Mcq Flashcards
(36 cards)
A 52-year-old female with a history of hypertension and hypercholesterolemia presents with mild
edema, weakness, and body aches. Her only medications are atorvastatin (Lipitor) and
chlorthalidone. Her previouslynormal serum creatinine level is now 2.6 mg/dL (N 0.64–1.27).
Her BUN level is 32 mg/dL (N 6–20) and her serum is clear without pigmentation. The urine
dipstick is positive for blood, buta microscopic examination isnegative for WBCs, RBCs, and
casts.
The most likely diagnosis is
A) allergic interstitial nephritis
B) glomerulonephritis
C) hemolysis
D) pyelonephritis
E) rhabdomyolysis
ANSWER: E
This patient with acute kidney injury (AKI) has clinical symptoms and signs consistent with
rhabdomyolysis, a known cause ofAKI. Furthermore, she is takinga medication known to cause
rhabdomyolysis. The urinalysis with a positive dipstick for blood and no RBCs on the microscopic
examination is indicative of either hemolysis or rhabdomyolysis. Darkened, pigmented serum would be
expected with hemolysis, while rhabdomyolysis is associated with clear serum. Urine abnormalities found
in glomerulonephritis include proteinuria and RBC casts, while patients with allergic interstitial nephritis
may have eosinophils and possibly WBC casts. Pyelonephritis is associated with WBCs in the urine, and
if the dipstick is positive for blood there will be RBCs on the microscopic examination.
A 36-year-old male with a history of ankylosing spondylitis and atrial fibrillation presents with
a 3-week history of cough with hemoptysis, anorexia, night sweats, and an 11-lb weight loss.
On examination he has rales in the right upper lobe, but there is no lymphadenopathy or
hepatosplenomegaly. A chest radiograph shows a cavitary lesion in the right lung apex, with
mediastinal hilar lymphadenopathy. His chronic disease symptoms have been well controlled
with a combination of meloxicam (Mobic), adalimumab (Humira), esomeprazole (Nexium),
ondansetron (Zofran), docusate sodium (Colace), and amiodarone (Cordarone).
Which one of the patient’s medications is most likely contributing to his current problem?
A) Adalimumab
B) Amiodarone
C) Esomeprazole
D) Meloxicam
E) Ondansetron
ANSWER: A
Tumor necrosis factor (TNF) inhibitors are currently approved by the U.S. Food and Drug Administration
(FDA) for the treatment ofrheumatic diseases such as rheumatoid arthritis, ankylosing spondylitis,
psoriatic arthritis, and juvenile idiopathic arthritis. All drugs in this class carry an FDA black-box warning
about the potential for developing primary tuberculosis or reactivating latent tuberculosis. These drugs are
also associated with an increased risk for invasive fungal infections and opportunistic bacterial and viral
diseases. The FDA also warns of reports of lymphomas and other malignancies in children and adolescents
taking these drugs.
A PPD skin test should be performed prior to initiating PNF-inhibitor therapy. An induration of 5 mm or
greater with tuberculin skin testing should be considered a positive test result when assessing whether
treatment for latent tuberculosis isnecessary prior to PNF-inhibitor use, even for patients previously
vaccinated with bacille Calmette-Guérin (BCG) (SOR B).
Ankylosing spondylitis patients may develop fibrosis of the upper lung fields with long-standing disease,
but esomeprazole, ondansetron, and meloxicam do not cause reactivation of tuberculosis. Amiodarone is
associated with a subacute cough and progressive dyspnea due to pulmonary toxicity (patchy interstitial
infiltrates)
You have just finished giving a prescription with instructions to a 28-year-old male from El
Salvador who speaks limited English. You gave the instructions with the aid of an interpreter,
but are concerned that the patient might not fully understand them.
Which one of the following is the best course of action?
