Mixed Categorical Flashcards

Question

Which one of the following is the best INITIAL management for hypercalcemic crisis? (check one) A. Intravenous furosemide B. Intravenous pamidronate (Aredia) C. Intravenous plicamycin (Mithramycin) D. Intravenous saline

Answer 1

D ## Footnote The initial management of hypercalcemic crisis involves **volume repletion and hydration**. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels over 14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels (. If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide. IV pamidronate, a diphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. The same is true for intravenous plicamycin.

Answer 2

D ## Footnote The differential diagnosis of urinary retention in the elderly is broad. While most causes are benign and readily treated, the physician must be vigilant in looking for conditions that require urgent intervention.This patient presents with many possible causes of urinary retention, with the most common being **benign prostatic hyperplasia**. **Acute prostatitis**, especially in a male with an enlarged prostate, is another relatively common reason for obstructive symptoms. This patients physical examination and abnormal urinalysis support this diagnosis, but his normal vital signs and lack of fever suggest he can be treated with an oral fluroquinolone and does not require hospital admission for intravenous therapy. **Medications such as oral decongestants** can contribute to urinary retention in men with enlarged prostate glands, and should be used with caution and discontinued if obstructive symptoms occur. **Obstipation** with stool impaction is another relatively common reason for urinary retention in the elderly and can be treated with manual disimpaction and enemas. In this patient, the presence of increasing low back pain and leg weakness, and the findings of anal sphincter laxity and numbness in the perianal area on examination, suggest **cauda equina syndrome**. Urgent diagnosis and treatment are necessary to reduce morbidity, and MRI should be performed immediately. The presence of a mildly elevated post-void residual is not an indication for urgent decompression with a Foley catheter.

Answer 3

A beta-carotene supplementation provides no benefit in the prevention of cancer in middle-aged and older adults. In two trials limited to heavy smokers, supplementation with beta-carotene was actually associated with a higher incidence of lung cancer and all-cause mortality

Answer 4

B ## Footnote There is a 30% probability of pregnancy resulting from unprotected intercourse 1-2 days _before_ ovulation, 15% 3 days before, 12% the day of ovulation, and essentially 0% 1–2 days after ovulation. Knowing the time of ovulation therefore has implications not only for “natural” family planning, but also for decisions regarding postcoital contraception.

Answer 5

C ## Footnote This patient’s history and clinical examination suggest heart failure. The most important distinction to make is whether it is diastolic or systolic, as the drug treatment may be somewhat different. An echocardiogram is the study of choice, as it will assess LV function. **_Diastolic dysfunction_** - LVEF is normal / slightly elevated; more common in elderly females and patients with HTN, and less common in patients with a previous history of CAD. **Diuretics and ARBs** are useful treatments. **Because of their effects on diastolic filling times, tachycardia and atrial fibrillation often cause decompensation in patients with diastolic heart failure.** At this time, cardiac catheterization is not indicated, and a stress test will not provide useful information. If the patient had systolic failure, a workup for ischemic disease would be needed, but most cases of diastolic dysfunction are not caused by ischemia. While hyperthyroidism can cause tachycardia and atrial fibrillation, the more immediate issue in this patient is the heart failure, which requires diagnosis and treatment. A pulmonary embolus can cause shortness of breath but usually has an acute onset, so a D-dimer level would not help at this time.

Answer 6

D In patients with renal failure, the risk for death and serious cardiovascular events is increased with higher hemoglobin levels (≥13.5 g/dL), and it is therefore recommended that **hemoglobin levels be maintained at 10-12 g/dL**. Studies have also demonstrated less mortality and morbidity when the dosage of epoetin alfa is set to achieve a target hemoglobin of

Answer 7

E Keratoacanthoma grows rapidly and may heal within 6 months to a year. Squamous cell carcinoma may appear grossly and histologically similar to keratoacanthoma but does not heal spontaneously. The other lesions do not resemble keratoacanthoma

Answer 8

D ## Footnote Common variable immunodeficiency (CVID) is a **disorder of humoral immunity** associated with reduced serum levels of IgG, IgM, and IgA, and frequently presents as late as the third or fourth decade of life. The disorder is **associated with recurrent sinus infections, otitis media, bronchiectasis, and chronic GI problems**. Recognition of the disorder is important, as infections may be reduced when patients are treated with IVIg Abnormalities in the other test results are compatible with less common primary immunodeficiencies. Lymphopenia suggests a disorder of cellular immunity such as severe combined immunodeficiency, thrombocytopenia suggests the Wiskott-Aldrich syndrome, and an abnormal nitroblue tetrazolium test suggests a phagocytic disorder.

Answer 9

E Believe it or not, peppermint oil has been shown to relieve symptoms of diarrhea-predominent IBS.

Answer 10

A ## Footnote In severely obese patients (\>330 lb) and those with renal failure, low molecular weight heparin therapy should be monitored with anti-factor Xa levels obtained 4 hours after injection. Most other patients do not need monitoring.

Answer 11

A The most common cause of nasal obstruction in all age groups is the common cold, which is classified as mucosal disease. Anatomic abnormalities, however, are the most frequent cause of constant unilateral obstruction. Of these, septal deviation is the most common. Foreign body impaction is an important, but infrequent, cause of unilateral obstruction and purulent rhinorrhea. Mucosal disease is usually bilateral and intermittent. Adenoidal hypertrophy is the most common tumor or growth to cause nasal obstruction, followed by nasal polyps, but both are less frequent than true anatomic causes of constant obstruction.

Answer 12

C Framingham Heart Study defined major risk factors for coronary heart disease: elevated BP, smoking, cholesterol levels, DM, and advancing age. Using measurements of each of these risk factors and consideration of the gender of the individual, a reliable determination of risk can be obtained in individuals 30–74 years of age who have no overt coronary heart disease. The largely white study population presumptively makes the risk determination most accurate for white patients.

Answer 13

C Childhood bullying has potentially serious implications for bullies and their targets. The target children are typically quiet and sensitive, and may be perceived to be weak and different. Children who say they are being bullied must be believed and reassured that they have done the right thing in acknowledging the problem. Parents should be advised to discuss the situation with school personnel. Bullying is extremely difficult to resolve. Confronting bullies and expecting victims to conform are not successful approaches. The presenting symptoms are not temporary, and in fact can progress to serious issues such as suicide, substance abuse, and victim-to-bully transformation.

Answer 14

D It has been shown that palliative care offered early in the course of a terminal disease leads to * improvement in a patient’s quality of life and mood * reduced aggressive end-of-life care and thus reduces health care costs. * enables patients to enter hospice care earlier and perhaps for longer * extend survival times in terminal patients

Answer 15

E ## Footnote Hyperparathyroidism is usually caused by a single adenoma of one of the four parathyroid glands. Studies that localize the glands, such as a technetium scan or ultrasonography, enable surgeons to perform parathyroidectomy, thus achieving a cure rate of 95-98%.

Answer 16

E ## Footnote Children under the age of majority must have proof of permission to treat from a parent or guardian for non-emergent care. This does not apply to emergency situations in which a delay in care could result in serious harm.

Answer 17

A ## Footnote At this time in the patient’s pregnancy, a gestational sac should be visible on ultrasonography. An empty uterus presents the highest risk (14%) for ectopic pregnancy, while nonspecific fluid and echogenic material are associated with a 5% and 4% risk, respectively. An abnormal or normal sac is associated with no risk, with the rare exception of multiple pregnancies with one being heterotopic.

Answer 18

A ## Footnote The p-value characterizes the **likelihood of achieving the observed results of a study by chance alone**; in this study that likelihood 5% or less. The confidence interval is a measure of variance and is derived from the test data. The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%. The α // type I error is akin to the error of *false-positive* assignment; the β // type II error is analogous to the *false-negative r*ate, or 1 – specificity, and cannot be calculated from the information given.

Answer 19

A Hemolytic anemia is established by reticulocytosis, increased unconjugated bilirubin, elevated lactate dehydrogenase (LDH), decreased haptoglobin, and peripheral blood smear findings.

Answer 20

E Healthy women may continue combination birth control pills into their fifties, and this patient has no contraindications. Screening for thrombophilic conditions is not indicated due to the low yield. FSH levels are not specific enough to evaluate the effect of stopping the contraceptive.

