea (OSA) is a common disorder that, if left untreated, can be associated with other serious health conditions such as atrial fibrillation, depression, heart failure, and stroke. Positive pressure therapy is effective and considered the first-line treatment for OSA, although some patients are unable to tolerate this therapy. In obese patients with OSA, bariatric surgery has been shown to reliably result in improvement in >75% of patients and result in remission in 40% of patients after 2 years. Nasal dilator devices and pharmacologic interventions such as clonidine have not been shown to improve symptoms or to be effective for treatment. Positional therapy is not recommended as a long-term solution for severe OSA due to poor long-term compliance. Currently there is insufficient evidence to support oral procedures such as uvulopalatopharyngoplasty as primary interventions for OSA.

Answer 413

Men 5.5 cm Women 5.0 cm

Answer 414

ANSWER: B Lung cancer is the second most common cancer in both women and men, after breast cancer for women and prostate cancer for men. It is the leading cause of cancer deaths in the United States, making it important for primary care providers to screen for this disease process. The primary risk factor for lung cancer is tobacco smoking, which accounts for 90% of all lung cancer cases. Lung cancer has a relatively poor prognosis, but early-stage lung cancer is more amenable to treatment and has a better prognosis. Low-dose CT has a reasonable specificity and high sensitivity for lung cancer in patients at high risk. The eligibility criteria were recently updated by the U.S. Preventive Services Task Force due to evidence of mortality benefit, with a recommendation for screening to begin at age 50 for patients with a 20-pack-year smoking history who are current smokers or have quit within the past 15 years.

Answer 415

Macular degeneration

Answer 416

ANSWER: D Incision and drainage of an abscess along with MRSA antibiotic coverage is recommended for all abscesses greater than 2×2 cm. Incision and drainage of an abscess is almost always indicated and is a cornerstone of treatment. A wound culture with antibiotic sensitivity must be obtained in all cases to guide therapy. MRSA is the most common causative pathogen, so an antibiotic that provides coverage against MRSA, such as sulfamethoxazole/trimethoprim, doxycycline, or clindamycin, should be used as an empiric first-line agent for treatment of a skin abscess, pending culture results. Additional anaerobic coverage is recommended when an abscess is located in the perirectal area or when an abscess occurs in an area where tissue ischemia is likely.

Answer 417

ANSWER: E This patient presents with stable angina and documented coronary atherosclerosis. His slight troponin elevation is a marker of elevated risk. The addition of low-dose rivaroxaban to aspirin has been shown to decrease cardiac and all-cause mortality in patients with coronary artery disease (CAD) and may be offered to this patient (SOR A). Dual antiplatelet therapy with clopidogrel and aspirin is recommended for 1 year after stenting but is not recommended in patients with stable angina who do not have stents. Colchicine has been associated with decreased cardiac events in patients with CAD but may increase all-cause mortality. Icosapent ethyl has been shown to decrease cardiac events but not mortality in patients with hypertriglyceridemia >150 mg/dL. Isosorbide mononitrate may be indicated to improve angina symptoms but does not improve mortality risk.

Answer 418

ANSWER: A This patient has osteomyelitis until proven otherwise. A radiograph of his right foot is the best initial test to look for evidence of this diagnosis. In most treatment settings, radiography is much easier to obtain than ultrasonography, CT, MRI, or technetium 99m bone scintigraphy. In addition, it is generally considerably less expensive than the other options listed. A radiograph also allows the physician to rule out other bony pathologies. MRI is useful if the radiograph is inconclusive, and is more helpful than radiography for determining bony versus soft-tissue infection. CT may be used in cases where MRI is contraindicated. Ultrasonography is not useful for evaluating bony lesions. Bone scintigraphy has low sensitivity, particularly in the setting of recent trauma or surgery.

Answer 419

ANSWER: E The majority of patients with systemic lupus erythematosus (SLE) follow a relapsing-remitting course, and management requires monitoring clinical symptoms and laboratory studies. Prolonged remission and persistently active disease are both infrequent. In addition to monitoring anti–double-stranded DNA, complement levels, erythrocyte sedimentation rates, C-reactive protein levels, WBC counts, platelet counts, serum creatinine levels, and glomerular filtration rates, monitoring urine studies for proteinuria is important to assess disease activity over time. Lupus nephritis is a significant cause of morbidity and mortality associated with SLE. Anti-cyclic citrullinated peptide and creatine kinase levels are associated with rheumatoid arthritis and polymyositis, respectively. These tests may assist in ruling out other autoimmune diseases but are not helpful once a diagnosis of SLE is made. While an antinuclear antibody (ANA) titer is helpful in making a diagnosis of SLE, it does not assist with assessing disease activity over time and should not be checked once it is known to be positive. Monitoring lipid levels and atherosclerotic cardiovascular risk is important in managing SLE, but lipid levels do not correlate with flares of SLE.

Answer 420

ANSWER: D The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV. Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200cells/ L.HepatitisBvaccineisrecommendedbutwouldnotbenecessaryforpatientssuchasthis one with natural immunity or confirmed immunity from vaccination.

Answer 421

ANSWER: B Patients with end-stage renal disease and diabetes mellitus need careful monitoring of glucose because insulin requirements are difficult to predict and there is an increased risk of hypoglycemia in this setting. The optimal hemoglobin A1c has not been established but maintaining a value between 6% and 9% does decrease mortality. With close monitoring, insulin is preferred for most individuals. Sulfonylureas such as glimepiride and glyburide are associated with a high risk of hypoglycemia and should be avoided in these patients. Metformin should be avoided in those with a glomerular filtration rate <30 mL/min/1.73 m2. Pioglitazone should also be avoided in chronic kidney disease due to the risk of fluid retention and precipitating heart failure.

Answer 422

ANSWER: E Vaccine delay and vaccine hesitancy are on the rise in the United States, so family physicians should be familiar with the nuances of vaccine catch-up schedules as well as contraindications. Rotavirus vaccine has age restrictions and should not be initiated after 14 weeks and 6 days of age. In addition, the rotavirus series must be complete by 8 months of age. These age restrictions are intended to ensure the vaccine is administered when it will be of maximal benefit to children given the slightly increased risk of intussusception after vaccine administration. Hepatitis B vaccine should be administered at routine intervals. Haemophilus influenzae type b, inactivated poliovirus, and pneumococcal conjugate can all be administered to this patient today. However, these vaccines have complex follow-up intervals based on the age at prior doses and age at catch-up. Therefore, the clinician should consult the CDC catch-up vaccine schedule to verify dosing intervals.

Answer 423

ANSWER: D This patient has shoulder impingement syndrome (with a positive Hawkins impingement sign) and evidence of supraspinatus tendinopathy (with a positive empty-can rotator cuff test). However, the negative drop-arm rotator cuff test is evidence against a complete rotator cuff tear with a negative drop-arm rotator cuff test, and the absence of night pain supports this. Physical therapy, along with pain control using NSAIDs, acetaminophen, or short-term opiate medication, would be most appropriate as initial therapy. Complete shoulder rest is inappropriate since his daily activities are not aggravating the problem, and cessation of play is not necessary since other treatment options are available. A subacromial corticosteroid injection, while commonly done and likely to provide short-term pain relief, is unlikely to provide long-term improvement in pain and function. Surgery is a potential option if other treatments fail and a significant tear is proven, but is not preferable as an initial treatment.

Answer 424

ANSWER: D A chest radiograph is appropriate in the initial evaluation of hemoptysis (SOR C). If the chest radiograph does not indicate a cause, then CT or CT angiography with intravenous contrast should be performed (SOR C). CT has become the preferred modality over bronchoscopy because it is more effective in determining the etiology. If CT does not identify the cause, bronchoscopy would be the next step. In addition, other tests including a sputum Gram stain, acid-fast bacillus smear, or sputum cytology can be useful depending upon the clinical situation. If there are concerns about the possibility of immunologic, rheumatologic, or vasculitic disease, testing for immunologic antibodies such as antineutrophil cytoplasmic antibody (ANCA) can be ordered.

Answer 425

ANSWER: C Surgical treatment for obesity results in remission of diabetes mellitus in 60%–80% of patients at 2 years and sustained remission in 30% at 15 years after a Roux-en-Y procedure. Postsurgical dietary recommendations include consuming protein first at each meal, rather than carbohydrates, to prevent malnutrition, and separating consumption of liquids from solids by 15–30 minutes to avoid food passing through the stomach too quickly, which can lead to a decreased sensation of satiety. Patients who are treated surgically for obesity rather than with nonsurgical interventions have a longer overall length of survival. All-cause mortality is decreased by 30%–50% at 7–15 years after surgery. Evaluation for nutritional deficiencies should be performed quarterly for the first year after surgery; after that, annual checks are recommended.

Answer 426

ANSWER: E When testosterone therapy is started, baseline and periodic measurements of PSA and hematocrit should be performed. If the hematocrit increases to >54% the testosterone dosage should be stopped or decreased to avoid hemoconcentration. Liver and renal function tests should be monitored routinely with many drugs but not specifically with testosterone. The C-reactive protein level is not monitored during testosterone therapy.

Answer 427

ANSWER: A Acute bronchitis is caused by a viral infection in 90%–99% of cases. Atypical organisms such as Mycoplasma pneumoniae and Chlamydia pneumoniae are rare causes and have been found in less than 1% of cases of acute bronchitis.

Answer 428

ANSWER: E Corneal abrasions are a common cause of acute eye pain and are often evaluated in primary care settings. Small (4 mm), uncomplicated abrasions typically heal within 1–2 days and usually respond to oral analgesics such as acetaminophen or NSAIDs. A 2013 review reported effective pain relief and earlier return to work with use of topical NSAIDs, although a 2017 Cochrane review subsequently found that evidence may be lacking to support their use, especially considering the higher cost when compared to oral options. Patching has been proven ineffective for pain relief and can delay healing, although ophthalmologists sometimes use patching to treat large abrasions or to provide a protective barrier for patients who may have difficulty avoiding rubbing their eyes, such as children or people with cognitive impairment. Patching of the unaffected eye is done to treat amblyopia but is not appropriate for managing corneal abrasions. Topical corticosteroids such as prednisolone are not appropriate for treatment of corneal abrasions due to increased susceptibility to infection and the risk of delayed healing and should only be used under the guidance of an ophthalmologist. While point-of-care use of topical anesthetics such as tetracaine may be considered, repeated administration is not recommended as continued use may cause damage to the corneal epithelium, delay healing, and mask symptoms. While topical antibiotics are often prescribed in the setting of corneal abrasion to prevent bacterial superinfection, evidence to support this practice in general is lacking. However, contact lens wearers are at increased risk of infection due to Pseudomonas aeruginosa and should be prescribed an antibiotic with antipseudomonal activity.

Answer 429

ANSWER: C This patient presents with symptomatic hyperglycemia in a catabolic state. In such cases insulin therapy is the most reliable way to control hyperglycemia and reverse catabolism. Oral metformin would not be adequate to control this degree of hyperglycemia and might not be tolerated well, given that the current symptoms include nausea and weight loss. Similarly, both empagliflozin, which increases glucosuria and volume contraction, and liraglutide, which decreases gastric emptying and is likely to exacerbate nausea, are likely to be poorly tolerated in this situation. While rapid and effective treatment is essential to prevent further complications, hospitalization is not necessary since the patient has no evidence of diabetic ketoacidosis.

Answer 430

ANSWER: A The traditional approach to outpatient management of acute diverticulitis consists of clinical diagnosis (with or without imaging), antibiotics, and bowel rest. Two cohort studies found no difference in the effectiveness of outpatient treatment of diverticulitis with amoxicillin/clavulanate or with metronidazole plus a fluoroquinolone. Azithromycin is more appropriate for Campylobacter or Escherichia coli infections that cause lower gastrointestinal bleeding. Cephalexin is not an appropriate treatment, and ciprofloxacin monotherapy will not provide adequate coverage. Doxycycline is a treatment for watery diarrhea caused by Vibrio cholerae and Yersinia infections.

Answer 431

ANSWER: D Patients found to have a PVC burden >10% are at risk for PVC-induced dilated cardiomyopathy (PVC-CM). In fact, a PVC burden of 16% has a sensitivity of almost 80% for PVC-CM. Echocardiography should be performed in patients with a PVC burden >10%. Treatment with anti-arrhythmic drugs or radiofrequency ablation reverses cardiomyopathy and its associated increase in morbidity, mortality, and health care spending. Further evaluation for ischemic heart disease may be performed if the patient has risk factors for ischemia. Symptomatic palpitations may be treated with -blockers or calcium channel blockers, even in patients with lower PVC burdens and no cardiomyopathy. Left heart catheterization would not be appropriate.