A) Refer the patient to a website about his condition
B) Repeat the instructions slowly to the interpreter and ask him or her to speak clearly to
the patient
C) Contact a family member who speaks English and ask him or her to repeat the
instructions to the patient
D) Ask the patient to repeat the instructions to you in his own words
ANSWER: D
To ensure that patients from other cultures understand instructions, it is helpful toask them to repeat the
instructions in their own words. A website would probably not be specific or culturally sensitive to the
patient’s condition. The physician should speak in a normal tone to the patient, and not to the interpreter.
Family members may be used as convenient translators if necessary, but to maintain confidentiality and
reduce miscommunication it is best to use a trained medical interpreter
Which one of the following accurately describes the classic rash of erythema migrans?
A) Scattered individual purple macules on the ankles and wrists
B) An annular rash with a bright red outer border and partial central clearing
C) A dry, scaling, dark red rash in the groin, with an active border and central clearing
D) A diffuse eruption withclear vesicles surrounded by reddish macules
E) A migratory pruritic, erythematous, papular eruption
ANSWER: B
An annular rash with a bright red outer border and partial central clearing is characteristic of erythema
migrans. It is important to remember that not all lesions associated with Lyme disease look this way, and
that some patients with Lyme disease may not have any skin lesions atall. Rocky Mountain spotted fever
causes scattered individual purple macules on the ankles and wrists. A dry, scaling, dark red rash in the
groin, with an active border and central clearing, is seen with tinea cruris. A diffuse eruption with clear
vesicles surrounded by reddish macules is found in chickenpox. A migratory pruritic, erythematous,
papular eruption is most consistent with urticaria.
A patient with chronic atrial fibrillation treated with dabigatran (Pradaxa) sees you for follow-up.
She says she can no longer afford the dabigatran and would like to switch to warfarin
(Coumadin). She has normal renal function.
Which one of the following would be the most appropriate approach?
A) Start warfarin and stop dabigatran when her INR is 2.0–3.0
B) Start warfarin now and stop dabigatran in 3 days
C) Stop dabigatran, start warfarin, and start low molecular weight heparinand enoxaparin
(Lovenox) every 12 hr until her INR is 2.0–3.0
D) Stop dabigatran for 24 hr and then start warfarin
E) Hospitalize the patient, stop dabigatran, start warfarin, and treat with heparin until her
INR is 2.0–3.0
ANSWER: B
The recommendation for switching to warfarin in a patient treated with dabigatran is to start warfarin 3
days prior to stopping dabigatran. Bridging with a parenteral agent is not necessary. Dabigatran is known
to increase the INR, so the INR will not reflect warfarin’s effect until dabigatran has been withheld for at
least 2 days.
A 27-year-old male requests youradvice regarding colon cancer screening. His brother died of
colon cancer, which was diagnosed at the age of 40.
You suggest that he begin colonoscopy screening
A) now
B) at age 30
C) at age 40
D) at age 45
E) at age 50
ANSWER: B
Average-risk adults should be screened for colon cancer starting at 50 years of age, and high-risk adults
either at age 40 or 10 years before the age at which colorectal cancer was diagnosed in the youngest
affected relative.
Which one of the following is the major mechanism of action of metformin (Glucophage)?
A) Stimulation of pancreatic insulin release
B) Inhibition of glucose production by the liver
C) Inhibition of carbohydrate absorption in the small intestine
D) Improved insulin sensitivity of skeletal muscl
ANSWER: B
Metformin has multiple mechanisms of action, but its main effect on serum glucose results from inhibition
of gluconeogenesis in the liver. Sulfonylureas and meglitinides stimulate insulin release from the pancreas,
and thiazolidinediones sensitize peripheral tissues to insulin. Carbohydrate absorption in the small intestine
is inhibited by the -glucosidase inhibitors
Which one of the following medications is most appropriate for treating moderate to severe
shortness of breath in a hospice patient with lung cancer?
A) Dexamethasone
B) Haloperidol
C) Scopolamine
D) Morphine
ANSWER: D
Morphine effectively decreases the feeling of shortness of breath in hospice patients. Randomized,
controlled trials have shown significant improvements in symptoms without a significant change in oxygen
saturation. Haloperidol can be used for nausea and vomiting (SOR B) and delirium, but is not helpful in
the treatment of shortness of breath. Scopolamine is used to decrease the production of secretions but is
not helpful for treating dyspnea. Corticosteroids will notmanage the sensation of shortness of breath in
a dying patient.