Answer 21

E ## Footnote This patient displays most of the criteria for borderline personality disorder. This is a maladaptive personality type that is present from a young age, with a strong genetic predisposition. Borderline personality disorder is defined by high emotional lability, intense anger, unstable relationships, frantic efforts to avoid a feeling of abandonment, and an internal sense of emptiness. Nearly every patient with this disorder engages in self-injurious behavior (cutting, suicidal gestures and attempts), and about 1 in 10 patients eventually succeeds in committing suicide. However, 90% of patients improve despite having made numerous suicide threats. Suicidal gestures and attempts peak when patients are in their early 20s, but completed suicide is most common after age 30 and usually occurs in patients who fail to recover after many attempts at treatment. In contrast, suicidal actions such as impulsive overdoses or superficial cutting, most often seen in younger patients, do not usually carry a high short-term risk, and serve to communicate distress. Inpatient hospitalization may be an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning, and pharmacotherapy may offer a mild degree of symptom relief. While these modalities have a role in certain patients, psychotherapy (DBT) is considered the mainstay of therapy, especially in a relatively stable patient such as the one described.

Answer 22

D ## Footnote Women older than 65 years of age who have low serum TSH levels, indicating physiologic hyperthyroidism, are at increased risk for new hip and vertebral fractures. Use of thyroid hormone itself does not increase the risk of fracture if TSH levels are normal

Answer 23

C ## Footnote In the ideal setting, the accuracy of fine-needle aspiration may be over 90%. Clinical information is critical for interpreting the results of fine-needle aspiration, especially given the fact that the tissue sample is more limited than with a tissue biopsy. It is crucial to determine whether the findings on fine-needle aspiration explain the clinical findings. Although the report from the mammogram and the biopsy are not ominous in this patient, they do not explain the clinical findings. **Immediate repeat fine-needle aspiration or, preferably, a tissue biopsy is indicated.** Proceeding directly to therapy, whether surgery or irradiation, is inappropriate because the diagnosis is not clearly established. Likewise, any delay in establishing the diagnosis is not appropriate.

Answer 24

B ## Footnote Plantar fasciitis pain is typically located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear. Condition may last for months-years and resolves in most patients over time w/ or w/o specific therapy. Treatments with limited evidence of effectiveness include off-the-shelf insoles, custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis, custom-made night splints, and surgery (for those who have failed conservative therapy).

Answer 25

D ## Footnote Post-thrombotic syndrome (PTS) is a complication of acute deep-vein thrombosis (DVT), and is characterized by chronic pain, swelling, and skin changes in the affected limb. Within 5 years of experiencing a DVT, one in three patients will develop PTS. The use of elastic compression stockings was associated with a highly statistically significant reduction in the incidence of PTS, with an odds ratio of 0.31

Answer 26

B ## Footnote Several studies have demonstrated that SSRIs are safe and effective in treating depression in patients with coronary disease, particularly those with a history of previous episodes of depression. Medications have performed significantly better than intensive interpersonal psychotherapy in this setting. Electroconvulsive therapy is not considered first-line therapy in the absence of severe symptoms. While it may be effective for sleep disturbance, amitriptyline has potential cardiac side effects and is unlikely to be effective for the treatment of depression in low doses

Answer 27

A ## Footnote Calcitonin, either intranasal or subcutaneous, provides pain relief within a few days in many patients with osteoporotic vertebral compression fractures. The remainder of the choices do not provide acute relief. Vertebroplasty/kyphoplasty procedures are generally reserved for cases in which medical management has failed.

Answer 28

C ## Footnote Anterior cruciate ligament (ACL) tears are the most common ligament injury requiring surgery. Females have a significantly higher rate of ACL tears, with the majority of tears in both men and women occurring without physical contact. In addition to the immediate problems, there is a significant increase in premature osteoarthritis of the knee. Findings that help make the diagnosis of ACL tear include a noncontact mechanism of injury, an audible popping sound, early swelling of the joint, and the inability to participate in the game after the injury. Many patients can walk normally and can perform such straight-plane activities as climbing stairs, biking, or jogging. Physical examination using the Lachman test or pivot shift test can be used to further assess whether the ligament is torn. MRI can be used to confirm the diagnosis, although it is not needed if the diagnosis is clear from the history and examination.

Answer 29

E The patient most likely has obsessive-compulsive disorder (OCD) with a depressive episode. SSRIs are most frequently used. Risperidone and clonazepam are considered second-line drugs and are used as augmentation drugs when there is a partial response to an SSRI.

Answer 30

C Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography.

Answer 31

A Watchful waiting with annual follow-up is appropriate for men with mild BPH. PSA levels correlate with prostate volume, which may affect the treatment of choice, if indicated. **PSA \>2.0 ng/mL** for men in their 60s correlate with a prostatic volume **\>40 mL**, for which **5 -reductase inhibitors** is recommended, as they provide symptomatic relief for moderate to severe BPH symptoms. A recent high-quality, randomized, controlled trial found no benefit from saw palmetto with regard to symptom relief or urinary flow after 1 year of therapy. The AUA does not recommend the use of phytotherapy for BPH. Surgical consultation is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.

Answer 32

A ## Footnote This patient has the cautious gait associated with visual impairment: slow, careful, “walking on ice” movements (a wide-based stance with abducted arms and legs // “en bloc” turns) Patients with cerebellar degeneration - ataxic gait that is wide-based and staggering. Frontal lobe degeneration - gait apraxia that is described as “magnetic,” with start and turn hesitation and freezing. Parkinson’s - short-stepped and shuffling gait, with hips, knees, and spine flexed, and may also exhibit festination and “en bloc” turns. Motor neuropathy - “steppage” gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping. ^{"en bloc": rather than the usual twisting of the neck and trunk and pivoting on the toes, patients keep their neck and trunk rigid, requiring multiple small steps to accomplish a turn.}

Answer 33

D ## Footnote **Pyloric stenosis** - characterized by the early onset of worsening projectile vomiting and poor weight gain, and occurs most often in full-term male infants who are otherwise healthy. Formula intolerance causes regurgitation, as would inappropriate feeding. Meningitis, whether viral or bacterial, would be associated with fever. Viral gastroenteritis is a common cause of vomiting in older children, and is usually associated with fever and diarrhea.

Answer 34

B ## Footnote Any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo clinical or laboratory assessment to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include diabetes mellitus, hypothyroidism, obstructive liver disease, chronic renal failure, and some medications.

Answer 35

B ## Footnote **Ipratropium** is the only nasally inhaled anticholinergic recommended for a **cough caused by the common cold**. One study showed that the nasal formulation decreases rhinorrhea and sneezing, and a Cochrane review found that ipratropium bromide nasal spray improved rhinorrhea but did not help nasal stuffiness. 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.

Answer 36

E ## Footnote **Adenosine**, an expensive IV drug, is *highly effective* in terminating many resultant ****_supra_**ventricular arrhythmias**. Although it can cause hypotension or transient a-fib, adenosine is probably safer than verapamil because it **disappears from the circulation** within seconds. Because of its safety, many cardiologists now prefer adenosine over verapamil for treatment of hypotensive supraventricular tachycardia. Bretylium tosylate, procainamide, and lidocaine are used to treat ventricular arrhythmias. Atropine is indicated in the treatment of sinus bradycardia.

Answer 37

A ## Footnote The patient described initially showed signs of acute mountain sickness (anorexia, nausea, vomiting, insomnia, dizziness, or fatigue), but then deteriorated to high-altitude cerebral edema, defined as the onset of ataxia and/or altered consciousness. The management of choice is a combination of descent and supplemental oxygen. Often, a descent of only 500-1000 m (1600-3300 ft) will lead to resolution of acute mountain sickness. Simulated descent with a portable hyperbaric chamber also is effective, but descent should not be delayed while awaiting helicopter delivery. If descent and/or administration of oxygen is not possible, medical therapy with dexamethasone and/or acetazolamide may reduce the severity of symptoms. Nifedipine has also been shown to be helpful in cases of high-altitude pulmonary edema where descent and/or supplemental oxygen is unavailable.