Answer 432

ANSWER: D Patients who have been treated with neck irradiation for lymphoma require follow-up surveillance with carotid artery ultrasonography every 10 years. There is evidence that asymptomatic carotid artery disease is more common in patients who have been treated with radiation for Hodgkin’s lymphoma compared to the general population. The risk of thyroid cancer is increased by neck irradiation. Hypothyroidism is also a common complication from neck irradiation, and a TSH level should be measured annually for up to 5 years. For patients who have completed treatment for lymphoma, additional surveillance laboratory studies include a comprehensive metabolic panel, fasting glucose level, and CBC. Patients with a history of chest or axillary irradiation should receive annual mammography screening starting 8–10 years after treatment or at age 40, whichever comes first. Breast MRI may be appropriate for patients who received chest irradiation treatment between ages 10 and 30. Parathyroid hormone levels, swallow studies, and neck CT would not be appropriate for this patient as surveillance to monitor for complications from radiation.

Answer 433

ANSWER: B A semen analysis is the first step in the evaluation of male infertility. In males with oligozoospermia (especially if the sperm count is <10 million/mL), the American Urological Association recommends an endocrine evaluation with an FSH level and early morning total testosterone levels. The results of that testing can dictate next steps. A CBC and a basic metabolic panel have no role in the evaluation of male infertility. Antisperm antibody testing is rarely recommended and should only be considered in consultation with a fertility specialist. Scrotal ultrasonography is not recommended in individuals with a normal physical examination and should only be performed in individuals with palpable varicoceles on physical examination. A testicular biopsy is not usually required to help differentiate between obstructive and nonobstructive azoospermia.

Answer 434

ANSWER: C This child displays characteristics of oppositional defiant disorder (ODD). The DSM-5 criteria for a diagnosis of ODD include frequently losing one’s temper, being easily annoyed, antagonism toward authority figures, deliberately annoying others, placing blame on others, and being spiteful or vindictive. These symptoms must occur for at least 6 months, cause distress or negative impacts, and not occur exclusively with substance use or in the course of a psychotic, depressive, or bipolar disorder. Treatment of common comorbid mental health conditions can be associated with improvement in ODD, so it is important to evaluate for attention-deficit/hyperactivity disorder, depression, and anxiety disorders, as well as ODD. Given the persistence of symptoms and maternal concern in this patient, reassurance alone would not be appropriate. Patients with ODD have a high risk of developing other mental health conditions later, and early therapy is recommended. While positive reinforcement is an important parenting strategy for children with ODD, it would not be expected to be effective in isolation. Medication is rarely indicated for ODD, and not as monotherapy. Parent management therapy is an important part of ODD treatment, but therapy should generally include both child therapy and parent training.

Answer 435

ANSWER: C This patient has a classic presentation of croup, which peaks in the fall and winter months. There may not be any particular history of sick contacts and it does not present with a prodrome, in contrast to respiratory syncytial virus. The diagnosis of croup is purely clinical and does not require laboratory studies, viral cultures, or imaging (SOR C). The treatment of croup includes corticosteroids such as dexamethasone in mild cases (SOR A) and the addition of epinephrine in moderate to severe cases (SOR A). The inhalation of humidified air does not improve outcomes (SOR B) nor does nebulized albuterol.

Answer 436

ANSWER: B Maturity-onset diabetes of the young (MODY) is a form of diabetes mellitus in nonobese young adults (under age 30) who have preserved pancreatic -cell function. Nearly 80% of patients with MODY are misdiagnosed as having type 1 or type 2 diabetes. These patients exhibit no signs of insulin resistance (metabolic syndrome, acanthosis nigricans, skin tags, androgenic alopecia), are not obese, have positive C-peptide levels, and have a strong family history of diabetes. MODY does not respond to metformin, but because -cell function is preserved, the hyperglycemia does respond to sulfonylureas. While exercise and a balanced diet of appropriate portions and low carbohydrates are also necessary in patients with MODY, a ketogenic diet is not specifically indicated. Insulin is required only during pregnancy.

Answer 437

ANSWER: B All unvaccinated household contacts and sexual contacts should receive postexposure prophylaxis following significant exposure to hepatitis A within the previous 2 weeks. Healthy individuals 12 months to 40 years of age should receive the hepatitis A vaccine as prophylaxis. Infants younger than 12 months of age should receive immune globulin as postexposure prophylaxis. Individuals >40 years of age, as well as immunocompromised patients, should receive both hepatitis A vaccine and immune globulin.

Answer 438

ANSWER: E The absolute risk reduction (ARR) in this meta-analysis was 0.4%. The number needed to screen is the reciprocal of the ARR. The number needed to screen would equal 1 divided by the ARR (1/ARR), or 1/0.004, which equals 250. Based upon this meta-analysis, 250 individuals would need to be screened to prevent one lung cancer death.

Answer 439

ANSWER: C The duration and characterization of this patient’s cough are most suggestive of pertussis. Of the options listed, azithromycin is the most appropriate for management of pertussis. Azithromycin is most effective for treatment and minimizing spread of the disease within 21 days of symptom onset. Sulfamethoxazole/trimethoprim and other macrolides, such as erythromycin and clarithromycin, are also acceptable options. Continued supportive care only does not provide the advantages of cure and minimization of community spread that are accomplished by initiating azithromycin. Symptomatic treatment with over-the-counter medication is appropriate but such supportive care does not replace the therapeutic advantages of azithromycin. This patient’s objection to routine vaccination should be explored as priorities allow. He should be vaccinated against pertussis with Tdap as soon as feasible, but the vaccination would not provide immediate treatment of his current episode of pertussis. Doxycycline has shown benefit in other bacterial infections but does not provide effective treatment of pertussis. Based upon the duration of symptoms, quality of his cough, and lack of documented fevers, this patient is not likely to have influenza, so oseltamivir would not be appropriate.

Answer 440

ANSWER: B Adrenal incidentalomas usually do not produce overt hormone excess, but mild autonomous cortisol secretion (MACS) is present in up to 30%–50% of cases. This mild secretion of cortisol may predispose patients to metabolic syndrome, osteoporosis, and cardiovascular events. MACS can be ruled out with an overnight 1-mg dexamethasone suppression test. The remainder of the evaluation can be based on CT findings and clinical symptoms. An ACTH stimulation test is used to evaluate for adrenal insufficiency, which is not caused by an adenoma. If no hypertension or hypokalemia are present, the serum aldosterone and plasma renin activity paired values may not be necessary. Testing for metanephrines is indicated only if pheochromocytoma is suspected. If no clinical symptoms of pheochromocytoma (such as hypertension, sweating, or headaches) are present and the lesions are <10 Hounsfield units on CT, pheochromocytoma and malignancy are very unlikely. A PET scan would not be indicated in this scenario.

Answer 441

ANSWER: C A nondisplaced spiral fracture of the distal tibial shaft (toddler’s fracture) should be suspected in children from 9 months to 3 years of age who present with pain in the distal third of the tibia after minor or even unnoticed injury. Toddler’s fractures can have subtle radiographic findings and may not be visible on initial radiographs, so repeat radiography to look for healing is appropriate. Standard treatment is immobilization of the affected leg. While the fracture may heal without immobilization, reassurance alone is not recommended given the unclear diagnosis. If repeat radiography is negative and symptoms have resolved, reassurance may then be appropriate. For children with possible septic arthritis, laboratory studies should be considered, but in this case there are no signs of infection. Bone scintigraphy is more sensitive than radiography and can be considered if follow-up radiography is negative and symptoms persist. Toddler’s fractures routinely heal without complication, so referral to an orthopedic surgeon at this time would be premature.

Answer 442

ANSWER: D Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD), the National Initiative for Health and Care Excellence, and the American College of Chest Physicians all recommend that in addition to smoking cessation, COPD should be treated initially with either a long-acting -agonist (LABA) or a long-acting muscarinic antagonist (LAMA). If symptoms persist with either of those inhaled medications then combination therapy should be initiated. An inhaled corticosteroid (ICS) can be added to the LABA/LAMA regimen for triple therapy if symptoms continue. Long-term use of an ICS as monotherapy is not recommended due to a slight increase in the incidence of pneumonia. Inhaled corticosteriod: Flovent® (fluticasone) Pulmicort® (budesonide) LAMA: tiotropium, aclidinium, umeclidinium, and glycopyrrolate LABA: Serevent (salmeterol), Foradil (formoterol), and Striverdi (olodaterol).

Answer 443

ANSWER: D COPD exacerbations, when caused by an infectious agent, may be bacterial or viral. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines support the use of antibiotics in patients with an acute COPD exacerbation with the three cardinal symptoms of increased dyspnea, increased sputum volume, and increased sputum purulence; in patients with increased sputum purulence and one of the other cardinal symptoms; and in patients who require invasive or noninvasive mechanical ventilation. Hypoxemia and fever, although often seen in the setting of COPD exacerbations, do not provide as strong an indication for treatment with antibiotics. Diffuse wheezing is a hallmark examination finding that is present in most COPD exacerbations, regardless of the underlying cause. Leukocytosis is a relatively nonspecific marker for acute inflammation and may be seen with either viral or bacterial etiologies. Serum biomarkers such as C-reactive protein and procalcitonin have yielded controversial and conflicting evidence in guiding antibiotic therapy.

Answer 444

ANSWER: B The first step in the evaluation of a palpable thyroid nodule is to obtain a TSH level and perform thyroid ultrasonography (SOR C). If the TSH level is low, a radionucleotide thyroid uptake scan is the appropriate next step to assess for a hyperfunctioning nodule. If the TSH level is normal or high, next steps are determined by the size and characteristics of the thyroid nodule on ultrasonography. Fine-needle aspiration (FNA) may be indicated depending on the size and nodule characteristics. Molecular testing of FNA specimens is useful in order to guide management of thyroid nodules with indeterminate cytology. Before molecular testing is performed, patients should be counseled about the potential benefits and limitations of the test (SOR C). Observation only would not be appropriate in this scenario.

Answer 445

ANSWER: C Obsessive-compulsive disorder (OCD) affects 3% of the population and is characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions). Obsessions are often religious, sexual, or violent in nature. They may include pathological doubting, preoccupation with contamination, concerns with symmetry, and a sense that something unpleasant or dangerous will happen if a particular ritual is not performed precisely. Typical compulsions include counting, checking, repeating, cleaning, and arranging behaviors. For the diagnosis to be made, these symptoms must be severe enough to cause marked distress or to impair functioning. Most patients develop symptoms prior to age 35, and a large number of them keep these symptoms a secret. There is often a delay of 5–10 years before the illness comes to medical attention. With optimum treatment, 90% have moderate to marked improvement. Treatment of OCD requires the integration of various approaches to maximize the outcome. Most patients experience substantial improvement using a combination of pharmacotherapy, particularly SSRIs, and cognitive behavioral therapy. Benzodiazepines such as alprazolam are capable of relieving generalized anxiety, but do not affect obsessions or compulsions. Antipsychotics such as risperidone may be added to an SSRI as second-line pharmacotherapy. Traditional psychodynamic psychotherapy is not effective for OCD.

Answer 446

ANSWER: E Meralgia paresthetica is a common cause of anterolateral hip pain and dysesthesia. It is caused by compression of the lateral femoral cutaneous nerve as it courses under the inguinal ligament into the subcutaneous tissue of the thigh. Tapping over this area during the examination can reproduce symptoms. Obesity is a common cause due to compression of the nerve from overlying pannus. Diabetes mellitus is associated with a sevenfold higher incidence over the general population. Cauda equina syndrome presents with saddle anesthesia and generally marked neurologic disability. Diabetic neuropathy is a peripheral neuropathy initially affecting distal structures such as the toes and feet. Femoral neuropathy would affect sensation in the anteromedial thigh and medial lower leg with weakness in the quadriceps muscle group. The anterolateral thigh would represent the L3-L4 dermatome rather than S1, and the normal straight leg raising test and absence of back pain are evidence against an S1 issue.

Answer 447

ANSWER: A This patient presents with microscopic hematuria without a clear cause. Past guidelines from the American Urologic Association recommended cystoscopy and CT urography for all patients over the age of 35 with microscopic hematuria. However, current guidelines recommend risk stratification and emphasize the use of imaging that has less radiation exposure. Because she is female and younger than 50 years of age, this patient is at low risk of urologic malignancy. Her smoking history and RBC count of <10 RBCs/hpf are also considered low risk. The guidelines recommend the option of repeating urinalysis in 6 months before proceeding with imaging or procedures, given her low risk (SOR C). Renal ultrasonography may be used in intermediate-risk patients, while CT urography is reserved for high-risk patients. Urine cytology is not a recommended test in this setting.