A 35-year-old nulligravida sees you for preconception counseling. She has hypothyroidism
treated with levothyroxine (Synthroid), and her most recent TSH level was in the therapeutic
range. She has no symptoms of hypothyroidism.
Which one of the following is the patient mostlikely to require if she becomes pregnant?
A) A decreased dosage of levothyroxine
B) An increased dosage of levothyroxine
C) The addition of liothyronine (Cytomel)
D) Substitution of desiccated thyroid hormone preparation (Armour Thyroid) for the
levothyroxine
ANSWER: B
Thyroid hormone requirements increase during pregnancy. Most women with hypothyroidism who become
pregnant require an increased levothyroxine dosage (SOR A). A common recommendation is to have
women on fixed daily doses of levothyroxine begin taking nine doses weekly (one extra dose on 2 days
of the week) as soon as the pregnancy is confirmed (SOR B). Thyroid function tests should be repeated
regularly throughout the pregnancy to guide additional dosage adjustments.
Which one of the following is considered to be the highest strength of recommendation by the
Strength of Recommendation Taxonomy (SORT) used by family medicine journals?
A) Expert opinion
B) A consensus guideline
C) A retrospective cohort study
D) Multiple good quality randomized, controlled trials
ANSWER: D
Family medicine journals, including American Family Physician, The Journal of Family Practice, and The
Journal of the American Board of Family Medicineutilize the Strength of Recommendation Taxonomy
(SORT) to label key recommendations in clinical review articles. These grades are assigned on the basis
of the quality and consistency of available evidence. The Cochrane Collaboration is an extensive database
of systematic reviews and clinical trials. A Cochrane review with a clear recommendation warrants a
strength of recommendation rating of A. This indicates consistent, good quality, patient-oriented evidence.
Consistent findings from atleast two randomized, controlled studies or a systematic review/meta-analysis
of randomized, controlled trials are also assigned a level A strength of recommendation. Expert opinion
and consensus guidelines are assigned a level C strength of recommendation. SORT also includes a grade
of 1 to 3 for levels of evidence. Retrospective cohort studies are considered level 2
Which one of the following tumors is most likely to cause hormonally induced hypercalcemia? A) Squamous cell carcinoma of the lung B) Pheochromocytoma C) Medullary thyroid cancer D) Prostatic carcinoma
ANSWER: A
Hypercalcemia due to malignancy has a poor prognosis. Up to 80%of cases are due to secretion of
parathyroid hormone–related protein. This is most common with squamous cell carcinomas. Breast cancer,
lymphomas, and multiple myeloma may cause hypercalcemia as a result of osteolytic activity at the site
of the metastasis.
Small cell carcinoma of the lung is a major cause of the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH) and may also cause Cushing syndrome. Prostate cancer can also cause SIADH, and
thyroid cancer can cause Cushing syndrome.
A 32-year-old meat cutter comes to your officewith persistent symptoms of nausea, vomiting,
and diarrhea, which began about 36 hours ago on the last day of a 5-day Caribbean cruise. His
wife was sick during the first 2 days of the cruise with similar symptoms. On the ship they both
ate the “usual foods” in addition to oysters. Findings on examination are negative, and a stool
specimen is negative for white blood cells.
Which one of the following is the most likely cause of his illness?
A) Escherichia coli
B) Rotavirus
C) Norovirus
D) Hepatitis A
E) Giardia
ANSWER: C
Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norovirusinfections due
to waterborne or foodborne spread. In the United States these viruses are responsible for about 90% of all
epidemics of nonbacterial gastroenteritis. The noroviruses are common causes of waterborne epidemics
of gastroenteritis, and have been shown to be responsible for outbreaks in nursing homes, on cruise ships,
at summer camps, and in schools. Symptomatic treatment by itself is usually appropriate.