Answer 38

C ## Footnote A large population study has established a significant increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy. Elevation of liver enzymes with the potential for hepatic dysfunction has been seen with tacrine, but it has not been noted with the other approved cholinesterase inhibitors. Cataract formation and thrombosis with pulmonary embolism do not increase with this therapy. Although improvement in mental function is often marginal with cholinesterase inhibitor therapy, the therapy has not been shown to increase the need for institutionalization.

Answer 39

D ## Footnote **Benign nocturnal limb pains of childhood (growing pains)** occur in many children, often between 4 - 6 yo. The etiology is unknown, but the course does not parallel pubescent growth, as would be expected if bone growth was the source of pain. The pain often **awakens the child within hours of falling asleep** following an active day. The pain is generally localized around the **knees**, **shins** or **calves**, but also may affect the thighs and the upper extremities. Reassurance that no additional tests or treatments are necessary and that the condition is self-limiting is the most appropriate response.

Answer 40

C ## Footnote Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory findings are a low serum free T4 and a low TSH. A free T4 level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in secondary hypothyroidism since the pituitary is malfunctioning. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.

Answer 41

C ## Footnote DSM-IV criteria for OCD indicate that the patient at some point recognizes that the obsessions or compulsions are excessive or unreasonable. The impulses of OCD are not related to excessive worry about one’s problems, and the patient recognizes that they are the product of his or her own mind. In addition, the patient experiences marked distress because of the impulses. Full remission is rare, but treatment can provide significant relief.

Answer 42

E Volvulus may present in one of three ways: * sudden onset of bilious vomiting and abdominal pain in a neonate * history of feeding problems with bilious vomiting that appears to be a bowel obstruction * failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the **double bubble sign**, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The **upper gastrointestinal contrast study** is considered the gold standard for diagnosing volvulus.

Answer 43

D ## Footnote Repeated doses of a short-acting β2-agonist and correction of hypoxia are the main elements of initial treatment for acute asthma exacerbations in children. **In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization**. Nebulizer treatments are no better than a metered-dose inhaler with a spacer. High-dose nebulized albuterol every 20 minutes for 1 hour has not been shown to be beneficial. Oral administration of corticosteroids is as effective as the intravenous route for reducing the need for hospital admission (SOR A). Mucolytics and chest physiotherapy have not been shown to be effective in children with acute asthma attacks.

Answer 44

D ## Footnote When a medical error has been made, patients prefer that their physician disclose the error and offer an explanation of events. Withholding that information from a patient is not ethical and is counter to standards set forth by various organizations. Using the word “error” is acceptable and does not lead to an increase in litigation. In fact, there is no evidence that malpractice litigation rates increase when an error is admitted, and rates often decrease. Private-practice physicians are less likely to admit errors to patients. It is surmised that these physicians have less access to training in disclosure than those employed by hospitals or health care organizations.

Answer 45

A ## Footnote **Antibiotic use** in moderately or severely ill patients with a COPD exacerbation reduces the risk of treatment failure or death, and may also help patients with mild exacerbations. Brief courses of systemic corticosteroids shorten hospital stays and decrease treatment failures. Inhaled corticosteroids are not helpful in the management of an acute exacerbation. IV levalbuterol and albuterol have similar benefits and adverse effects. Acetylcysteine, a mucolytic agent, has _not_ been shown to be helpful for routine treatment of COPD exacerbations.

Answer 46

A LiNdaNe’s efficacy has waned over the years and it is inconsistently ovicidal. Furthermore, because of its **Neurotoxicity**, lindane carries a black box warning and is specifically recommended only as second-line treatment by the FDA.

Answer 47

C ## Footnote This patient has secondary hyperparathyroidism, a common cause of hypercalcemia in patients with chronic renal insufficiency. **Sevelamer** is a newer synthetic agent in the therapeutic class of **phosphate binders**, which includes calcium acetate. **Decreasing serum phosphate lowers the feedback stimulation of parathyroid hormone secretion by the parathyroid gland,** which is often excessive in chronic renal insufficiency. Normalizing parathyroid levels improves serum calcium levels.

Answer 48

B Continued oral feeding in diarrhea aids in recovery, and an age-appropriate diet should be given. Breastfeeding or regular formula should be continued. Foods with complex carbohydrates (e.g., rice, wheat, potatoes, bread, and cereals), lean meats, yogurt, fruits, and vegetables are well tolerated. Foods high in simple sugars (e.g., juices, carbonated sodas) should be avoided because the osmotic load can worsen the diarrhea. Fatty foods should be avoided as well. The BRAT diet has not been shown to be effective.

Answer 49

d The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker’s diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.

Answer 50

B ## Footnote Sjögren’s syndrome - common systemic autoimmune diseases; results from lymphocytic infiltration of exocrine glands and leads to acinar gland dysfunction. A positive **anti-SS-A** or **anti-SS-B** antigen test or a positive salivary gland biopsy is diagnostic. In addition to ocular and oral complaints, clinical manifestations include arthralgias, thyroiditis, pulmonary disease, and GERD. Most patients with sarcoidosis present with shortness of breath or skin manifestations, and patients with lupus generally have fatigue and joint pain. Ocular rosacea causes eye symptoms very similar to those of Sjögren’s syndrome, but oral findings would not be expected. Drugs such as anticholinergics can cause a dry mouth, but this would be unlikely a month after the medication was discontinued (

Answer 51

C Most infants with face presentation, mentum anterior, can be delivered vaginally, either spontaneously or with _low_ forceps. C-section is indicated for fetal distress and failure to progress. **_Mid_**forceps delivery is not indicated. If fetal electrodes are attached, the chin is the preferred location.

Answer 52

C Xerosis is a pathologic dryness of the skin that is especially prominent in the elderly. It is probably caused by minor abnormalities in maturation of the epidermis that lead to decreased hydration of the superficial portion of the stratum corneum. Xerosis often intensifies in winter, because of the lower humidity and cold temperatures. Stasis dermatitis, due to chronic venous insufficiency, appears as a reddish-brown discoloration of the lower leg. Lichen simplex chronicus, the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center. Rosacea is most often seen on the face as an erythematous, acneiform eruption, which flushes easily and is surrounded by telangiectasia. Candidiasis is an opportunistic infection favoring areas that are warm, moist, and macerated, such as the perianal and inguinal folds, inframammary folds, axillae, interdigital areas, and corners of the mouth.

Answer 53

E ## Footnote Abnormal uterine bleeding is a relatively common disorder that may be due to functional disorders of the hypothalamus, pituitary, or ovary, as well as uterine lesions, though younger women rarely have a structural uterine defects. _For women younger than 30 years old_ : once pregnancy, hematologic disease, and renal impairment are excluded, administration of **intramuscular or oral progesterone** will usually produce definitive flow and control the bleeding. No further evaluation should be necessary unless the bleeding recurs. _For older women,_ Endometrial aspiration, dilatation and curettage, and other diagnostic procedures are appropriate for recurrent problems or for older women. Estrogen would only increase the problem, which is usually due to anovulation with prolonged estrogen secretion, producing a hypertrophic endometrium.

Answer 54

C Trichomonal vaginitis findings * yellowish discharge which sometimes has a frothy appearance * colpitis macularis (strawberry cervix) Monilial/Candidal vaginitis classically causes a cheesy, whitish exudate with associated vaginal itching and burning. There may be vaginal and vulvar erythema and edema. Bacterial vaginosis is characterized by a grayish discharge with few other physical signs or symptoms, if any. Chlamydia may cause a yellowish cervical discharge and symptoms of pelvic inflammatory disease or, alternatively, may be totally asymptomatic. Herpes simplex type 2 causes ulcerations on the vulva and vaginal mucosa which are exquisitely tender, often with marked surrounding erythema and edema.

Answer 55

D ## Footnote This patient has classic findings for acute rectal fissure. Although patients often require an internal sphincterotomy, nonsurgical measures that relax or dilute the sphincter have proven helpful. Drugs that dilate the internal sphincter: **diltiazem, nifedipine, and nitroglycerin** **ointment**, have proven to be beneficial in healing acute fissures Botulinum toxin injected into the internal sphincter has proven most beneficial, but topical preparations are not yet available and have not been shown to be effective for this problem. Corticosteroid creams may decrease the pain temporarily, but potent fluorinated corticosteroid creams such as clobetasol are not indicated in the treatment of fissure. Capsaicin cream can be helpful for pruritus ani, but not for anal fissures.