Answer 448

ANSWER: A Annular lesions can be a presentation of several different conditions. This patient’s history of possible tick exposure and current prodromal constitutional symptoms suggest acute Lyme disease. Erythema migrans is the characteristic rash of acute Lyme disease. Erythema multiforme can be spontaneous, related to a viral or Mycoplasma infection, or associated with a medication reaction. Prodromal symptoms are uncommon in limited erythema multiforme and the clinical context of this case suggests a different etiology. Nummular eczema is an intensely pruritic, annular lesion that is not associated with constitutional symptoms. Pityriasis rosea is thought to be viral in etiology and is usually otherwise asymptomatic. Tinea corporis is a fungal infection and is not associated with systemic symptoms.

Answer 449

ANSWER: A This patient has apophysitis at the insertion of the patellar tendon at the tibial tubercle. The clinical diagnosis of Osgood-Schlatter disease is based on history and examination, and imaging is not needed initially. If this patient’s symptoms persist despite treatment, or if there are atypical features or a history of trauma, imaging would be appropriate. Plain film radiography or ultrasonography would be a good first step, with ultrasonography offering the advantage of no radiation exposure. MRI and a bone scan would not be indicated.

Answer 450

ANSWER: C Forced vital capacity (FVC) is the total amount of air that can be expelled from full lungs. A decreased FVC on spirometry indicates a restrictive pattern. FEV1 is the volume of air (in liters) that is exhaled in the first second during forced exhalation after maximal inspiration. A normal FEV1/FVC ratio and normal FVC would indicate a normal pattern. A decreased FEV1/FVC ratio with a decreased FVC is consistent with a mixed pattern. A reduced FEV1/FVC ratio indicates an obstructive pattern. A bronchodilator is then utilized to determine whether the obstructive pattern is reversible or irreversible.

Answer 451

ANSWER: E Resistant hypertension occurs in 5%–10% of adults with hypertension. In this patient, renal artery stenosis is suggested by the increase in creatinine of more than 50% after starting an ACE inhibitor. CT angiography, renal artery duplex ultrasonography, and MR angiography are appropriate diagnostic tests for renal artery stenosis. Other causes of resistant hypertension include hyperaldosteronism (diagnosed with renin and aldosterone levels), thyroid disorders (diagnosed with TSH levels), Cushing syndrome (diagnosed with 24-hour urinary free cortisol), and pheochromocytoma (diagnosed with 24-hour urinary fractionated metanephrines and normetanephrines).

Answer 452

ANSWER: B Chronic alcohol use is one of the most common causes of macrocytic anemia. This patient’s normal peripheral smear and reticulocyte index <2% in the setting of anemia suggest decreased red blood cell production, which may be related to alcohol use or nutritional deficiency. Vitamin B12 and folate levels in the normal range rule out deficiencies in these vitamins, though patients with low-normal vitamin B12 and folate levels may warrant testing of homocysteine and methylmalonic acid levels. Anemia of chronic disease is typically characterized by a normocytic or microcytic anemia and a low reticulocyte count. Blood loss and hemolytic anemia are typically associated with a reticulocyte index >2%. Myelodysplastic syndrome is not suggested by the peripheral smear and is less common than anemia related to alcohol use disorder.

Answer 453

ANSWER: A Of the options listed, any primigravida should be encouraged to consider a hospital delivery rather than an out-of-hospital delivery. Pregnant patients with a previous cesarean delivery, multiple gestation (twins or higher), or fetal malpresentation (breech or other) should also be strongly encouraged to deliver in a hospital setting (SOR B). Similarly, pregnant patients at 41 weeks gestation should be encouraged to pursue a hospital delivery (SOR B). The age of the mother is not relevant in this decision unless there are other related increased risks and comorbidities that need to be considered. Patients who do plan a community birth should ensure that their maternity and neonatal health professionals are licensed and meet international Confederation of Midwives Global Standards for Midwifery Education, are practicing within an integrated and regulated health system, and have access to timely and safe transport to a hospital if necessary (SOR C). Unassisted childbirth should also be strongly discouraged (SOR C).

Answer 454

ANSWER: A Vitamin A intoxication can cause hypercalcemia. This includes analogs of vitamin A such as those used to treat acne. The excessive intake of vitamin A is associated with multisystem effects that can include bone resorption and hypercalcemia. Sources of preformed vitamin A include supplements as well as animal sources such as liver, fish liver oil, dairy, and eggs. Vitamin A toxicity should be considered in unexplained cases of parathyroid hormone–independent hypercalcemia. Vitamins B1, C, E, and K are not associated with hypercalcemia.

Answer 455

ANSWER: E This EKG shows a short P-R interval with a slurred upstroke in the QRS complex in the precordial leads. These findings are classic for Wolff-Parkinson-White (WPW) syndrome. In symptomatic patients with sustained ventricular tachycardias, especially with the more dangerous paroxysmal atrial fibrillation, catheter ablation is the preferred therapy. Up to 95% success has been reported. Aspirin alone would be ineffective for anticoagulation in atrial fibrillation, and would not be indicated for this young patient with no other risk factors for stroke. “Pill-in-the-pocket” therapy with agents such as flecainide or propafenone can be used for paroxysmal atrial fibrillation in structurally normal hearts. However, they are not the treatment of choice with WPW syndrome.-Blockers, adenosine, digitalis, diltiazem, and verapamil are contraindicated because they can facilitate conduction on the accessory pathway. This can lead to more rapid atrial fibrillation or even degeneration into ventricular fibrillation. A young patient with a structurally normal heart does not require anticoagulation with warfarin.

Answer 456

Norepinephrine In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and blood pressure. Norepinephrine and dopamine are the preferred pressor agents; however, norepinephrine appears to be more effective and has a lower mortality rate. Norepinephrine is the preferred drug for shock due to sepsis. Its relative safety suggests that it be used as an initial vasopressor. It is a potent vasoconstrictor and inotropic stimulant and is useful for shock. As a first-line therapy norepinephrine is associated with fewer adverse events, including arrhythmia, compared to dopamine. Phenylephrine, epinephrine, or vasopressin should not be used as first-line therapy. Vasopressin is employed after high-dose conventional vasopressors have failed. The use of low-dose dopamine is no longer recommended based on a clinical trial showing no benefit in critically ill patients at risk for renal failure. If an agent is needed to increase cardiac output, dobutamine is the agent of choice.

Answer 457

Prednisone, 10–20 mg once daily The patient described has polymyalgia rheumatica (PMR). The hallmark of this condition is the rapid and often dramatic response, typically within a few days, to low-dose corticosteroids. In fact, the lack of response to low-dose prednisone in such a case should prompt the physician to consider another diagnosis. A related condition, giant cell arteritis, is associated with transient or even permanent vision loss, typically unilateral but sometimes bilateral. This condition usually presents with headache and tenderness of the affected artery, most commonly the temporal artery. Prompt recognition and the initiation of high-dose corticosteroids are keys to preventing blindness. The other options listed are not pertinent to the management of PMR. While prompt response to low-dose corticosteroids confirms the diagnosis, they are usually continued for 1–2 years, with gradual tapering beginning several months after initiation of treatment (SOR C).

Answer 458

Roseola infantum This patient has the classic presentation for roseola infantum, which is caused by human herpesvirus 6. The typical history includes a high fever in a child with either mild upper respiratory symptoms or no other symptoms. After the fever subsides, a rash will appear. The rash is self-limited and no treatment is required. Pityriasis rosea typically presents with a single herald patch that is oval-shaped and scaly with central clearing, followed by a symmetric rash on the trunk in a typical distribution along the Langer lines. The rash may last up to 12 weeks and no treatment is required. Erythema infectiosum is caused by parvovirus B19 and is also known as fifth disease. The child will typically have mild symptoms then an erythematous facial rash that has a “slapped cheek” appearance. This is sometimes followed by pink patches and macules in a reticular pattern. Once the rash appears the child is no longer contagious. Molluscum contagiosum is caused by a poxvirus and is characterized by scattered flesh-colored papules with umbilicated centers. Atopic dermatitis typically presents as scaly, erythematous plaques, commonly on the flexor surfaces of the extremities.

Answer 459

Surgical referral This patient has a Jones fracture. The treatment plan for this type of fracture needs to account for the activity level of the patient. It has been shown that active patients have shorter healing times and return to activity sooner with surgical management. A competitive dancer would be best managed with surgery. If the nonsurgical option is chosen the patient is given an initial posterior splint and followed up in 3–5 days, then placed in a short non–weight-bearing cast for 6 weeks, at which time a repeat radiograph is taken. If the radiograph shows healing, the patient can return to gradual weight bearing. If the radiograph does not show proper healing, then the period of non–weight bearing is extended.

Answer 460

Evaluation of the pleural fluid is important to assist in determining the cause of the effusion. Protein, glucose, LDH, and cell counts should be measured in the pleural fluid. This can help determine if the effusion is exudative or transudative. A pleural protein to serum protein ratio >0.5 or a pleural fluid LDH to serum LDH ratio >0.6 suggests an exudative effusion. Lower ratios suggest a transudative process. With transudates, the pleural fluid pH is typically between 7.40 and 7.55, with fewer than 1000 WBCs, and the glucose level is similar to the serum glucose level. Cirrhosis with ascites is a cause of transudative effusion. Pleural effusions associated with malignancy, pneumonia, viral illness, and asbestosis tend to be exudative.

Answer 461

Pleural effusions associated with malignancy, pneumonia, viral illness, and asbestosis tend to be exudative. A pleural protein to serum protein ratio >0.5 or a pleural fluid LDH to serum LDH ratio >0.6 suggests an exudative effusion.

Answer 462

Hyperkalemia is a known side effect of ACE inhibitors and angiotensin receptor blockers such as olmesartan. The risk of hyperkalemia is increased with chronic kidney disease, diabetes mellitus, moderately severe to severe heart failure, NSAID use, and older adults. Chlorthalidone and hydrochlorothiazide can cause hypokalemia, while amlodipine and metoprolol have no significant effect on potassium levels.

Answer 463

Primary hyperaldosteronism serum aldosterone/ renin ratio

Answer 464

Neuroendocrine tumor Flush and diarrhea

Answer 465

Tick exposure annular rash with or without central clearing

Answer 466

consists of raised, annular, target-like lesions with central erythema and is usually associated with herpes simplex virus type 1.

Answer 467

paresthesia and pain in the posterior forearm and dorsal hand as well as weakness in wrist and finger extensors, which can result in wrist and finger drop.

Answer 468

IV Only with acute hemorrhage

Answer 469

Propranolol

Answer 470

Amiodarone

Answer 471

Hemolysis Gilbert

Answer 472

This patient’s clinical picture is most consistent with chronic autoimmune thyroiditis, traditionally known as Hashimoto thyroiditis. This diagnosis is suggested by her neck fullness and symptoms of hypothyroidism. Additionally, a nontender goiter that feels like pebbles on examination is classically reported with chronic autoimmune thyroiditis. Graves disease typically presents with symptoms of hyperthyroidism and, in many patients, orbitopathy (eye bulging). A patient with lymphadenitis typically shows symptoms of a causative infection. Lymphadenitis tends to rapidly enlarge the lymph nodes, which are also typically painful and tender. Lymphoma more commonly presents with fevers, night sweats, unintentional weight loss, itchy skin, and dyspnea. This patient lacks a discrete thyroid nodule, which makes thyroid cancer less likely. Thyroid nodules are more frequently painful, while the neck fullness in chronic autoimmune thyroiditis is usually painless and nontender.

Answer 473

3 years old

Answer 474

Vasoconstriction Avoid in coronary artery disease, cerebrovascular disease, or peripheral vascular disease;

Answer 475

HCTZ ACE inhibitor

Answer 476

Toxic multinodular goiter This patient has a low serum TSH level in the presence of normal free T4 and total or free T3 levels, which is consistent with subclinical hyperthyroidism. The etiology of overt and subclinical hyperthyroidism should be determined by clinical symptoms, biochemical markers, and, if indicated, diagnostic studies such as a radioactive iodine uptake (RAIU) scan. A scan that shows multiple areas of increased and suppressed uptake is consistent with toxic multinodular goiter. There is no RAIU with exogenous ingestion of thyroid hormone, painless thyroiditis, and recent excess iodine intake. Graves disease causes diffuse RAIU. It is important to determine the etiology of subclinical hyperthyroidism in order to treat it appropriately. In patients who have TSH levels that are persistently <0.1 μU/mL, the American Thyroid Association has a strong recommendation with moderate-quality evidence for treating patients 65 years of age and older; persons with cardiac risk factors, heart disease, or osteoporosis; postmenopausal women not on estrogens or bisphosphonates; and those with hyperthyroid symptoms.