A 47-year-old postmenopausal female falls while carrying groceries into her house and sustains
a right distal radial fracture. A chemistry panel reveals a calcium level of 11.2 mg/dL (N
8.6–10.6) and further evaluation leads to a diagnosis of primary hyperparathyroidism.
Which one of the following is the best course of treatment for this patient?
A) Estrogen replacement therapy
B) Long-term bisphosphonate therapy
C) Daily furosemide treatment with increased oral fluids
D) Elimination of calcium and vitamin D from the diet
E) Referral to a surgeon for consideration of parathyroidectomy
ANSWER: E
Hyperparathyroidism is usually caused by a single adenoma of one of the fourparathyroid glands. A
minority of cases (10%–15%) are associated with four-gland hyperplasia. Studies that localize the glands,
such as a technetium scan or ultrasonography, help surgeons who are familiar with this condition achieve
a cure rate of 95%–98%, with an estimated complication rate of 1%–3%. For patients
Activated protein C resistance (factor V Leiden) is most commonly found in patients with A) hemolytic anemia B) carcinoma of the lung C) familial hypercholesterolemia D) venous thrombotic disease E) cystic fibrosis
ANSWER: D
Venous thrombosis, both acute and recurrent, is associated with several hematologic abnormalities, in
addition to the well-known factors of trauma, surgery, malignancy, sepsis, and oral contraceptive use.
Notably, activated protein C resistance (factor V Leiden) has beenfound to be one ofthe most common
hereditary causes of thrombophilia.
Which one of the following is most consistent with a diagnosis of asthma?
A) Reduced FEV1and a decreased FEV1/FVC ratio
B) Reduced FEV1and a normal FEV1/FVC ratio
C) Reduced FEV1and an increased FEV1/FVC ratio
D) Reduced FVC and a normal FEV1/FVC ratio
E) Reduced FVC and an increased FEV1/FVC ratio
ANSWER: A
Asthma is typically associated with an obstructive impairment that is reversible with short-acting
bronchodilators. A reduced FEV1and a decreased FEV1/FVC ratio indicates airflow obstruction. A
reduced FVC with a normal or increased FEV
1/FVC ratio is consistent with a restrictive pattern of lung
function
A 43-year-old female presents toyour office 2 days after discovering a rash on her back, shown below. Which one of the following treatments will decrease her chances of developing long-term sequelae? A) Amitriptyline B) Gabapentin (Neurontin) C) Oral corticosteroids D) Topical corticosteroids E) Oral acyclovir (Zovirax)
ANSWER: E
While some studies have shown mixed results, there is good evidence that oral acyclovir reduces the
incidence of herpetic neuralgia when given within 72 hours of the onsetof the rash, and that it reduces the
duration of symptoms (SOR A). Acyclovir, valacyclovir, and famciclovir have also been shown to reduce
the formation of new lesions, reduce viral shedding, and hasten the resolution of lesions. The effect of
acyclovir on preventing neuralgia appears to be strongestin the first month. Oral or topical corticosteroids
can reduce the duration of the rash and pain in the acute phase. Tricyclic antidepressants and gabapentin
can be used to treat the pain of postherpetic neuralgia if it does develop (SOR A
You receive a telephone call from the mother of a 5-year-old female. The child has had diarrhea
and a decreased appetite for the past 2 days. She is still playing some. The mother reports no
vomiting, but says her daughter has complained of a dry mouth and does not have tears when
she cries. You suspect that the child may be mildly dehydrated.
Which one of the following would you advise?
A) Increased water intake
B) Clear liquids with sodium, such as chicken broth
C) An over-the-counter oral rehydration solution
D) Intravenous fluids in the emergency department
E) Loperamide (Imodium
ANSWER: C
When children show signs of dehydration from diarrhea, the first step is to assess its extent. In one study,
four factors predicted dehydration: a capillary refill time >2 seconds, the absence of tears, dry mucous
membranes, and an ill general appearance; the presence of two or more of these signs indicates a fluid
deficit of at least 5%. This child has two of the signs, but does not require intravenous fluidsat this point.