Answer 56

A The Beers criteria, a list of drugs that should generally be avoided by older patients, was developed by expert consensus, and was last updated in 2002. Indomethacin is on the list due to its propensity to produce more central nervous system adverse effects than other NSAIDs.

Answer 57

D ## Footnote Diagnosis of **Duchenne muscular dystrophy** is usually not made until the affected individual presents with an established gait abnormality at the age of 4–5 years. The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. Massive elevation of creatine kinase (CK) from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies. Hypothyroidism and phenylketonuria could present as delayed walking. However, these diseases cause significant mental retardation and would be associated with global developmental delay. Furthermore, these disorders are now diagnosed in the neonatal period by routine screening. Disorders of amino acid metabolism present in the newborn period with failure to thrive, poor feeding, and lethargy. Gross chromosomal abnormalities would usually be incompatible with a normal physical examination at 18 months of age.

Answer 58

D Orthostatic proteinuria accounts for up to 60% of all cases of asymptomatic proteinuria reported in children, with an even higher incidence in adolescents.

Answer 59

B ## Footnote Two doses of varicella vaccine are recommended for all children unless they are immunocompromised, in which case they should not be immunized against varicella, or with other live-virus vaccines. Shingles is evidence of prior varicella infection and is a reason not to vaccinate with varicella vaccine.

Answer 60

C ## Footnote In 50%–90% of patients, pityriasis rosea starts with an erythematous, scaly, oval patch a few centimeters in diameter. This is usually followed within a few days by smaller patches on the trunk and sometimes the proximal extremities. Pityriasis rubra pilaris is a rare disease with five types. The classic adult type begins with a small red plaque on the face or upper body that gradually spreads to become a generalized eruption. The other conditions listed typically begin with multiple lesions.

Answer 61

D ## Footnote CDC recommends that all adults \> 65 receive a _single_ dose of pneumococcal polysaccharide vaccine. Immunization _before_ 65 is recommended for certain subgroups of adults, including institutionalized individuals; those with chronic cardiac or pulmonary disease, DM, asplenia, chronic liver disease, or kidney failure; and health-care workers. It is recommended that those receiving the vaccine before the age of 65 receive an _additional dose at age 65 or 5 years after the first dose_, whichever is later.

Answer 62

A Croup is a syndrome most often caused by viruses, but can occasionally be of bacterial origin. **Mild** croup is manifested by an occasional barking cough with no stridor at rest, and mild or absent intercostal retractions. **Moderate** croup presents with a more frequent barking cough, stridor with suprasternal and sternal retractions at rest, but no agitation. **Severe** croup includes more prominent inspiratory and expiratory stridor with agitation and distress. **Corticosteroids produce significant improvement** - give as a single-dose dexamethasone (0.6 mg/kg PO or IM) OR 4 doses over a 2-day period. Longer courses of corticosteroids have not proven to be more effective and may be harmful, leading to secondary infections.

Answer 63

C ## Footnote In patients with no known CAD, the **presence of frequent premature ventricular contractions (PVCs) is linked to acute myocardial infarction and sudden death**. The Framingham Heart Study defines **frequent as \>30 PVCs per hour**. AHA recommends **evaluation for CAD in patients who have frequent PVCs and cardiac risk factors, such as hypertension and smoking**. Evaluation for CAD may include stress testing, echocardiography, and ambulatory rhythm monitoring. Strong evidence from randomized, controlled trials suggests that **PVCs should not be suppressed with antiarrhythmic agents**, as **using encainide or flecainide to suppress PVCs increases mortality.**

Answer 64

D ## Footnote Red yeast rice (Monascus purpureus) is a Chinese herbal medication that is used as a **dietary supplement**, and as an **alternative management of hyperlipidemia**. Extracts of red yeast rice contain several active ingredients, including monacolin K and other monacolins, that have **HMG-CoA reductase inhibitory activity** and are **considered to be** ***naturally occurring forms of lovastatin***. Red yeast rice extract lowers total cholesterol, LDL-cholesterol, and triglycerides. It may be useful for patients unable to tolerate statins due to myalgias, but **requires periodic monitoring of liver enzymes** because its metabolic effects and potential for consequences are similar to those of statins.

Answer 65

D ## Footnote Both pyridoxine (vitamin B6), 50–100 mg/day, and chasteberry, 20 mg/day, have been shown in randomized, controlled trials to reduce the symptoms of PMS compared with placebo. No good evidence supports the use of vitamin E, saffron, St. John’s wort, or soy.

Answer 66

A The refusal to accept any medical intervention, including life-saving blood transfusions, has been well established for adults who have the ability to definitively communicate their wishes. Also, parents have the power to give or withhold consent to medical treatment on behalf of their children. However, Western courts have deemed that parents cannot refuse emergency, life-saving treatment to children based on these principles: (1) the child's interests and those of the state outweigh parental rights to refuse medical treatment; (2) parental rights do not give parents life and death authority over their children; and (3) parents do not have an absolute right to refuse medical treatment for their children, if that refusal is regarded as unreasonable.

Answer 67

D ## Footnote This child meets the criteria for possible **septic arthritis**. In this case **US** is recommended as it is **highly sensitive for detecting effusion of the hip joint**. If an effusion is present, urgent US-guided aspiration should be performed. Bone scintigraphy is excellent for evaluating a limping child when the H/P, and radiographic and sonographic findings fail to localize the pathology. CT is indicated when cortical bone must be visualized. MRI provides excellent visualization of joints, soft tissues, cartilage, and medullary bone. It is especially useful for confirming osteomyelitis, delineating the extent of malignancies, identifying stress fractures, and diagnosing early Legg-Calvé-Perthes disease. Plain film radiography is often obtained as an initial imaging modality in any child with a limp. However, films may be normal in patients with septic arthritis, providing a false-negative result.

Answer 68

A ## Footnote SSRIs have been shown to benefit children and adolescents with depression, but there are concerns regarding their association with suicidal behavior. Fluoxetine seems to be the most favorable SSRI, and is the only one recommended by the FDA for treatment of depression in children 8–17 years old. There is limited or no evidence to support the use of lithium, venlafaxine, or St. John’s wort in children and adolescents. Amitriptyline and other tricyclic antidepressants are ineffective in children and have limited effectiveness in adolescents, and safety is an issue in both of these groups

Answer 69

C The key to making a diagnosis of imperforate hymen, aside from the obvious finding on physical examination, lies in the systematic drawing of inferences. One can speculate that this patient’s recurrent crescendo abdominal cramping represented six menstrual sheddings, with no egress from the body. Her delay in menarche, despite normal growth parameters, offers another clue that structural amenorrhea is present. Hymenotomy will relieve the pressure, and normal menses should ensue.

Answer 70

D ## Footnote Barrett’s esophagus = acquired intestinal metaplasia of the distal esophagus associated with longstanding GERD, although a quarter of patients with Barrett’s esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include **obesity** and **tobacco** use. It is a risk factor for **adenocarcinoma** of the esophagus, with a rate of about one case in every 200 patients with Barrett’s esophagus per year. Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk. One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available.

Answer 71

D ## Footnote Orthostatic hypotension - drop in SBP ≥ 20 mm Hg or DBP ≥ 10 mm Hg diastolic that occurs **within 3 minutes of standing**. When symptomatic it is often described as lightheadedness or dizziness upon standing. Etiologies to consider include iatrogenic, neurologic, cardiac, and environmental causes, plus many others alone or in combination. Since orthostatic hypotension may result in syncope, leading to falls and substantial injury, identifying it and taking corrective steps can produce a significant benefit.

Answer 72

C ## Footnote Intensive management of hyperglycemia, with a goal of achieving nondiabetic glucose levels, helps reduce microvascular complications such as retinopathy, nephropathy, and neuropathy. Foot infections are less common in patients without neuropathy and in patients with good glycemic control. Intensive management of hyperglycemia also has a beneficial effect on cardiovascular disease in patients with type 1 diabetes mellitus but, unfortunately, not in patients with type 2 diabetes. In fact, there is data to suggest 1c that intensive glycemic control (hemoglobin A

Answer 73

D ## Footnote Long-term H2-blocker or PPIs use is associated with decreased absorption of calcium carbonate. Patients taking these medications who require calcium supplementation should use calcium citrate to improve absorption. Calcium carbonate preparations should be given with a meal to improve absorption. Vitamin D is important in calcium absorption.