Answer 477

Hyperuricemia secondary hypocalcemia, hyperkalemia, and hyperphosphatemia

Answer 478

A repeat TB skin test 2 months after she returns Individuals who travel internationally to areas with a high prevalence of tuberculosis (TB) are at risk for contracting the disease if they have prolonged exposure to individuals with TB, such as working in a health care setting. The CDC recommends either a TB skin test or an interferon-gamma release assay prior to leaving the United States. If the test is negative, the individual should repeat the testing 8–10 weeks after returning. A chest radiograph in asymptomatic individuals or prophylactic treatment at any point is not recommended. Isoniazid and rifampin are options for treatment of latent TB.

Answer 479

Begin thyroid hormone replacement and repeat the TSH level in 6–8 weeks This patient has thyroiditis with biochemical evidence for autoimmune (Hashimoto’s) thyroiditis. The most appropriate plan of care is to begin thyroid hormone replacement and monitor with a repeat TSH level 6–8 weeks later. It is not necessary to include a T3 level when assessing the levothyroxine dose. There is no need to routinely order thyroid ultrasonography when there are no palpable nodules on a thyroid examination. Fine-needle aspiration may be necessary to rule out infectious thyroiditis when a patient presents with severe thyroid pain and systemic symptoms.

Answer 480

c. Oral chewable aspirin (162-325 mg)

Answer 481

c. Ezetimibe, 10 mg daily

Answer 482

Increased potassium

Answer 483

Thiazide diuretic HCTZ Chlorthalidone

Answer 484

Hypercalcemia Increased uric acid Increased lithium in body Hypokalemia Hypomagnesium

Answer 485

Amlodipine Felodipine Nicardipine Nifedipine

Answer 486

Verapamil Diltiazem

Answer 487

Amlodipine Most statins are metabolized in the liver by cytochrome P450 3A4 (CYP3A4) enzymes. In patients on statin therapy, concurrent use of other medications that are also metabolized by this system, including amiodarone, calcium channel blockers such as amlodipine, certain anti-HIV medications, and certain antifungal medications, can increase the risk of complications such as statin-induced myopathy. In this patient, only simvastatin and amlodipine are metabolized by CYP3A4. Losartan is metabolized by cytochrome P450 enzymes other than 3A4 (2C9), and this patient’s other medications are metabolized by different mechanisms (empagliflozin) or not significantly metabolized (hydrochlorothiazide and metformin).

Answer 488

Appetite stimulant Dont use in elderly

Answer 489

Donepezil (Aricept) The 2015 American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults 65 years of age states that donepezil use should be avoided in patients with syncope, due to an increased risk of bradycardia (Moderate Evidence Level; Strong Strength of Recommendation). Donepezil is a cholinesterase inhibitor. Due to their cholinergic effect, these medications have a vagotonic effect on the sinoatrial and atrioventricular nodes. This can cause bradycardia or heart block in patients with or without underlying cardiac conduction abnormalities. Syncope has been reported with these medications. Memantine is an N-methyl-D-aspartate receptor antagonist and is not associated with bradycardia. Escitalopram, lisinopril, and zolpidem are also not associated with bradycardia.

Answer 490

Obesity Esophageal adenocarcinoma has become the predominant type of esophageal cancer in North America and Europe, and gastroesophageal reflux and obesity are the main risk factors. Helicobacter pylori infection, aspirin therapy, NSAID use, and Crohn’s disease are not significant risk factors.

Answer 491

Corticosteroids Immune (idiopathic) thrombocytopenic purpura is an acquired immune-mediated disorder defined as isolated thrombocytopenia not found to have another cause. Treatment is usually restricted to severe thrombocytopenic cases (platelet count <50,000/mm3) unless there is evidence of acute bleeding. Corticosteroids are considered the first-line therapy (SOR C). Intravenous immunoglobulin and rituximab have also been used as first-line agents. Second-line therapies include thrombopoietin-receptor agonists and splenectomy. Further evaluation, including a bone marrow biopsy, to rule out myelodysplastic syndrome and lymphoproliferative disorders is indicated in patients over the age of 60 (SOR C). Platelet transfusion is not indicated in the absence of hemorrhage or a need for surgery.

Answer 492

Divide ERR/CER [a/ (a+c)] / [b/(b+d)]

Answer 493

Subtract CER- EER [b/(b+d)] -[a/ (a+c)]

Answer 494

1/ ARR 1/ [b/(b+d)] -[a/ (a+c)]

Answer 495

1/ ARR [a/ (a+c)] - [b/(b+d)]

Answer 496

a. Recommends 1 time screening in men aged 65-75 years who have ever smoked for AAA with ultrasound (B)

Answer 497

35-70 overweight

Answer 498

a. Age 40-59 w/ 10% CVD risk: decision to initiate low dose aspirin for primary prevention of CVD in adults should be individual one. (C) b. 60 years and old: Recommends against initiating low dose aspirin for primary prevention

Answer 499

a. Recommends biennial screening mammography for women aged 50-74 years (B)

Answer 500

a. Recommends screening for MDD in age 12 and up (B)

Answer 501

a. Recommends screening for hepatitis C virus infection in adults aged 18 to 79 years (B)

Answer 502

a. Screen for HIV infection age 15-65. Younger or older who are at risk should also be screened. (A) b. Recommends screening for HIV in all pregnant patients including those who present in labor with unknown HIV status

Answer 503

a. Recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia (B)

Answer 504

a. Recommends annual screening for lung cancer with LDCT in adults 50-80 who have a 20 pack year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued who person has not smoked for 15 years or develops health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Answer 505

a. Decision for Age 55-69 men should be individualized to have PSA screened. b. Men 70 and older, recommend against screening

Answer 506

a. Recommends that clinicians prescribe statin for the primary prevention of CVD for adults aged 40 to 75 who have 1 or more CVD risk factors (dyslipidemia, diabetes, HTN, or smoking) and an estimated 10 year risk of a CV event of 10% of greater.

Answer 507

a. Recommends screening at 24 weeks or after (B)

Answer 508

1. Heart disease 2. Cancer 3. COVID 4. Unintentional injury 5. Stroke

Answer 509

Bupropion Nortriptyline (SSRI, TCA ineffective)

Answer 510

Those with unstable angina and acute coronary syndrome

Answer 511

MMR Varicella HPV Influenza LAV (different from IV?)

Answer 512

Ichthyosis (hereditary)

Answer 513

Lichen Planus

Answer 514

Fish scaling (Hereditary)

Answer 515

Violet Plaques

Answer 516

Lichen Plaques

Answer 517

Erythema Multiforme

Answer 518

Furuncle (boil) - deep infection of the hair follicle in which purulent material extends through the dermis into the subcutaneous tissue Carbuncle -Coalescence of several furuncle into a single inflammatory mass

Answer 519

Avoid exposure to contaminated water Will resolved Severe cases: ciprofloxacin

Answer 520

white head

Answer 521

Comedonal acne - ketatinolytic agent (topic retinoid) Mild inflammatory acne - ketatinolytic agent or benzyl peroxide Moderate inflammatory acne - retinoid + benzyl peroxide + antibiotic (doxycycline) Severe: Isotretinoin (highly teratogenic)

Answer 522

Erythrasma Corynebacterium minutissimum Topical clindamycin Mod: erythromycin

Answer 523

Near oral treatment Griseofluvin Terbinafine Itraconazole Fluconazole

Answer 524

Start 4 factor prothrombin complex concentrate + IV vitamin K

Answer 525

Pneumococcal vaccine Hib Meningococcal Influenza

Answer 526

Augmentin Any bite: cat human dog

Answer 527

Vibrio fulnificus 3rd gen cephalosporin Doxycycline

Answer 528

Mycobacterium marinum Minocycline Clarithromycin

Answer 529

Borrelia bugdorferi Doxycycline Erythema migranes and bells palsy

Answer 530

Rickettsia Rickettsii Flu like Rash

Answer 531

Agitation anxiety Hyperthermia Hyperreflexia/ clonus/ tremor Sweaty

Answer 532

Iron def anemia Splenectomy Renal failure Aplastic anemia

Answer 533

liver disease hemolytic anemia blood loss hemoglobin variants (sickle cell)

Answer 534

Fasting >= 126 2 hr >= 200 Random >= 200

Answer 535

Predispose to DKA Increase fractures Risk of foot amputations Increased UTI and genital infections

Answer 536

DPP-4 inhibits Use linagliptin in elderly not renally excreted

Answer 537

Metformin Liraglutide Insulin

Answer 538

Lithium Amiodarone

Answer 539

Radioiodine uptake study

Answer 540

Hyperthyroidism TSH receptor stimulating antibodies

Answer 541

Hypothyroidism Thyroiditis

Answer 542

Graves disease - TSH receptor stimulating antibodies Tx: Methimazole better than PTU Surgery

Answer 543

1. TSH If low TSH Get scan (Hot/cold) Hot --> Surgery Cold --> FNA If normal/ high TSH - FNA

Answer 544

Hashimotos Type of thyroiditis

Answer 545

PTU 1st trimester Then methimazole

Answer 546

Increase dose by 25-50%

Answer 547

Primary hyperparathyroidism Sarcoidosis Hodgkin's lymphoma SCC Thiazide diuretic Lithium

Answer 548

Cushings syndrome

Answer 549

Addison disease

Answer 550

AM cortisol Dexamethasone suppression

Answer 551

Addision disease ACTH suppression test

Answer 552

severe alcohol use disorder This patient presents with 6 out of 11 symptoms of alcohol use disorder within a 12-month period, including a strong desire or urge to use alcohol, recurrent alcohol use that has contributed to the inability to fulfill work obligations, continued alcohol use despite interpersonal problems with her family, continued alcohol use despite knowledge that it is causing physical damage to her liver, development of a tolerance to the effects of alcohol over time, and 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 553

A spot urine protein/creatinine ratio 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 554

SGLT2 inhbitors Dapagliflozin

Answer 555

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. The 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 556

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 557

SBP rapidly lower to 100-110s or lower

Answer 558

Pulmary stenosis Aortic stenosis Mitral regurg Tricuspid regurg

Answer 559

Diltazem (Beta blocker as well)

Answer 560

CHA2DS2-VASc Congestive HF HTN Age > 75 (+2) Diabetes Stroke or TIA (+2) Vascular disease Age 65-74 Sex (female) 0= ASA 1= ASA or anticoag >2= anticoag

Answer 561

Wolf parkinson white Bundle of kent If SVT: vagal adenosine If Afib: Ibutilide and procainamidee Fix: Catheter ablation

Answer 562

Prolonged QT Tx IV magnesium

Answer 563

Macrolides (erythromycin, azithromycin) Azyl antifungal (ketoconazole) Fluroquinoles (ciprofloxacin, levofloxacin) Zofran Tricycle antidepressants (amitriptyline, nortriptyline) Amiodarone Procainamide

Answer 564

Factor Xa - Apixaban (eliquis) - Rivaroxaban (xarelto)

Answer 565

if pulseless: defib stable: lidocaine & amiodarone

Answer 566

AAA - smoking aortic dissection - HTNA

Answer 567

Increase in PPV Decrease NPV

Answer 568

Hepatitis B RSV (Birth- 6 month anytime)

Answer 569

RSV (Birth- 6 month anytime) Hep B (2nd dose) Rotavirus DTAP Hib (haemophilus infuenzae) Pneumococcal conjugate Inactived polio

Answer 570

Rotavirus DTAP Hib (haemophilus infuenzae) Pneumococcal conjugate Inactived polio

Answer 571

3rd dose Hep B DTAP (3rd dose) Pneumococcal (3rd dose) Inactivated polio (3rd dose) COVID Flu

Answer 572

Pneumo MMR Varicella Hep A (2 dose series) (6 month apart, have until 18 yrs old)

Answer 573

2 dose series Give 6 months apart Can give from 12 mo to 18 yr

Answer 574

4 dose If given after 15 month no more catch up dose 2 mn, 4 mn, 6 mn, 12 month

Answer 575

Dose 5 not necessary if dose 4 given at 4 years or older 2 mn, 4 mn, 6 mn, 15/18 mn, 4-6 yr

Answer 576

4 factor prothrombin complex concentrate _ Vit K 10 mg IV

Answer 577

> 5 year since last dose

Answer 578

Grade 1 - No blisters - Ibuprofen Grade 2 - Blisters - Ibuprofen Grade 3 - Hemorrhagic blisters & black eschar - Ibuprofen + TPA Grade 4 - Muscle/ bone involvement - Ibuprofen + TPA