Early oral rehydration therapy is recommended and can be started at home. This should be done using an
oral rehydration solution that is designed for children (SOR C). Adult oral rehydration solutions should
not be used in children
Water and other clear liquids, even those with sodium, such as chicken broth, should not replace an oral
rehydration solution because they are hyperosmolar. These fluids do not adequately replace potassium,
bicarbonate, or sodium, and can sometimes cause hyponatremia. Antidiarrheal medications are usually not
recommended for use in children with acute gastroenteritis because they delay the elimination of infectious
agents from the intestine
A 42-year-old male with a history of chronic hepatitis C develops left leg cellulitis and is treated
with cephalexin (Keflex). He returns to your office 5 days later for follow-up, and the cellulitis
is responding favorably to treatment. However, the patient has a generalizedmaculopapular rash
and a low-grade fever, which he says began 3 days ago. He also complains of arthralgias. You
admit him to the hospital for further evaluation.
His serum creatinine level is 3.2 mg/dL (N 0.6–1.5), which is elevated from his baseline level
of 0.8 mg/dL. A urinalysis is normal, except for the presence of occasional eosinophils. The
remainder of his evaluation, including liver enzyme levels and renal ultrasonography, is normal.
Which one of the following is the most appropriatenext step in the management of this patient?
A) A postvoid residual urine volume
B) A hepatitis C viral load and genotype
C) Discontinuing cephalexin
D) Antibiotics to cover methicillin-resistant Staphylococcus aureus(MRSA)
E) Aggressive fluid resuscitation with normal saline
ANSWER: C
Acute kidney injury (AKI) is currently defined as either a rise in serum creatinine or a reduction in urine
output. Creatinine must increase by at least 0.3 mg/dL, or to 50% above baseline within a 24–48 hour
period. A reduction in urine output to 0.5 mL/kg/hr for longer than 6 hours also meets the criteria. Acute
interstitial nephritis is an intrinsic renal cause of AKI. These patients are often nonoliguric. A history of
recent medication use is key to the diagnosis, as cephalosporins and penicillin analogues are the most
common causes. Approximately one-third of patients present with a maculopapular rash, fever, and
arthralgias. Eosinophilia and sterilepyuria may also be seen in addition to eosinophiluria. Discontinuation
of the offending drug is the cornerstone of management.
Although up to 30% of patients with chronic hepatitis C infection havesome kidney involvement, acute
interstitial nephritis is uncommon. Measuring postvoid residual urine volume is indicated if an obstructive
cause for the AKI is suspected. Starting anantibiotic to cover methicillin-resistant Staphylococcus aureus
(MRSA) is not indicated
Which one of the following medicationsis most likely to cause hypokalemia? A) Albuterol (Proventil, Ventolin) B) Doxazosin (Cardura) C) Erythromycin D) Felodipine (Plendil) E) Lisinopril (Prinivil, Zestril)
ANSWER: A
B-Agonists activate potassium uptake by the cells. This includes bronchodilators and tocolytic agents. Other
agents that can induce hypokalemia include pseudoephedrine and insulin. Diuretics, particularly thiazides,
can also cause hypokalemia as a result of the renal loss of potassium.
An abandoned infant is brought tothe hospital for evaluation. Based on the presence of a dried
umbilical cord remnant and her overall appearance, you believeher to be no more than 5 days
of age. A thorough examination is normal except for a finding of bilateral conjunctival erythema
and exudate. A Gram stain of the exudate is remarkable for numerous WBCs, very few of which
are noted to contain gram-negative diplococci.
Which one of the following treatment options is most appropriate?