Answer 74

D About 3% of persons over age 55 have glaucoma, making it a leading cause of vision impairment. Although it is usually asymptomatic, the most common presenting symptom is **tunnel vision, a gradual loss of peripheral vision.**

Answer 75

A ## Footnote ACEi can significantly worsen renal failure in patients with HTN caused by renovascular disease. Hyperkalemia is an associated problem. Captopril renography is a useful diagnostic screening test. The other agents are useful for lowering blood pressure but may cause mild creatinine elevations. They do not, however, cause the significant elevations of creatinine seen with ACEi in cases of significant renovascular disease.

Answer 76

D ## Footnote **Patients with PID and tubo-ovarian abscess (R adnexal mass) and high fever** should be hospitalized and treated for at least 24 hours with IV antibiotics. Amoxicillin/penicillin G procaine are no longer recommended because of the increasing prevalence of penicillinase-producing and chromosomally-mediated resistant N. gonorrhoeae. If cefoxitin IM is used as an outpatient treatment, it should be combined with probenecid. If ceftriaxone is used for outpatient treatment, probenecid is not required. Reexamination should be done within 3 days of initiation of therapy.

Answer 77

E ## Footnote This patient is experiencing the **Jarisch-Herxheimer reaction**, an acute, transient, febrile reaction that occurs within the first few hours after treatment for syphilis. The condition peaks at 6–8 hours and disappears within 12–24 hours after therapy. The temperature elevation is usually low grade, and there is often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to liberation of antigens from the spirochetes secondary to antibiotics effects.

Answer 78

A Exclusive breastfeeding for the first 4 months of life has been shown to reduce the cumulative incidence of atopic dermatitis in the first 2 years of life for infants at high risk of developing atopic disease; doing so beyond 4 months does not appear to provide additional benefit.

Answer 79

A "ex" those pounds! Of the diabetic medications, only **metformin** and **incretin mimetics/ exenatide** have the additional benefit of helping the overweight or obese patient lose a significant amount of weight. Most of the other medications, including all the insulin formulations, unfortunately lead to weight gain or have no effect on weight.

Answer 80

C An elevation in serum methylmalonic acid is both sensitive and specific for cellular vitamin B 12 deficiency.

Answer 81

A ## Footnote **_N_**_ormal pressure hydrocephalus_ **-** mild impairment of memory develops gradually over weeks/ months, accompanied by mental and physical slowness; condition progresses insidiously to **severe dementia**. Patients also develop an **unsteady gait** and **urinary incontinence**, but there are **no signs of increased intracranial pressure.** **_Alzheimer’s disease_** brain gradually atrophies; **disturbance in memory** for recent events is usually the first symptom, along with **disorientation** **to time and place**; otherwise, there are no symptoms for some period of time. **_Subacute sclerosing panencephalitis_** usually occurs in children and young adults between the ages of 4 and 20 years and is characterized by **deterioration in behavior and work**. The most characteristic neurologic sign is mild clonus. **_Multiple sclerosis_** is characteristically marked by **recurrent attacks of demyelinization;** typical features of **incoordination, paresthesias, and visual complaints**. Mental changes may occur in the advanced stages of the disease. About two-thirds of those affected are between the ages of 20 and 40.

Answer 82

E ## Footnote Hepatitis B immune globulin (HBIG) should be administered as soon as possible to patients with known exposure to hepatitis B. Hepatitis B vaccine is a killed-virus vaccine and can be used safely in pregnancy, with no need to wait until after organogenesis. This patient has been exposed to sexual transmission for at least 6 weeks, given that the incubation period is at least that long, so it is too late to use condoms to prevent infection. The patient is unlikely to be previously immune to hepatitis B, given that she has no history of hepatitis B infection, immunization, or carriage. Because the patient's HBsAg is negative, she is not the source of her husband's infection. Full treatment for this patient has an efficacy of only 75% so follow-up testing is still needed.

Answer 83

c Nerve gas agents such as sarin resemble organophosphate insecticides and inactivate anticholinesterase, leading to the accumulation of ACh at nerve endings. Respiratory symptoms include rhinorrhea, bronchorrhea, bronchospasm, and respiratory muscle paralysis. GI symptoms include NVD. CNS symptoms include HA, vertigo, agitation, seizures, and coma. Exposed patients benefit from treatment with **atropine**, which competitively inhibits acetylcholine. **Pralidoxine chloride** and **diazepam** are also beneficial. Although ß-agonists and corticosteroids are beneficial in the general treatment of bronchospasm, atropine is preferred in this situation. Verapamil and ciprofloxacin have no role in the treatment of nerve gas exposure.

Answer 84

A ## Footnote Acute pericarditis - A friction rub can be heard in up to 85% of patients with acute pericarditis. An ECHO is often performed to determine the type and amount of effusion. Conventional therapy for acute pericarditis includes NSAIDs, such as aspirin and ibuprofen. Recent studies demonstrate that adding colchicine to aspirin may be beneficial in reducing the persistence and recurrence of symptoms.

Answer 85

D ## Footnote Radiofrequency catheter ablation of bypass tracts is possible in over 90% of patients and is safer and more cost effective than surgery, with a similar success rate. IV and PO digoxin can shorten the refractory period of the accessory pathway, and increase the ventricular rate, causing ventricular fibrillation. Beta-blockers will not control the ventricular response during atrial fibrillation when conduction proceeds over the bypass tract.

Answer 86

A **Trazodone** has been found useful for its sedative and hypnotic effects, and is often used in combination with another antidepressant. **Benzodiazepines** are not recommended for long-term use. **Zaleplon** is more short-acting than zolpidem and therefore would not be more effective. **Amitriptyline** could be used for its antidepressant and sedative effects, but its chronotropic side effects make it less preferable for someone with a disposition to cardiac arrhythmia.

Answer 87

A ## Footnote When pregnancy is desired, myomectomy offers the best chance for a successful pregnancy when prior pregnancies have been marked by fibroid-related complications. Endometrial ablation eliminates fertility, and there is a lack of long-term data on fertility after uterine artery embolization. Observation without treatment would not remove the risk for recurrent complications during subsequent pregnancies.

Answer 88

A ## Footnote **Sialadenosis**, bilateral non-inflammatory enlargement of the parotid gland, **is associated with diabetes mellitus**. *Periodontal bleeding and inflammation, candidiasis, and delayed wound healing also are associated with diabetes mellitus*. Tooth erosion can be an oral manifestation of GERD or bulimia. Cobblestone oral mucosa is seen in Crohn’s disease. Diffuse melanin pigmentation is an oral finding of Addison’s disease. Painful oral ulcers occur in several conditions, including Behçet syndrome, aphthous ulcers, pemphigus, and pemphigoid.

Answer 89

B ## Footnote **Laryngoscopy** should be performed to visualize the larynx and evaluate for vocal cord pathology in a patient whose hoarseness does not resolve within **3 months.** If a serious condition is suspected for some other reason, laryngoscopy should be performed regardless of the duration of symptoms. If there is a recent history of upper respiratory infection or vocal abuse, then it would be appropriate to recommend voice rest for 2 weeks. Laryngoscopy would then be indicated if the hoarseness did not improve or recurred after voice rest. For patients with symptoms of gastroesophageal reflux, a trial of a proton pump inhibitor is recommended. Inhaled corticosteroids, especially fluticasone, may cause hoarseness. Oral corticosteroids do not have a role in the management of hoarseness.

Answer 90

D Several disorders that are common in women with polycystic ovary syndrome are associated with an increased risk for endometrial carcinoma, including obesity, hyperinsulinemia, diabetes mellitus, anovulatory cycles, and high androgen levels.

Answer 91

D ## Footnote An AST/ALT ratio \>2 supports a diagnosis of alcoholic liver disease. Elevated (-glutamyl transpeptidase (GGTP) is also associated with alcohol abuse, especially in a patient with an AST/ALT ratio \>2.