Answer 579

Heat exhaustion - Temp 104 - No neuro Heat stroke - Temp 104 - Neuro

Answer 580

Ulnar nerve

Answer 581

Ring and pinky finger Spread fingers apart Bend and straighten ring and pinky finger

Answer 582

Radial nerve

Answer 583

Radial nerve

Answer 584

N- acetylcysteline

Answer 585

Hyperthermia Mydriasis Thirst Flushing Delirm DRY Hot as Hades Blind as a bat Dry as a bone Red as a beat Mad as a hatter Difference from serotonin is dry not sweating

Answer 586

Cyprohepatadine

Answer 587

Lithium Amiodarone

Answer 588

Campylobacter - Azithroymcin Shigella - TMP-SMX (bactrim) , quinolone Salmonella - Levofloxacin

Answer 589

Children: Rota Adulta: Noro

Answer 590

Starts in rectum No SKIPS Only mucosa Rectal bleeding Tx Sulfasalazine, 5- ASA

Answer 591

Full wall thickness Any part of GI tract (terminal ileum) SKIPS around Cobblestonning Ulcerations Strictures Tx Budesonide 5-ASA Steroids

Answer 592

Metoclopramide (For nausea/vomiting) Prochlorperazine (antipsychotic, antiemetic) Sodium Valproate (anticonvulsant)

Answer 593

Ibandronate RaloxifeneR

Answer 594

Stacked coins AML

Answer 595

>100.4 Group B strep Ecoli Listeria

Answer 596

Febrile UTI < 2 y.o Recurrent UTI

Answer 597

Epiglottitis Haemophilus Airway Management Cephalosporin +/- clindamycin

Answer 598

Hand foot and mouth Coxsackie virus

Answer 599

Hand foot and mouth aka Herpangina

Answer 600

Croup aka laryngotracheobronchitis Parainfluenza virus Nebulized epinephrine and dexamethasone

Answer 601

Azithromycin

Answer 602

Fifth disease Erythema infectiosum Parvo B 19

Answer 603

Children < 10 Follows URI Purpura, Colicky abdominal pain, arthritis Can get hematuria and proteinuria Tx: Prednisone

Answer 604

Tinidazole Dont use in pregnancy

Answer 605

Ceftriaxone 500 mg IM if < 150 kg (300 lb) 1 g if > 300 lb

Answer 606

Doxycycline 100 mg BID 7 days Azithromycin 1 g 1x dose ( use in pregnancy)

Answer 607

Glomerulonephritis

Answer 608

Pyelonephritis

Answer 609

Increase in serum creatinine of >= 0.3 within 48 hours Increase in serum creat of >= 1.5 x baseline within 7 days

Answer 610

Acute tubular necrosis

Answer 611

PPIs (omeprazole) Allopurinol NSAIDS Ciprofloxacin Penicilllin cephalosporin Sulfonamides Thiazides/ furosemide

Answer 612

Post infxn glomerulonephritis IgA nephropathy Membranoproliferative glomerulonephritis Henoch-Schonlein purpura

Answer 613

Protein > 3.5 Diabetic nephropathy Minimal change disease Focal segmental glomerulosclerosis Preeclampsia Primary amyloidosis

Answer 614

Metformin Diuretics NSAIDS ACE/ ARB

Answer 615

NSAIDS LIthium Antibiotics - Aminoglycosides - Vancomycin - Amphotericin - IV accylovir ACE/ARB Diuretic PPI Methotrexate

Answer 616

Nitrofurantoin

Answer 617

100 x (UNa x plasma cr)/ (plasma Na x Ucr) < 1% prerenal 1-2 intrinsic renal 2-3 ATN

Answer 618

Fractional excretion of urea

Answer 619

Metabolic acidosis Hyperphosphatemia Hyperkalemia Hypercalcemia/ hypocalcemia

Answer 620

Calcium gluconate Insulin Sodium bicarbonate

Answer 621

Creatinine increased by more than 30%

Answer 622

1) DM 2 ) HTN

Answer 623

GFR < 60 for 3 months

Answer 624

Stage 1: > 90 Stage 2: 60-89 Stage 3a: 45-59 Stage 3b: 30-44 Stage 4: 15-29 Stage 5: < 15 ESRD

Answer 625

Stage 4 < 30

Answer 626

Loop diuretic

Answer 627

Low Ca HIgh PO4 HIght PTH

Answer 628

1) CKD GFR < 60 2) CKD & Albuminuria > 30 3) HTN 4) NOn-diabetic CKD if albuminuria > 300

Answer 629

Tx if BP > 220/120

Answer 630

Tx if BP 150-220 lower to < 140

Answer 631

Duel therapy Asparin + clopidogrel 3 months

Answer 632

Monotherapy clopidogrel or ASA not both

Answer 633

TIA or non-disabiling CVA with ipsilateral 70-99% stenosis

Answer 634

< 16 Oxcarbazepine > 60 Lamotrigine

Answer 635

Ethosuxamide

Answer 636

Suicidality 2x risk Neurotoxicities -ataxia - dizziness - somnuolence - fatigue - HA Rash Liver enzymes

Answer 637

Macrulopapular rash Fever Arthralgias Lymphadenopathy Causing by: Carbamazepine, lamotrigine, valproate, allopurinol, sulfonamides

Answer 638

Decreased effectiveness of hormones Doesnt affect Depo or IUDs

Answer 639

Lamotrigine

Answer 640

4 mg per day

Answer 641

TCA - Amitriptyline - Imipramine

Answer 642

TOpamax depakote

Answer 643

> 100,000 cfu/mL Cephalexin

Answer 644

36-38 weeks

Answer 645

starting aspirin after 12 weeks

Answer 646

Ursodeoxycholic acid

Answer 647

Oxytocin at shoulder delivery

Answer 648

D. Methylergonovine

Answer 649

GLP-1 agonist Dulaglutide (Trulicity®). Exenatide (Byetta®). Exenatide extended-release (Bydureon®). Liraglutide (Victoza®). Lixisenatide (Adlyxin®). Semaglutide injection (Ozempic®). Semaglutide tablets (Rybelsus®)

Answer 650

Median nerve

Answer 651

Radial nerve

Answer 652

OCPs Spironolactone Finasteride

Answer 653

Von Willebrand disease

Answer 654

Endometrial atrophy

Answer 655

Clindamycin MRSA: clindamycin/ bactrim OTher wise: clindamycin, cephalexin, dicloxacilllin

Answer 656

Rifampin Anticonvulsants (except valproic acid) Antifungals HIV meds

Answer 657

Shoulder impingement

Answer 658

DM Parkinson's

Answer 659

Flick sign aka phalens test

Answer 660

Thyroid disease Diabetes Pregnancy ALcholism RA

Answer 661

Plantar fasciitis

Answer 662

40-60 Women DM RA Repeative hand activities

Answer 663

Rolls over

Answer 664

Sits w/o support

Answer 665

pull to stand

Answer 666

stairs, kick ball

Answer 667

stand 1 foot

Answer 668

Duchenne muscular dystrophy

Answer 669

Resolved with skeletal maturity

Answer 670

9-12 months if needed

Answer 671

Left side most common Girls First born Breech Oligohydramnios

Answer 672

webbed fingers or toes

Answer 673

Osteosarcoma

Answer 674

Femoral anteversion 80% improved by age 9-10 Surgery at 9-10 if severe

Answer 675

Metatarsus adductus

Answer 676

Interanl tibial torsoin PT orthotics splints are nto effective ** Resolved by 8

Answer 677

Pain at shin

Answer 678

Observe is cobb angle < 30 perform serial radiographs q 6 months Brace cobb angle 30-40 Surgery cobb angle >40

Answer 679

Supracondylar fracture Long cast 3 week

Answer 680

Hyperpronation

Answer 681

Clavicle fx

Answer 682

Median nerve

Answer 683

Shortened leg and externally rotated

Answer 684

Jersey Finger Avulsion to teh flexor digitorum profundus Surgery

Answer 685

Cetnral slip injury to PIP joint Boutonniere deformity Immobilize in extension

Answer 686

Mallet finger Avulsion to extensor digitorum tendon Splint in extension

Answer 687

Radial nerve

Answer 688

Malleolar pain (posterior margin) Navicular pain Proximal 5th metatarsal pain Cant bear 4 steps

Answer 689

Non displaced spiral fracture Long leg cast 4 weeks

Answer 690

Beta blockers

Answer 691

Blunt chest wall trauma causing arrthymia Need defibritllation

Answer 692

Ascending aortic dilation Aortic dissection

Answer 693

Asymptomatic 3 weeks after postiive test

Answer 694

SCAT (5) SPorts concussion assessment tool

Answer 695

No same day return to play

Answer 696

Face/ Head

Answer 697

posterior drawer

Answer 698

Thessaly maneuver

Answer 699

Entrapment of ulnar nerve at Guyans canal Paresthesias in palmar 5th and ulnar aspect of 4th digit

Answer 700

Throwers and pitchers Ulnar nerve at cubital tunnel Paresthesias/pain in teh ulner forearm and dorsal aspect of 5th and ulnar aspect of 4th digit of throwing arm

Answer 701

Cyclists Pudendal nerve

Answer 702

Looks @ face Responds to voice Lifts head

Answer 703

Laughs Follows past midline No persistent clenching hands

Answer 704

Rolls over Hand to hand transfer

Answer 705

sit w/o support dada mama

Answer 706

Stands Babbles

Answer 707

Walks backward 3-6 words

Answer 708

speaks 2 word together

Answer 709

Throws ball Tricycle

Answer 710

dresses self Speech understandable

Answer 711

18 and 24 month

Answer 712

Oppositional defiant disorder (ODD)

Answer 713

Strep pneum 5-18 yr: mycoplasma pneumoniae - Tx macrolide

Answer 714

Read induration not erythema

Answer 715

Histoplasmosis

Answer 716

Cocccidiomycosis

Answer 717

Outpatient -Amoxicillin -Doxycycline Outpatient w/ comorbidities - Augmentin plus macrolide or doxy or Fluoroquinolone Inpatient - Fluoroquinolone or Beta lactam + macrolide (Ampicillin/sulbactam, ceftriaxone plus clarithromycin, azithromycin) Severe - Beta lactam plus macrolide - Beta lactam plus fluroquinolone

Answer 718

Isonazid and Rifapentine for 12 weeks or Isonazid 6 months (9 months if HIV pos) Aggressive therapy 1) 2 month Isonazid, rifampin, ethambutol, pyrazinamide 2) 4 months isonazid and rifampin

Answer 719

Rifampin 4 months Isoniazid plus rifampin 3 months

Answer 720

day: > 2 per wk but not daily night: > 2 per month

Answer 721

Day: daily Night > 2 per week

Answer 722

Day: <= 2 per week Night <= 2 per month

Answer 723

Day: Daily Night: freqent night symptoms

Answer 724

Intermittent: SABA prn Mild persistent: daily or prn ICS with inhaled SABA prn Moderate to severe: ICS-formoterol therpay (SMART)

Answer 725

Used with ICS in moderate to severe persistent asthma NOT used as monotherapy Formoterol Salmeterol

Answer 726

LABA use w/ ICS Do not use as monotherapy Used in moderate/severe persistent asthma

Answer 727

SMART ICS/formoterol

Answer 728

LAMA Used more in copd Add on to ICS/LABA if uncontrolled severe persistent asthma Dont use if urinary retention/ glaucoma

Answer 729

At firts 2-6 weeks COntrolled every 6 months

Answer 730

Not on ICS Overuse (>= 1 canister) per MONTH of inhaled SABA Absense of Wheezing (silent chest)

Answer 731

Triple therapy for asthma/ copd overlap ICS/ LAMA/ LABA

Answer 732

Triple therapy for asthma/ copd overlap ICS/ LAMA/ LABA COPD FDA approved only

Answer 733

FEV1 < 80 Mild

Answer 734

50 <= FEV1 < 80 Moderate

Answer 735

30<= FEV1 < 50 Severe

Answer 736

FEV1 < 30 Very severe

Answer 737

SABA or LABA

Answer 738

LABA or LAMA

Answer 739

LAMA LAMA/LABA if CAT >= 20 LABA/ ICS if eos > 300

Answer 740

Beta agonist LABA over SABA Formeterol > Albuterol

Answer 741

Sarcoidosis

Answer 742

Sarcoidosis

Answer 743

DEMARDS - non biologicals methotrexate Hydroxychloroquine sulfalazine - biologicals (anti-TNF biologics) Adalimumab Infliximab Etanercept