A) Application of moist, warm saline eye compresses
B) Irrigation of both eyes with povidone-iodine (Betadine)
C) One-time application of ophthalmic erythromycin ointment into both eyes
D) Instillation of silver nitrate solution into both eyes
E) Intramuscular injection of ceftriaxone (Rocephin)
ANSWER: E
Infantile gonococcal infection is usually the result of exposure to infected cervical exudate during delivery
and manifests 2–5 days after birth. Ophthalmia neonatorum and sepsis are the most severe gonococcal
infections in newborns and immediate treatment is warranted based on the presumptive diagnosis. Topical
antibiotics are appropriate for prophylaxis, but not for treatment. Silver was usedfor prophylaxis at one
time, but is no longer available. Povidone-iodine has not been studied for prevention. A single dose of
25–50 mg/kg of ceftriaxone administeredintravenously or intramuscularly is the recommended treatment
Which one of the following has been shown to have a beneficial effect for symptoms of the common cold in an adult? A) Diphenhydramine (Benadryl) B) Ipratropium (Atrovent) nasal spray C) Intranasal zinc D) Intranasal corticosteroids E) Systemic corticosteroids
ANSWER: B
Ipratropium is the only nasally inhaled anticholinergic recommended by the American College of Chest
Physicians for a cough caused by the common cold. One study showed thatthe nasal formulation decreases
rhinorrhea and sneezing, and a Cochrane review found that ipratropium bromide nasal spray improved
rhinorrhea but did not help nasal stuffiness (SOR B). Antihistamine monotherapy (either sedating or
nonsedating) such as diphenhydramine was no more effective than placebo (SOR A). Corticosteroids have
not been found to be effective for the symptoms of a common cold. Intranasal zinc should not be used
because it may result in the permanent loss of smell.
A 50-year-old white male is injured while mountain biking. The CT scan of the patient’s
abdomen shown below is most consistent with which one of the following?
A) Rupture of the spleen
B) Subcapsular hematoma of the spleen
C) Subcapsular hematoma of the kidney
D) Ruptured hollow viscus
E) Herniated vertebral disc
ANSWER: C
The CT scan shows a subcapsular hematoma of the kidney. This is considered a grade I injury and does
not require surgical treatment.
A 21-year-old primigravida at 10 weeks gestation has a negative titer for rubella. The best
procedure to follow is to
A) institute a -globulin regimen and maintain it throughout her pregnancy
B) administer rubella vaccine after 12 weeks gestation
C) administer rubella vaccine immediately post partum
D) administer rubella vaccine 12 weeks post partum
ANSWER: C
Rubella has been directly responsible for inestimable pregnancy wastage, aswell as for severe congenital
malformations. Identification and vaccination of unimmunized women immediately after childbirth or
abortion is recommended. The use of -globulin to prevent viremia in nonimmune subjects exposed to
rubella is not recommended. The vaccine should be avoided shortly before or during pregnancy since it
is an attenuated live virus. Because of herd immunitythere is a very low likelihood that this patient will
be exposed to rubella.
A postmenopausal female who has recently been diagnosed with hypertension returns for
follow-up 3 months after the initiation of therapeutic lifestyle changes. Her blood pressure has
improved but remains higher than goal at 142/90 mm Hg, and pharmacologic treatment is
indicated. The patient has a family history of osteoporosis.
Which one of the following may slow the demineralization of bone in this patient?
A) An ACE inhibitor
B) An -blocker
C) A -blocker
D) A calcium channel blocker
E) A thiazide diuretic
ANSWER: E
An adult patient with a confirmed systolic blood pressure >139 mm Hg or a diastolic blood pressure >89
mm Hg is hypertensive. JNC-7 guidelines recommend the adoption of healthy lifestyles for all patients,
especially those with hypertension,and the addition of pharmacologic treatment as necessary to reach a
goal blood pressure -blockers post myocardial infarction.
The selection of an agent with favorable side benefits is recommended. Thiazide-type diuretics are useful
in slowing demineralization from osteoporosis, making this the most appropriate choice for this patient.
Other examples of choosing drugs based on side benefits include -blockers for patients with a history of
migraine or tachycardia, calcium channel blockers for patients with Raynaud’s syndrome, and -blockers
for patients with benign prostatic hyperplasia