Answer 92

B Finasteride has considerable efficacy in treating obstructive symptoms, but it unfortunately falsely depresses PSA levels. In patients taking finasteride, this can affect the evaluation for carcinoma of the prostate. **F**inasteride can **F**ake the PSA levels

Answer 93

B ## Footnote At present there is no approved treatment for Raynaud’s disease. However, patients with this disorder reportedly experience subjective symptomatic improvement with calcium channel antagonists, with nifedipine being the calcium channel blocker of choice. ß-Blockers can produce arterial insufficiency of the Raynaud type, so propranolol and atenolol are contraindicated. Drugs such as ergotamine preparations and methysergide can produce cold sensitivity, and should therefore be avoided in patients with Raynaud’s disease.

Answer 94

C ## Footnote For patients undergoing major orthopedic surgery, the American College of Chest Physicians recommends **outpatient** **thromboprophylaxis for a duration of up to 35 days**. Older recommendations for 10–14 days of prophylaxis were based on studies performed when this was the usual hospital stay. This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.

Answer 95

A ## Footnote Probiotics are microorganisms with likely health benefits, based on recent randomized, controlled trials. Good evidence suggests that probiotics reduce the incidence, duration, and severity of antibiotic-associated and infectious diarrhea. Common side effects include flatulence and abdominal pain. Contraindications include short-gut syndromes and immunocompromised states. There are no known drug interactions, and these agents appear safe for all ages.

Answer 96

C ## Footnote **Henoch-Schonlein purpura** typically follows an URI, and presents with low-grade fever, fatigue, arthralgia, colicky abdominal pain, and **rash**, which begins as pink maculopapules, progresses to petechiae or purpura, which are clinically palpable, and changes in color from red to dusty brown before fading. Arthritis, usually involving the knees and ankles, is present in two-thirds of cases, and GI tract involvement results in heme-positive stools in 50% of cases. Laboratory findings are not specific or diagnostic, and include indications of mild to moderate thrombocytosis, leukocytosis, and anemia, and an elevated ESR. Treatment is typically **symptomatic and supportive**, although **corticosteroids** are indicated in the rare patient with life-threatening GI or CNS manifestations. Systemic juvenile-onset rheumatoid arthritis usually presents with an evanescent salmon-pink rash. Rocky Mountain spotted fever does not present with arthritis and the rash begins distally on the legs. Iron ingestion does not typically cause a rash, fever, or arthritis. Disseminated anthrax does not present with a rash and joint symptoms

Answer 97

E ## Footnote Overly rapid correction of hyponatremia may cause **osmotic demyelination syndrome aka central pontine myelinolysis**. Signs and symptoms may include **dysarthria, dysphagia, paresis, coma,** and **seizures**. It is believed that brain volume shrinks because it cannot assimilate the new electrolytes fast enough and water is lost from the cells. Rapid correction of hypernatremia that has been present for a short time is relatively safe. Hyperkalemia is a life-threatening condition that should be corrected promptly. Rapid correction of hypoglycemia is not an issue. Overly rapid correction of hyperglycemia and subsequent cerebral edema is unusual and is primarily seen in children.

Answer 98

D ## Footnote Emollients are a mainstay of chronic therapy for atopic dermatitis, but topical corticosteroids are the first-line treatment for flare-ups. Calcineurin inhibitors such as pimecrolimus are a second-line treatment for moderate to severe atopic dermatitis. Antibiotics are not useful in reducing flare-ups of atopic dermatitis unless there is clear evidence of a secondary infection. Neither topical nor oral antihistamines are recommended for routine treatment of atopic dermatitis because they are not effective in treating the associated pruritus.

Answer 99

E Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease. This is because the surgical risk of aortic valve replacement outweighs the approximately 1% annual risk of sudden death in asymptomatic patients with aortic stenosis.

Answer 100

C ## Footnote Traveler’s diarrhea commonly occurs in travelers to Mexico and developing countries. It is usually caused by bacterial organisms such as **E. coli, Campylobacter, Shigella, and Salmonella.** Viral and parasitic organisms are less common causes, unless the diarrhea persists for 2 weeks. Appropriate medications include antidiarrheal agents such as loperamide, bismuth subsalicylate, and antibiotics. **Azithromycin** is generally effective and safe in children. Fluoroquinolones are effective in adults, but should not be used in an 8-year-old. Metronidazole, mebendazole, and metoclopramide would not be likely to successfully treat bacterial traveler’s diarrhera.

Answer 101

D Stimulant medication can be prescribed for preschool children, but only after a thorough trial of behavior modification. Foods and additives have never been shown to cause or aggravate ADHD. Children with ADHD often have other behavioral problems such as depression or oppositional-defiant disorder.

Answer 102

D ## Footnote Antiphospholipid antibody syndrome in pregnancy is associated with an increased risk of thromboembolism, fetal loss, thrombocytopenia, and poor pregnancy outcome. **Combination of aspirin and heparin is most effective for decreasing fetal loss.** One study showed decreased fetal loss with a combination of corticosteroids and aspirin, but the results have not been reproduced in subsequent studies. In addition, the use of *prednisone was associated with an increased risk of premature rupture of membranes, preterm delivery, fetal growth restriction, infection, preeclampsia, diabetes, osteopenia, and avascular necrosis*. Progesterone may be useful for recurrent spontaneous abortion related to a luteal phase defect, but has not been shown to be effective in preventing complications associated with antiphospholipid antibody syndrome.

Answer 103

B ## Footnote Hyperparathyroidism is present in more than half of patients who have a **GFR , and is independently associated with increased mortality and an increased prevalence of cardiovascular disease.** In patients with stage 4 chronic kidney disease, current guidelines recommend monitoring of **serum calcium and phosphate levels every 3–6 month**s and **bone-specific alkaline phosphatase activity every 6–12 months** with the goal of normalizing these values. The other metabolic abnormalities listed are less common than hyperparathyroidism.

Answer 104

A ## Footnote Developmental dysplasia of the hip: subluxation, dislocation, or anatomic abnormalities. Common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. The current recommendation is to treat all children with closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age.

Answer 105

D Nightmares occur in the second half of the night, when REM sleep is most prominent. Parasomnias, including sleepwalking, confusional arousal, and sleep terrors, are disorders of arousal from non-REM sleep. These are more common in children than adults because children spend more time in deep NREM sleep. Such disorders usually occur within 1-2 hours after sleep onset, and coincide with the transition from the first period of slow-wave sleep.

Answer 106

B ## Footnote Estimation of gestational age by US is most accurate early in the first trimester and begins to decline by 22 weeks gestation. Crown-rump length is typically used to estimate gestational age before 13 weeks gestation (1st trimester) After 11 weeks gestation, biparietal diameter, femur length, head circumference, and abdominal circumference are used (second + third trimester)

Answer 107

E ## Footnote Midshaft clavicle fractures are usually treated nonoperatively, but have a higher risk of nonunion. **Risk factors for nonunion include female gender, comminuted fractures, or displacement, clavicle shortening**, **advanced age,** and **greater extent of initial trauma**. These fractures in children heal extremely well, even if displaced or comminuted, because of periosteal regenerative potential.

Answer 108

E The recommended duration of **DUAL antiplatelet therapy** following placement of a drug-eluting coronary artery stent is 1 year. The recommended dosages are **aspirin, 162–325 mg + clopidogrel, 75 mg OR prasugrel, 10 mg**. Ticlopidine is an option for patients who do not tolerate clopidogrel or prasugrel. The minimum recommended duration of dual antiplatelet therapy is * 1 month with bare-metal stents * 3 months with sirolimus-eluting stents * 6 months with other drug-eluting stents.

Answer 109

C Inhaled corticosteroids improve asthma control in adults/children more effectively than any other single long-term controller medication, and all patients should also receive a prescription for a short-acting β-agonist.

Answer 110

E This patient has IBS and meets the Rome criteria by having 3 days per month of abdominal pain for the past 3 months, a change in the frequency of stool, and improvement with defecation. According to current clinical guidelines IBS can be diagnosed by history, physical examination, and routine laboratory testing, as long as there are no warning signs. Warning signs include rectal bleeding, anemia, weight loss, fever, a family history of colon cancer, onset of symptoms after age 50, and a major change in symptoms. Colonoscopy, CT, and GI contrast studies are not indicated. A gluten-free diet would not be indicated since the antibody tests for celiac disease are negative. Antidiarrheal agents such as loperamide are generally safe and effective in the management of diarrheal symptoms in IBS.