Answer 744

Ankylosing sponylitis HLA B27 Tx NSALDS

Answer 745

DEMARDS - Etanercept - Infliximab

Answer 746

Dactylitis Nail changes Asymmetric polyarthritis

Answer 747

Can see, pee, climb a tree Urethritis Conjunctiivits Arthritis

Answer 748

DIP: Heberdens PIP: Bouchards B before H

Answer 749

Anti smith Anti ds DNA

Answer 750

Anti-centromete

Answer 751

Anti- SSA/Ro Anti- SSB/ La

Answer 752

C-ANCA P- ANCA

Answer 753

Scleorderma

Answer 754

Polymyositis

Answer 755

Head and neck Abdominal Ortho Prostate

Answer 756

ENdoscopic Cataract Breast Plastic

Answer 757

Antibiotics Steroids Long acting insulin Anti-arrhythmic agents HTN med Statins Neuro/psych meds Anti-parkinson ANtiseizure Benzo Non-biologic Demards (methotrexate) HIV meds

Answer 758

Stop 5-7 days

Answer 759

Stop 5 days prior to surgery STart day after or when taking PO

Answer 760

Stop warfarin 4 days preop Start LMWH Stop LMWH 12-18 hr preop Restart LMWH 6 hr Postop Restart warfarin when taking PO

Answer 761

Day ofStop

Answer 762

stop 7 days

Answer 763

stop 24 hr

Answer 764

stop `1-3 days

Answer 765

Stop all but Long acting insulin

Answer 766

D. Petrolatum Antibiotics aggravate wounds

Answer 767

1. Prosthetic heart valve 2. Previous infective endocarditis 3. Congenital heart disease - unrepaired cyanotic congenital heart disease - repaired heart defect w/ prosthetic devices < 6 month - repair heart defect with lead at prosthetic site 4. Transplant with resultant valvulopathy

Answer 768

B. Perforated duodenal ulcer

Answer 769

B. Ascending cholangitis due to occluded common bile duct Charcot triad - Fever - abd pain - Jaundice

Answer 770

Charcots triad Ascending cholangitis

Answer 771

Appenditicits LLQ palpation causes RLQ pain

Answer 772

Appendicitis RLQ pain on thigh extension while lying in left lateral decubitus position

Answer 773

Appendicitis RLQ pain with internal rotation of flex right thigh

Answer 774

Abdominal crunch (+) if pain persists/worsens --> abdominal wall pathology

Answer 775

age < 14 or pregnancy

Answer 776

Non-contrast CT

Answer 777

Elderly Crampy abd pain Sudden onset N/V Distension

Answer 778

Chronic mesenteric ischemia

Answer 779

Acute mesenteric arterial thrombosis Afib not anticoagulated usually SMA

Answer 780

Ischemic colitis Left colon

Answer 781

Intussuception Meckels diverticulum Hypertrophic pyloric stenosis Necrotizing enterocollitis

Answer 782

Intussusception Male 5-10 month Sausage like mass Tx: barium enema

Answer 783

Meckels diverticulum 2% population 2x more likely male 2 ft from ileocecal valve Technetium 99 scan

Answer 784

Intussusception

Answer 785

Meckels diverticulum

Answer 786

Hypertrophic pyloric stenosis Male >female 3 wks RUQ Olive mass

Answer 787

Necrotizing enterocolitis Increased risk with prematurity pneumatosis interstinalis: gas in wall of intestines NGT decompression, Abx

Answer 788

Amblopia= lazy eye Strabismus: cross eye

Answer 789

Chronic pulmonary emboli Low diffusing capacity of the lungs for carbon monoxide (DLCO) with normal spirometry indicates a disease process that disrupts gas transfer in the lungs without causing lung restriction or airflow obstruction. Common causes include chronic pulmonary emboli, heart failure, connective tissue disease with pulmonary involvement, and primary pulmonary hypertension. Asthma, bronchiectasis, COPD, and pulmonary fibrosis are associated with abnormalities on spirometry.

Answer 790

Clindamycin (Cleocin) Patients with an artificial heart valve should be given antibiotic prophylaxis prior to dental procedures to prevent infectious endocarditis. The organisms that most frequently cause infectious endocarditis include Staphylococcus aureus (31%), Streptococcus viridans (17%), coagulase-negative staphylococci (11%), Enterococcus (11%), Streptococcus bovis (7%), and other streptococci (5%). Amoxicillin is the preferred medication for prophylaxis. Clindamycin or azithromycin can be used in patients with a penicillin allergy. If the penicillin allergy is not associated with anaphylaxis, angioedema, or urticaria, then cephalexin would be an appropriate antibiotic choice. Ciprofloxacin, doxycycline, rifampin, and trimethoprim/sulfamethoxazole are not used for bacterial endocarditis prophylaxis.

Answer 791

Backup contraception is not necessary The Centers for Disease Control and Prevention (CDC) provides specific recommendations for backup contraception after IUD insertion. According to the CDC guidelines, this patient does not need to use backup contraception if her IUD is inserted today because it was inserted within 7 days after menstrual bleeding started. If the levonorgestrel IUD is inserted more than 7 days after menstrual bleeding starts, the patient needs to abstain from sexual intercourse or use additional contraceptive protection for the next 7 days.

Answer 792

Continuous nasogastric enteral nutrition The American College of Gastroenterology recommends that patients with severe acute pancreatitis receive enteral nutrition. Enteral feedings help prevent infectious complications, such as infected necrosis, by maintaining the gut mucosal barrier and preventing translocation of bacteria that may seed pancreatic necrosis. Currently, continuous enteral feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay. Total parenteral nutrition is not recommended because of infectious and line-related complications. It should be avoided unless the enteral route cannot be used.

Answer 793

7% The annual failure rate of combined oral contraceptive pills with typical use is 7%. Typical failure rates for other contraceptive methods are 0.2% for the levonorgestrel IUD, 4% for injectable progestin, 13% for male condoms, and 22% for the withdrawal method.

Answer 794

evidence of symptoms of ADD must be present before age 12 Diagnosing attention-deficit disorder in adults requires symptoms that interfere with social, academic, or occupational functioning and are present in more than one setting. DSM-5 states that a history of symptoms before age 12 is required for the diagnosis. DSM-IVspecified that symptoms must have been present before age 7.

Answer 795

Gastroesophageal reflux Gastroesophageal reflux accounts for a significant number of cases of failure to thrive, crib death, and recurrent pneumonia. Features of gastroesophageal reflux include a history of recurrent pneumonia, a low growth curve, a family history of sudden infant death syndrome, and normocytic anemia. A sweat chloride level of 20 mEq/L rules out cystic fibrosis. Normal serum calcium excludes DiGeorge’s syndrome. The battered child generally presents with more than just a single recurring medical problem. β-Thalassemia would be indicated by a microcytic anemia.

Answer 796

scoliometer measurement with the patient bent over to 90° The forward bend test, combined with a scoliometer measurement, is the most appropriate initial test when evaluating for scoliosis. A scoliometer should be used with the patient’s spine parallel to the floor (bent over to approximately 90°), with the arms hanging down, palms together, and feet pointing forward. If 5°–7° of trunk rotation is assessed by the scoliometer or by a scoliometer app on a smartphone, radiography can be performed to assess the Cobb angle. This radiography should be performed with the patient upright. A Cobb angle >20° may signify scoliosis, which may benefit from bracing, depending on skeletal maturity. Comparing the length from the pelvic brim to the pelvic floor on the left and the right is not indicated in the evaluation for scoliosis. The U.S. Preventive Services Task Force changed its recommendation for scoliosis screening from grade D to grade I in 2018. Bracing has been found to reduce by over 50% the chance that mild to moderate curvatures will progress to curvatures of greater than 50°.

Answer 797

180 mg/dL Sepsis is a severe life-threatening disorder that has a 25%–30% mortality rate. Early aggressive management has been shown to decrease the mortality rate. The initial step in the management of sepsis is respiratory stabilization. Fluid resuscitation should be started and followed by vasopressor therapy if there is an inadequate blood pressure response. Antibiotics should be initiated within 1 hour of presentation. Other interventions in early goal-directed therapy that have been shown to improve mortality rates include blood transfusions, low-dose corticosteroid therapy, and conventional (not intensive) glycemic control with a target glucose level of <180 mg/dL. Intensive management of glucose in critically ill adult patients (a target glucose level of 80–110 mg/dL) has been shown to increase mortality.

Answer 798

Metoclopramide (Reglan) This patient’s history fits the diagnosis of functional dyspepsia. Two subtypes of this disorder have been described. The first, epigastric pain syndrome, is described as intermittent pain and burning in the epigastrium. The second, postprandial distress syndrome, is more typical of the symptoms this patient describes: postprandial fullness and early satiety. Although there is considerable benefit from reassurance and “naming” a patient’s condition, empiric treatment is also warranted. Patients with epigastric pain syndrome are more likely to respond to proton pump inhibitors or H2-blockers. Patients with predominantly postprandial distress symptoms are more likely to improve with a motility agent such as metoclopramide. Sucralfate, antacids, and selective antidepressants have not been shown to be more effective than placebo in functional dyspepsia, whereas tricyclic antidepressants and buspirone have shown some benefit and are reasonable next steps for this patient.

Answer 799

Hypotension Recent guidelines have suggested that hypotension (a systolic blood pressure <90 mm Hg or a diastolic blood pressure <60 mm Hg, for 15 minutes or longer) should be treated with thrombolysis in patients who are not at high risk for bleeding. Patients who have other indicators of cardiopulmonary impairment without signs of hypotension should be given anticoagulation therapy and aggressive supportive care, but should not be treated with thrombolytic therapy. If the patient’s condition continues to deteriorate as evidenced by the development of hypotension or other clinical indicators of cardiopulmonary compromise, thrombolysis may be considered.

Answer 800

1 month According to the guidelines of the American Academy of Pediatrics, elemental iron supplementation (2 mg/kg per day) should begin at 1 month of age for exclusively breastfed infants born before 37 weeks gestation and should continue until 12 months of age, unless the infant had multiple blood transfusions.

Answer 801

2 shots 9-14 - 6 to months apartment - if under 6 months then needs 3 shots > 14 then 3 shots

Answer 802

rota - dont give after 14 weeks

Answer 803

Pemphigus Vulgaris Associated with autoimmune disorder Tx Glucocorticoids Need skin biopsy

Answer 804

T score: -1.1 to -2.4

Answer 805

Elevated parathyroid homrone (PTH) GFR decreases --> increased phosphate due to reduced renal filtering and excretion of phosphate Hyperphosphatemia interferes with renal calcitriol production --> decreased intestinal calcium absorption --> Hypocalcemia Hypocalcemia & hyperphosphatemia stimulate pTH release TX: Limit phosphate and take VItamin D2 (ergocalciferol) - also phosphate binders (sevelamer)

Answer 806

Central disease - Cerebellar stroke - Multiple sclerosis

Answer 807

Suppressible nystagmus that is unidirectional Beats away from the lesion Vestibular neuritis Meniere disease

Answer 808

> 35 who smoke Migraine w/ aura HTN >= 160/100

Answer 809

Lung malignancies Idiopathic pulmonary fibrosis Cystic fibrosis

Answer 810

bicuspid aortic valve Aortic dissection

Answer 811

Hypoalbuminuria Low albumin

Answer 812

1) benzyl peroxide + topical tretinoin 2) Topical antibiotic (clindamycin/ erythromycin) 3) oral antibiotics

Answer 813

Decreased TSH and increased T4 If hypothyroidism before pregnancy - will need increased dose of levothyroxine

Answer 814

Sensitivity/ 1- specificity

Answer 815

Loop diuretic - Furosemide

Answer 816

Dilated pupils Nausea Abdominal pain Tremors

Answer 817

severs disase aka calcaneal apopphytitis

Answer 818

carboprost tromethamine

Answer 819

single dexamethasone dose

Answer 820

B. Thyrotropin receptor antibody levels Serum thyroid peroxidase antibodies may be elevated in both Graves and postpartum thyroiditis Whereas thyrotropin receptor antibodies are elevated only in Graves.

Answer 821

Amantadine can be used for patients under 65 years of age who are only experiencing tremors. Parkinson

Answer 822

DDP DDP-4 Inhibitors: Saxagliptin, sitagliptin, linagliptin, alogliptin cause headache URI, elevated liver enzymes

Answer 823

Thiazolidinediones: Pioglitazone and rosiglitazone, weight gain, salt retention, edema

Answer 824

such as rasagiline and non-ergot dopamine agonists such as ropinirole are not as effective as carbidopa/levodopa for motor symptoms, but they do not cause the dyskinesias and motor fluctuations seen with levodopa. Monoamine oxidase inhibitors are considered first-line therapy for patients under age 65 with mild motor symptoms.

Answer 825

dexamethasone

Answer 826

Beta blocker CCB next verapamil

Answer 827

Glipizide, Glimepride Weight Gain Hypoglycemia

Answer 828

GLP-4 N/V Diarrhea

Answer 829

Gram negative Rods

Answer 830

Gram positive and Gram Negatiev Shigella Salmonella

Answer 831

Bactrim Clindamycin Vancomycin Doxycycline

Answer 832

Cefepime Meropenem Ciprofloxacin Levofloxacin Bactrim

Answer 833

MRSA Gram positive and Ecoli

Answer 834

Short acting anticholinergic or short acting beta 2 agonist Short acting anticholinergic= ipratropium Short acting beta 2 agonist= Albuterol

Answer 835

A) SABA + LAMA or B) SAMA + LABA Albuterol + Tiotropium (spiriva) Ipratropium + salmeterol

Answer 836

LAMA + LABA

Answer 837

umeclidinium (Ellipta) Tiotropium (Spiriva)

Answer 838

Serevent (salmeterol) Foradil (formoterol) Striverdi (olodaterol)

Answer 839

Albuterol [Proair, Ventolin]

Answer 840

Polymyositis

Answer 841

smooth dome shaped red papules that expand rapid overly weeks to sun damaged skin Can have central keratin plug Seen on elderly

Answer 842

A. Ferric citrate

Answer 843

dexamethasone

Answer 844

Primary hyperALDOSTERONISM hypokalemia HTN

Answer 845

Enoxaparin (LMWH) Lovenox

Answer 846

Xarelto (rivaroxaban)

Answer 847

Anterior LAD

Answer 848

Lateral Circumflex

Answer 849

Fluxetine (8 or greater) Escitalopram (12 or greater)

Answer 850

Citalopram Escitalopram Sertraline

Answer 851

Increase pressure > 1000 WBC Protein > 200 (normal 15-45) Low glucose (< 40)

Answer 852

Normal pressure WBC elevated but < 300 Protein elevated but < 200 NORMAL glucose

Answer 853

Median nerve

Answer 854

Sertraline

Answer 855

TTP: FEVER, neurologic signs, thrombocytopenia, anemia, renal dysfunction HUS: thrombocytopenia, kidney disease, BLOODY DIARRHEA, increased creatinine (ecoli)

Answer 856

Desmopressin

Answer 857

Polycythema vera JAK2 mutation hydroxyurea

Answer 858

Fluticasone Budesonide

Answer 859

Cushing disease

Answer 860

parvovirus B19 infection Slap cheek

Answer 861

ANSWER: D This patient needs a tetanus toxoid–containing vaccine for the management of her wound. Since pregnant people should receive a dose of Tdap between 27 and 36 weeks gestation to protect against pertussis, Tdap is the best choice for this patient. Tetanus immune globulin would be appropriate if this patient had not previously completed the primary series or were showing signs of clinical tetanus. Td would be an appropriate option for tetanus prophylaxis in nonpregnant patients who have previously received Tdap. Because this patient requires some form of tetanus prophylaxis at this time, waiting until 38 weeks to administer Tdap is not appropriate.

Answer 862

ANSWER: A Amitriptyline is a tricyclic antidepressant (TCA) used for treating neuropathic pain. It has the potential to cause or exacerbate postural orthostatic hypotension. Compared to other TCAs, first-generation TCAs such as amitriptyline are more prone to cause autonomic nervous system dysfunction and dizziness. Fludrocortisone acetate (9-α-fluorohydrocortisone) is used to treat postural hypotension. It causes salt and fluid retention and may cause supine hypertension and hypokalemia. Midodrine is an α-agonist approved to treat postural hypotension. It also can cause fluid retention and hypertension. Pseudoephedrine and ephedrine cause norepinephrine release from presynaptic neurons. Both are α-agonists and have been used to treat postural hypotension, however they may exacerbate supine hypertension. Epoetin alfa is used to treat anemia associated with chronic kidney disease. It causes hypertension, and is unlikely to trigger or exacerbate postural hypotension.

Answer 863

ANSWER : D This patient has more than a 30% rise in her creatinine level and has no other indication for ACE inhibitor or angiotensin receptor blocker (ARB) therapy for her hypertension. Discontinuing lisinopril and starting a medication from a different class is therefore the most appropriate treatment at this time. The clinical finding of an abruptly rising creatinine level >30% from baseline after the initiation of an ACE inhibitor or ARB may be associated with underlying renal disease such as renal artery stenosis. The rise in creatinine level is associated with an increased risk of renal failure, adverse cardiac outcomes, and death, and the medication should be stopped pending evaluation. A 2017 study suggests that rises in serum creatinine of <30% also put patients at risk for these outcomes, with a dose-response relationship between the magnitude of creatinine change and the risk of adverse outcomes. Renin-angiotensin system blockade has also been associated with long-term benefits, and balancing the benefits and risks of these medications may be complex. Patients with other indications for ACE inhibitors and ARBs such as heart failure benefit from individualized decision-making in this regard. Appropriate alternatives include a calcium channel blocker such as amlodipine or a thiazide-type diuretic.

Answer 864

ANSWER: D Henoch-Schönlein purpura is an IgA vasculitis that is usually diagnosed clinically. It is the most common vasculitis in children and occurs less commonly in adults. It presents as palpable purpura of the lower extremities with at least one of the following diagnostic criteria: diffuse abdominal pain, arthritis or arthralgia, renal involvement (hematuria and/or proteinuria), or a skin biopsy showing predominant IgA deposition. Thrombocytopenia and coagulopathy are not present. Henoch-Schönlein purpura is a self-limited condition with an average duration of 4 weeks, and initial treatment is supportive only. Current evidence only recommends corticosteroids for those with more severe disease such as glomerulonephritis. 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 presents with the classic triad of hemolytic anemia, thrombocytopenia, and kidney injury. Thrombotic thrombocytopenic purpura is rare in the pediatric age group.

Answer 865

ANSWER: A 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. People who are pregnant 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 866

ANSWER: B Patients with high-risk (massive) pulmonary embolism (PE) include those who have experienced hemodynamic decompensation with hypotension, cardiogenic shock, or cardiac arrest. Recent guidelines have suggested that patients with hypotension (a systolic blood pressure <90 mm Hg or a diastolic blood pressure <60 mm Hg, for 15 minutes or longer) should be treated with reperfusion therapy with thrombolysis if they are not at high risk for bleeding, or with other interventions aimed at rapid reversal such as surgical pulmonary embolectomy. Intermediate-risk (submassive) PE describes normotensive patients with evidence of right ventricular compromise or an elevated troponin level, whereas low-risk PE patients are hemodynamically stable, have low risk factor scoring via the Pulmonary Embolism Severity Index (PESI) or other risk calculator, and have neither evidence of an elevated troponin level or right ventricular dysfunction.

Answer 867

ANSWER: C Asymptomatic carotid stenosis of 50%-70% should be treated medically to reduce ASCVD. Initiating statin therapy and smoking cessation will have the greatest impact on reducing his risk. Without past neurologic symptoms from carotid artery disease, surgical intervention would not be indicated due to the potential risks of surgery, but repeat ultrasonography is considered reasonable. Extracranial carotid artery atherosclerosis is a risk factor for stroke and warrants risk factor reduction. Nonsurgical approaches that lower stroke risk include smoking cessation, hypertension management with a goal blood pressure of <130/80 mm Hg, management of diabetes mellitus if present, and initiation of high-intensity statin therapy with a target LDL-cholesterol level of <70 mg/dL. Regular physical activity regardless of BMI is associated with a reduction in stroke risk. Surgical interventions for carotid disease, such as endarterectomy or stenting, carry a significant risk of mortality and disabling stroke. Because of the risks of intervention, screening of asymptomatic patients is not routinely recommended. Similarly, the benefits of intervention must be weighed against the potential risks. Generally, intervention is recommended if the patient has experienced significant symptoms from carotid artery disease such as stroke or high-risk TIA with stenosis >50%. For asymptomatic patients, the average annual risk of stroke with stenosis ≥70% is about 1% and evaluation for carotid endarterectomy or stenting is recommended if the patient is considered to be at acceptable surgical risk.

Answer 868

ANSWER: E This patient has asymptomatic bacteriuria (ASB) and does not require antibiotic therapy at this time. In women age >70 the incidence of ASB is nearly 20%, and in patients with chronic incontinence and older adults with disabilities rates may be as high as 50%. Symptoms consistent with a urinary tract infection (UTI) include acute dysuria, new or worsening urinary urgency or frequency, new incontinence, gross hematuria, and suprapubic or costovertebral angle tenderness. The Infectious Diseases Society of America recommends close observation without antibiotic treatment for patients with bacteriuria who have non-urinary symptoms such as delirium, malaise, or fall as long as they do not have signs of serious systemic infection such as fever or sepsis. It is reasonable to hold off on ordering a urinalysis in a patient without UTI-specific symptoms who also does not have serious systemic signs. When antibiotic therapy is indicated for a true UTI, empiric therapy is often guided by recommendations based on local antibiotic resistance patterns, which can vary widely. Generally, agents with Escherichia coli resistance rates >10%-20% should not be used as empiric therapy. Nitrofurantoin is a common recommendation but should be used with caution in patients with a creatinine clearance of 30-60. TMP-SMX is also recommended unless local resistance patterns indicate otherwise. Historically fluoroquinolones have also been effective, but resistance rates have been rising and thus may not be recommended in some communities. Fosfomycin and first-generation cephalosporins are also first-line empiric therapy options without widespread resistance, although fosfomycin can be cost-prohibitive. Once a culture and sensitivity result is known, antibiotic choice can be tailored to the results.

Answer 869

ANSWER: B Colonoscopy In patients with chronic nonbloody diarrhea, the differential diagnosis includes microscopic (lymphocytic or collagenous) colitis. The mucosa appears normal on colonoscopy but a biopsy will show lymphocytic infiltration of the epithelium. The etiology is unknown but there are several risk factors to consider, including older age, female sex, and smoking status. Drugs with a high level of evidence causing microscopic colitis include NSAIDs, PPIs, sertraline, acarbose, aspirin, and ticlopidine. C. diff should be suspected in individuals who have taken antibiotics in the past 3 months. Fecal calprotectin is elevated in inflammatory diarrhea such as Crohn's disease or ulcerative colitis. A stool culture would be indicated if there is a suspicion of an infectious bacterial diarrhea such as Shigella or Salmonella, but these bacteria tend to cause bloody diarrhea. Checking for a parasitic infection should be considered for patients with a history of recent travel or exposure to unpurified water.

Answer 870

ANSWER: B. Dexamethasone Malignant bowel obstruction is a common issues with GI cancers. Corticosteroids can help alleviate these symptoms, which is the focus in end of life care. Corticosteroids have numerous beneficial effects in these situations, such as central antiemetic, anti-inflammatory, anti-secretory, and analgesic effects. Intravenous dexamethasone is generally recommended at a dosage of 4 mg 3-4 times daily for malignant bowel obstruction because it has more greater anti-inflammatory effects than methylprednisolone. Although octreotide is commonly used for this purpose, there is little evidence to support its use. Medical cannabis can be used to treat nausea and vomiting in end of life care but is not effective for bowel obstruction. Morphine can be used to treat pain and end of life dyspnea, but not for nausea and vomiting. The use of polyethylene glycol for a malignant obstruction could worsen the patient's symptoms significantly.

Answer 871

ANSWER: A. Current pregnancy Statins have been associated with fetal anomalies and are contraindicated during pregnancy and not recommended during breastfeeding. With appropriate monitoring, statins may be used in patients with chronic hepatitis C infection, ESRD, and transaminitis due to NASH. Statins may also be continued in the setting of myositis with a creatine kinase up to 10 times the upper limit of normal, provided that the muscle related symptoms are tolerable to the patient.

Answer 872

ANSWER: E ulnar nerve Initial general neurovascular assessment of an upper extremity injury includes evaluating for radial pulse and digit movement and sensation. Weakness of the thumb and index finger pincer mechanism is indicative of an ulnar nerve injury. Weakness in the shoulder or upper arm would indicate a potential brachial plexus injury. Symptoms related to the median nerve generally include paresthesia of the thumb, index finger, and long finger. Weakness of supination of the forearm would indicate a potential musculocutaneous nerve injury. Weakness of active wrist extension would indicate a potential radial nerve injury.

Answer 873

ANSWER: A has no proven benefit Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4 level. It is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST (Thyroid Hormone Replacement for Subclinical Hypothyroidism) trial and subsequent meta-analyses of randomized, controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as muscle strength, fatigue or tiredness, depression, and BMI do not improve with L-thyroxine treatment (SOR A), and up to 60% of cases resolve within 5 years without intervention in older adults. Appropriate management of an elevated TSH level includes repeat testing in 1-3 months along with a free T4 level. If SCH is diagnosed, levels should be monitored yearly. Only 2%-4% of patients with SCH develop overt hypothyroidism.