Answer 111

B USPSTF recommends one-time screening for AAA by abdominal US in men aged 65–75 who have ever smoked. USPSTF found good evidence that screening these patients for AAA and surgical repair of large AAAs (≥5.5 cm) leads to decreased AAA-specific mortality.

Answer 112

B ## Footnote The most common cause of hypoglycemia in a previously stable, well-controlled diabetic patient who has not changed his or her diet or insulin dosage is **diabetic renal disease,** resulting in spillage of glucose into the urine A reduction in physical activity or the appearance of insulin antibodies (unlikely after 20 years of therapy) would increase insulin requirements and produce hyperglycemia. Spontaneous improvement β -cell function after 20 years would be very rare.

Answer 113

C ## Footnote The use of automated external defibrillators (AEDs) by lay persons, trained and otherwise, has been quite successful, with up to 40% of those treated recovering full neurologic and functional capacity.

Answer 114

E ## Footnote Diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available). The preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate. Endoscopy is reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation.

Answer 115

C Testing for androgen excess is indicated in the young woman with an acute onset of hirsutism or when it is associated with menstrual irregularity, infertility, central obesity, acanthosis nigricans, or clitoromegaly. Elevated early morning total testosterone is most often associated with polycystic ovary syndrome. Testing to r/o other etiologies would include: * pregnancy testing if the patient has amenorrhea * serum prolactin level to exclude hyperprolactinemia * DHEA-S and early morning 17-hydroxyprogesterone to detect adrenal hyperandrogenism and congenital adrenal hyperplasia * Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present * Pelvic US to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and US has a low sensitivity.

Answer 116

B ## Footnote A single dose of activated charcoal is the decontamination treatment of choice for most medication ingestions. It should be **used within 1 hour of ingestion** of a potentially toxic amount of medication. Gastric lavage, cathartics, or whole bowel irrigation is best for ingestion of medications that are poorly absorbed by activated charcoal (iron, lithium) or medications in sustained-release or enteric-coated formulations. Ipecac has no role in home use or in the health care setting

Answer 117

B ## Footnote An accepted regimen for outpatient treatment of diverticulitis is amoxicillin/clavulanate, 875 mg every 12 hours. The other regimens are not optimal treatments because they do not include anaerobic coverage.

Answer 118

E **Anticholinergics benztropine** and **amantadine** may provide some improvement of symptoms, but the *effects wane within a few months* and is not a good option in this patient with advanced disease. **Dopamine agonists (Pramipexole (Mirapex))** provide some improvement in motor complications, but are *mainly used to delay the introduction of levodopa in younger patients*, to avoid levodopa-related adverse reactions. **Carbidopa/levodopa** is better for initial therapy in older patients, and those who present with more severe symptoms. Slow-release versions may decrease motor fluctuations. **Stereotactic thalamotomy** is used to ameliorate tremors that have become disabling. This procedure has been replaced by other surgical options such as pallidotomy and high-frequency, deep-brain stimulation of specific nuclei.

Answer 119

A Paroxetine has been found to cause higher rates of sexual dysfunction than bupropion, fluoxetine, and sertraline. Bupropion has been found to have significantly lower rates of adverse effects on sexual function than fluoxetine or sertraline.

Answer 120

A ## Footnote While all of the medications listed can be used to treat osteoporosis, only **calcitonin-salmon is useful in the management of pain associated with acute or chronic vertebral fractures**. Calcitonin is an antiresorptive agent that has been shown to decrease the risk of vertebral fractures, but it is **_not considered a first-line treatment for osteoporosis_** because there are more effective agents. However, it does have modest analgesic properties that make it useful in the treatment of the pain associated with vertebral fractures.

Answer 121

C The Ottawa ankle rules have been designed and validated to reduce unnecessary radiographs. Radiographs should be obtained for all patients with an acute ankle injury who meet any of the following criteria: * inability to take four steps, either immediately after the injury or when being evaluated * localized tenderness of the navicular bone _or_ the base of the fifth metatarsal * localized tenderness at the posterior edge or tip of either malleolus.

Answer 122

A Shift-work insomnia is the only circadian sleep disorder listed. It may respond to bright-light therapy.

Answer 123

B ## Footnote A helpful guideline for assessing normal growth in the very young infant is that birth weight should be regained within 14 days

Answer 124

E ## Footnote Primidone and propranolol are the first-line drugs for essential tremor. Alprazolam is considered to be possibly effective. The tremor described is not due to Parkinson’s disease and would not respond to carbidopa/levodopa. Levetiracetam is not effective. There is not enough evidence to recommend for or against the use of olanzapine.

Answer 125

D ## Footnote β-Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD) and have been shown to reduce the risk of death by 23% at 2 years. They should also be given to normotensive patients with CAD if tolerated. Cardioselective (β1) β-blockers such as metoprolol and atenolol are preferred, as they cause fewer adverse effects.

Answer 126

B ## Footnote Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates.

Answer 127

D ## Footnote Fetal alcohol syndrome - thin upper lip, a smooth philtrum, and a flat nasal bridge; clinodactyly (curved fifth finger towards the adjacent fourth finger); prenatal and postnatal growth retardation; and functional or structural CNS abnormalities. Down syndrome - hypotonia, a flat face, upward and slanted palpebral fissures and epicanthic folds, and speckled irises (Brushfield spots); varying degrees of mental and growth retardation; dysplasia of the pelvis; cardiac malformations; a simian crease; short, broad hands; hypoplasia of the middle phalanx of the 5th finger; and a high, arched palate. Marfan syndrome - pectus carinatum or pectus excavatum, an arm span to height ratio \>1.05, a positive wrist and thumb sign, limited elbow extension, pes planus, and aortic ascendens dilatation with or without aortic regurgitation. Potter syndrome - bilateral renal agenesis that leads to death shortly after birth; separated eyes with epicanthic folds, low-set ears, a broad and flat nose, a receding chin, and limb anomalies. Prader-Willi syndrome - severe hypotonia at birth, obesity, short stature (responsive to growth hormone), small hands and feet, hypogonadism, and mental retardation.

Answer 128

A ## Footnote **Low urine calcium levels** (24 hr) or a **low urine Ca:Cr ratio** suggest **familial hypocalciuric hypercalcemia;** not hyperparathyroidism!! Awareness of this condition is important to avoid unnecessary surgery. The PTH level may be mildly elevated. PTH is elevated in hyperparathyroidism. Serum chloride tends to be high normal or mildly elevated. Alkaline phosphatase may be elevated in more severe cases, while serum phosphate levels tend to be low.

Answer 129

D Vacuum-assisted delivery is associated with * higher rates of neonatal cephalhematoma and retinal hemorrhage compared with forceps delivery * less maternal soft-tissue trauma when compared to forceps delivery * increased likelihood of a severe perineal laceration without episiotomy; even higher risks with episiotomy. * shoulder dystocia is more common with vacuum-assisted delivery than with forceps delivery * increased likelihood of a severe perineal laceration is increased in women who have vacuum-assisted delivery without episiotomy compared to women wiht spontaneous vaginal delivery

Answer 130

A ## Footnote This patient should be provided with a **regular diet**, which may promote weight gain in nursing-home residents with unintentional weight loss. Malnutrition and unintentional weight loss are significant problems in nursing-home residents and lead to multiple complications, including pressure ulcers and infections. The American Dietetic Association recommends **liberalizing diets to improve nutritional status and quality of life in older adults**. A small study demonstrated equivalent glycemic control in nursing-home residents who ate a regular diet compared to those who ate a restricted American Diabetes Association diet. Low-salt and low-cholesterol diets are unpalatable and are often associated with protein-energy malnutrition and postural hypotension in older persons. Special diets should be avoided whenever possible in nursing-home patients.