Answer 874

ANSWER: C GERD Sleeve gastrectomy is currently the most common bariatric procedure. The most common complication is development of GERD, which occurs in 20% of patients. Since this procedure does not produce a malabsorption component, complications such as cholelithiasis, dumping syndrome, and small bowel obstruction are not as likely as with other available procedures. A postoperative leak develops in <2% of cases. A sleeve gastrectomy involves removing the majority of the greater curvature of the stomach, which creates a tubular stomach. Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch both combine volume restriction and nutrient malabsorption.

Answer 875

ANSWER: D Bupropion (Wellbutrin XL) This patient has seasonal affective disorder (SAD) that has recurred and is likely to continue to recur. Bupropion is the only medication beneficial for prevention of SAD. Light therapy and SSRIs are helpful for treating this disorder but do not prevent it. Exercise and cognitive-behavioral therapy are beneficial adjuncts to treatment but would not prevent recurrence.

Answer 876

ANSWER: C Exenatide (Byetta) Exenatide is a GLP-1 receptor agonist that is not associated with hypoglycemia and can also assist with weight loss, which would be helpful in this patient with obesity. All of the other listed medications, including both types of insulin, sulfonylureas, and meglitinides, can be associated with hypoglycemia. Since this patient's hemoglobin A1c is only moderately elevated at 8.4%, exenatide is reasonable, although it can be an expensive option. If her hemoglobin A1c was severely elevated, insulin would be indicated, with close monitoring for hypoglycemia.

Answer 877

ANSWER: E Yoga Nonspecific low back pain is a condition with no distinct etiology to explain the patient's associated symptoms. Physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention in the treatment of nonspecific low back pain. The Choosing Wisely campaign states that bed rest should not be recommended for low back pain, and lumbar supports or braces should not be prescribed for the long-term treatment or prevention of low back pain. Studies have consistently shown that NSAIDs combined with muscle relaxants have no benefit over NSAIDs alone. Interventions such as shoe insoles have shown little benefit.

Answer 878

ANSWER: B An inhaled corticosteroid (ICS)/long-acting -agonist (LABA) as needed For patients with mild asthma, recent evidence has shown that an inhaled corticosteroid (ICS)/long-acting-agonist (LABA), such as budesonide/formoterol, as needed was as effective at preventing exacerbations as a daily maintenance ICS plus a short-acting-agonist (SABA) at one-fifth of the total corticosteroid dose. In addition, it was more effective at preventing exacerbations than continued use of a SABA alone as needed. A daily maintenance ICS inhaler plus either a LABA or a leukotriene receptor antagonist are management strategies for persistent asthma.

Answer 879

ANSWER: C A positive direct antibody titer (Coombs test) Although up to 84% of term newborns experience neonatal jaundice, severe hyperbilirubinemia (total serum bilirubin level >20 mg/dL) occurs in <2% of term infants. Prompt identification and management of severe hyperbilirubinemia is critical due to the risk of neurologic injury from untreated bilirubin toxicity. Acute bilirubin encephalopathy develops in 1 in 10,000 infants, and kernicterus (chronic bilirubin encephalopathy) occurs in 1 in 100,000 infants and can lead to permanent neurodevelopmental delay. Neonates at high risk of bilirubin toxicity are treated with phototherapy to decrease bilirubin levels through the breakdown of unconjugated bilirubin into byproducts that are excreted into stool and urine. In infants at even higher risk, exchange transfusion may be indicated. Treatment guidelines published by the American Academy of Pediatrics stratify infants according to risk. Risk factors for toxicity include earlier gestational age at birth, hemolysis, sepsis, acidosis, G6PD deficiency, lethargy, asphyxia, temperature instability, acidosis, and hypoalbuminemia. Of the options listed, hemolysis, which is associated with a positive direct antibody titer (Coombs test), is the most significant risk factor for developing acute bilirubin encephalopathy, and therefore impacts the treatment threshold for initiation of phototherapy. While East Asian race, exclusive breastfeeding, and a sibling with a history of neonatal jaundice are risk factors for severe hyperbilirubinemia, they do not impact the phototherapy treatment threshold. Similarly, untreated maternal group B Streptococcus colonization may increase an infant's risk of developing neonatal sepsis, although it is not a direct risk factor for bilirubin encephalopathy.

Answer 880

ANSWER: D Fenofibrate (Tricor) Fibrates reduce the likelihood and recurrence of pancreatitis due to severe hypertriglyceridemia when triglyceride levels are 500 mg/dL, measured in a fasting or nonfasting state (SOR A). This patient's risk of atherosclerotic cardiovascular disease is <7.5% and his LDL-cholesterol level is within normal range, so initiating a statin or ezetimibe is not indicated. Colesevelam may be used to reduce LDL-cholesterol and glucose levels but is not considered a first-line treatment. Omega-3-acid ethyl esters will reduce the triglyceride levels but this patient has severe hypertriglyceridemia, so fibrate therapy is recommended to prevent recurrent pancreatitis.

Answer 881

ANSWER: B An external cardiac event monitor Syncope is generally classified into three broad categories: cardiac, neurally mediated, and orthostatic hypotension. The history of an abrupt unprovoked episode of syncope in this patient suggests a cardiac source. The most frequent cause of cardiac-associated syncope is an arrhythmia. The fact that this patient's syncope occurred during exercise (walking) also suggests an arrhythmia. A clinical history suggestive of arrhythmia places the patient in a higher risk stratification. An EKG should be performed. Continuous cardiac monitoring correlates symptoms with cardiac rhythm. Options for monitoring include a Holter monitor for up to 72 hours, an external cardiac event monitor or loop recorder for up to 4-6 weeks, and an implantable loop recorder for up to 3 years. The more prolonged monitoring increases the chances of confirming the diagnosis. Orthostatic blood pressure measurements should be performed in all patients presenting with syncope, but this patient's symptom pattern is not consistent with orthostatic hypotension. Recommendations from the Choosing Wisely campaign regarding syncope include the following: * The American College of Emergency Physicians does not recommend imaging of the brain if there is no history of significant trauma and a neurologic examination is normal. * The American College of Physicians does not recommend imaging of the brain for simple syncope in the setting of a normal neurologic examination. * The American Academy of Neurology does not recommend imaging of the carotid arteries for simple syncope without other neurologic symptoms.

Answer 882

A 12-year-old male with type 1 diabetes is brought to your office for routine follow-up. Laboratory work performed prior to the appointment shows an LDL-cholesterol level of 120 mg/dL. In addition to counseling the patient on a heart-healthy diet and daily physical activity, which one of the following would you recommend? A) No additional measures B) Fish oil supplements C) Atorvastatin (Lipitor) D) Ezetimibe (Zetia) E) Gemfibrozil (Lopid)

Answer 883

ANSWER: D Malignancy The leading cause of mortality among people aged 45-64 years is malignancy. The U.S. Preventive Services Task Force generally recommends a focus on cancer screening in this age group. Accidents are the third most common cause of mortality in people 45-64 years of age, but they are the leading cause of mortality among people 15-44 years of age, and preventive recommendations reflect interventions to prevent accidents. Diabetes mellitus is the sixth most common cause of mortality in people 45-54 years of age, and the fifth most common cause in people 55-64 years of age. Heart disease is the second most common cause of mortality in people 45-64 years of age, but it is the leading cause of mortality in people 65 years of age and older. Suicide is the fourth most common cause of mortality in adults 45-54 years of age, and the eighth most common cause in adults 55-64 years of age.

Answer 884

ANSWER: E Coronary angiography Takotsubo syndrome (acute stress-induced cardiomyopathy) is characterized by transient wall motion abnormalities on echocardiography, usually following an emotionally triggering event. Although coronary artery disease may be present, and the two diagnoses may be seen together, the International Takotsubo Registry reports coronary artery disease in only about 15%, so coronary angiography is more likely to be normal than the other listed diagnostic tests. Cardiac biomarkers such as CK-MB and troponin are usually elevated, but to a lesser degree than with an acute myocardial infarction. An abnormal EKG is found in >95% of patients with Takotsubo syndrome.

Answer 885

ANSWER: E Individual trauma-focused psychotherapy Posttraumatic stress disorder (PTSD) is regularly seen in primary care practices, with estimated incidences of 8%-20% in the general population. Expert guidelines recommend screening adults at risk of PTSD, such as this patient who was exposed to a traumatic event, with standardized screening tools and then using a structured interview tool if the screen is positive. Once the diagnosis is established, individual trauma-focused psychotherapy is the intervention that demonstrates the most significant benefit. Pharmacotherapy may be used if psychotherapy is not effective or available. Recommended options include fluoxetine, paroxetine, venlafaxine, or sertraline. Benzodiazepines and escitalopram are not recommended in the treatment of PTSD. Dialectical behavioral therapy is used in the treatment of borderline personality disorder.

Answer 886

ANSWER: E Varenicline (Chantix) Varenicline, an @4- B2 nicotinic receptor partial agonist, works to reduce nicotine withdrawal by activating the nicotine receptor and producing about 50% of the effect of nicotine. It also prevents tobacco smoke nicotine from binding to the receptor. Acamprosate is a gamma-aminobutyric acid (GABA) agonist and glutamate antagonist that is effective for the treatment of alcohol use disorder. Bupropion is a norepinephrine-dopamine reuptake inhibitor that reduces nicotine withdrawal and the reward from tobacco smoking. Clonidine is an @2-adrenergic agonist, and it has been shown to assist with smoking cessation but is not FDA approved for this purpose. Naltrexone is a pure opioid receptor antagonist that is effective for the treatment of alcohol use disorder and opioid use disorder.

Answer 887

ANSWER: D Propranolol According to the International Classification of Headache Disorders, this patient meets criteria for the diagnosis of migraine without aura. Many medications have been studied for the prevention of migraine. Divalproex, topiramate, metoprolol, propranolol, and timolol have been shown to be effective for migraine prevention by consistent, good-quality evidence. One of these medications should be offered as first-line treatment. Studies of fluoxetine have demonstrated inconsistent results. Gabapentin has been evaluated in six randomized, controlled trials with mixed results. Three studies have been conducted with ACE inhibitors and angiotensin receptor blockers for migraine prevention, with just one study showing some benefit. Verapamil has previously been considered effective, but on reevaluation of previous studies, the supporting data for verapamil is insufficient to prove efficacy.

Answer 888

ANSWER: D Left heart disease This patient has signs and symptoms of pulmonary hypertension. Diagnostic tests, particularly echocardiography, can confirm this diagnosis. It is important to determine the etiology since addressing the underlying condition is the preferred treatment for most cases of non-severe pulmonary hypertension. Left heart disease, including both preserved and reduced systolic function, is the most common cause of pulmonary hypertension, while chronic thromboembolism, COPD, and sleep-disordered breathing are other possible but less common causes. Idiopathic pulmonary arterial hypertension is a rare cause.

Answer 889

ANSWER: B Test for Helicobacter pylori and treat if positive This patient presents with dyspepsia but does not have any alarm symptoms such as weight loss, blood in the stools, or difficulty swallowing. An important cause of dyspepsia is gastric infection with Helicobacter pylori. In patients younger than 55 years of age with no alarm symptoms, a test-and-treat strategy is effective and safe, with esophagogastroduodenoscopy reserved for patients not meeting these criteria (SOR A). Lifestyle interventions and proton pump inhibitor therapy are more effective for GERD. A barium swallow would not be appropriate for this patient at this time.

Answer 890

Vocal Cord Dysfunction! -Get nasolaryngoscopy to evaluate -Tx with breathing techniques

Answer 891

<200: Bactrim for PJP <100: Bactrim for Toxo <50: Azithro for MAC

Answer 892

-Overnight 1mg dexamethasone suppression test -Adrenal incidentalomas usually do not produce overt hormone excess, but MILD cortisol secretion can happen -This would predispose pt to metabolic syndrome, osteoporosis, and CV events

Answer 893

T1DM: low C-peptide lvls with + anti-GAD antibodies T2DM: elevated C-peptide

Answer 894

Septic arthrtis vs transient synovitis Fever T > 101.3 Refusal to bear weight WBC > 12 ESR > 40Gest

Answer 895

Paroxetine

Answer 896

Transvaginal Ultra sound If endometrial strip > 4 mm then need biopsy

Answer 897

Median nerve OK sign

Answer 898

Urea Breath Test (h. pylori infection) DYSPEPSIA: >60? Get an EGD and biopsy for h pylori <60? Urea breath test

Final Review Flashcards

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