Answer 131

C Ottawa rules: ankle radiograph series is required only if there is * pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus. * Inability to bear weight for four steps, both immediately after the injury and in the ED Foot radiographs are required only if there is * pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular * inability to bear weight both immediately after the injury and in the ED

Answer 132

A Granuloma annulare is a self-limited condition. It is not contagious, and therefore would not need to be covered to prevent transmission. Treatments may include injected or topical corticosteroids, but oral corticosteroids have not been specifically recommended. It may be necessary to refer the patient to a dermatologist because many of the potential treatments can have serious side effects.

Answer 133

C ## Footnote The most appropriate exercises for pregnancy-related pelvic pain and low back pain target the low back, trunk, and abdominal muscles to increase core stability. Examples of such exercises include Pilates, back extension exercises, and abdominal crunches.Isometric and isotonic exercises work muscle groups against either an external force or opposing muscle groups, and are best suited for the development of muscle tone, strength, and conditioning in the extremities. Likewise, concentric and closed kinetic chain exercises involve working muscles against resistance, and are best suited for rehabilitating and strengthening the extremities.

Answer 134

A ## Footnote Patients attempting to conceive - not candidates for conservative management of cervical dysplasia, because treatment of progressive disease during pregnancy may be harmful. When possible, the problem should be resolved *before* conception. Patients who have had 3 consecutive normal Paps - candidates for lengthened screening intervals. However, once a problem is found, they should be managed the same as other cases. A negative test for HPV - used to assess risk of patients with atypical squamous cells of undetermined significance (ASC-US) or a low-grade squamous intraepithelial lesion (LSIL); it ***does* *not change the management*** of patients with a high-grade intraepithelial lesion (HSIL). HPV infection is common and **transient** in most young women in their first few years of sexual activity. With careful follow-up, they can be observed rather than treated for HSIL. Patients over 70 years of age no longer require screening if they have a long history of normal Pap smears, but when an abnormality is found it should be treated.

Answer 135

D ## Footnote This patient has **lateral epicondylitis** aka tennis elbow, which is an **overuse tendinopathy of the common extensor tendon origin of the lateral elbow**. Conservative care that includes offloading the involved tendons is the key to improving outcomes at 1 year, which would mean modifying this patient’s work. PT can improve pain and function in the short term, but has not been shown to improve long-term outcomes at 1 year in randomized trials. The evidence is weaker for bracing, with some studies showing improved pain and function at 3–6 weeks. Recent randomized, controlled trials have made it clear that while corticosteroid injections reduce acute pain for up to 6 weeks, their use increases rates of poor long-term outcomes

Answer 136

A ## Footnote **Cognitive-behavioral therapy** has been shown to be at least as effective as medication for treatment of GAD, but with less attrition and more durable effects. Many SSRIs and SNRIs have proven effective for GAD in clinical trials, but only **paroxetine, escitalopram, duloxetine,** and **venlafaxine** are approved by the FDA for this indication. **Benzodiazepines** have been widely used because of their rapid onset of action and proven effectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneficial than benzodiazepine or buspirone therapy for patients with GAD and comorbid depression.

Answer 137

A ## Footnote Behavioral symptoms such as agitation and wandering become common as Alzheimer’s disease progresses. Cholinesterase inhibitors may improve some of these symptoms. **Atypical** **antipsychotics** can help control problematic delusions, hallucinations, severe psychomotor agitation, and combativeness. **Typical** **antipsychotics** help control these same problems, but are used more as second-line therapy in those who do not respond to atypical agents. **Mood-stabilizing drugs** can help control these symptoms as well, and may also be useful alternatives to antipsychotic agents for controlling severe agitated, repetitive, and combative behaviors. **Benzodiazepines** are used to manage insomnia, anxiety and agitation. Some behaviors, such as wandering and pacing, are not amenable to drug therapy.

Answer 138

E **Hyperbilirubinemia** - **phototherapy** should be initiated when the bilirubin level is * **\> 15 mg/dL for infants at age 29–48 hours old** * **at 18 mg/dL for infants 49–72 hours old** * **at 20 mg/dL in infants older than 72 hours.** Generally, this problem is not considered pathologic unless it presents during the first hours after birth and the total serum bilirubin rises by \> 5 mg/dL/day or is \> 17 mg/dL, or if the infant has signs or symptoms suggestive of a serious underlying illness such as sepsis. **Physiologic jaundice follows a pattern, with the bilirubin level peaking on the third or fourth day of life and then declining over the first week after birth.** Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice, with the total bilirubin level rising as high as 17 mg/dL. **Breastfed infants are 6x more likely to develop physiologic jaundice compared to formula-fed infants because of relative caloric deprivation in the first few days of life**. **For breastfed newborns who have an early onset of hyperbilirubinemia, the _frequency of feeding should be increased to more than 10 times per day_**. If the newborn has a decrease in weight gain, delayed stooling, and continued poor intake, then formula supplementation may be necessary. Breastfeeding should be continued to maintain breast milk production. Supplemental water or dextrose and water should not be given, as this can decrease breast milk production and may place the infant at risk for iatrogenic hyponatremia

Answer 139

A ## Footnote RA is primarily a clinical diagnosis and no single laboratory test is considered definitively diagnostic. **Anti-cyclic citrullinated peptide (anti-CCP) antibody** is more specific than rheumatoid factor (RF), and may predict erosive disease more accurately. Antinuclear antibody has limited usefulness for the diagnosis of rheumatoid arthritis. Anti-Sm antibody is useful to help diagnose systemic lupus erythematosus. Nonspecific changes in complement levels are seen in many rheumatologic disorders. The erythrocyte sedimentation rate is useful in monitoring disease activity and the course of rheumatoid arthritis, but is not specific.

Answer 140

A The threshold for prophylactic platelet transfusion is 10,000/μL. Platelet transfusion decreases the risk of spontaneous bleeding in such patients. A count below 50,000/μL is an indication for platelet transfusion in patients undergoing an invasive procedure.

Answer 141

A ## Footnote Intertrigo is skin inflammation caused by skin-on-skin friction. It is facilitated by moisture trapped in deep skinfolds where air circulation is limited. When intertrigo does not respond to usual conservative measures, including keeping the skin clean and dry, evaluation for infection is recommended. A Wood’s light examination, KOH preparation, and exudate culture can assist in identifying causative organisms. The moist, damaged skin associated with intertrigo is a fertile breeding ground for various microorganisms; with **Candida** the most common one. In the interdigital spaces dermatophytes (e.g., Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum) are more common. S. aureus may present alone or with group A β-hemolytic Streptococcus. Pseudomonas aeruginosa, Proteus mirabilis, or Proteus vulgaris also may occur alone or simultaneously.

Answer 142

D ## Footnote The cause of Still’s murmur is unknown, but it may be due to vibrations in the chordae tendinae, semilunar valves, or ventricular wall. A venous hum consists of a continuous low-pitched murmur caused by the collapse of the jugular veins and their subsequent fluttering, and it worsens with inspiration or diastole. The murmur of physiologic peripheral pulmonic stenosis (PPPS) is caused by physiologic changes in the newborns pulmonary vessels. PPPS is a systolic murmur heard loudest in the axillae bilaterally that usually disappears by 9 months of age. Mitral stenosis causes a diastolic murmur, and Eisenmenger’s syndrome involves multiple abnormalities of the heart that cause significant signs and symptoms, including shortness of breath, cyanosis, and organomegaly, which should become apparent from a routine history and examination.

Answer 143

A Diuretics such as hydrochlorothiazide are known to increase serum uric acid levels, but losartan has been shown to decrease uric acid. Metoprolol, simvastatin, and acetaminophen have no specific effect on serum uric acid levels.

Answer 144

E ## Footnote **Preeclampsia** - is manifested as HTN, proteinuria, edema, and rapid weight gain after 20 weeks gestation. Very young mothers and those over age 35 have a higher risk. Patients who have had preeclampsia have a 4-fold increased risk of hypertension and a 2-fold increased risk of ischemic heart disease, stroke, and venous thromboembolism.

Answer 145

A ## Footnote CBT and interpersonal therapy are two modalities that have been proven effective in the treatment of adolescent depression. Medications should be considered for more severe depression or depression failing to respond to psychotherapy. A Cochrane review found that **_fluoxetine_ was the only agent with consistent evidence of effectiveness in decreasing depressive symptoms in adolescents.** Consensus guidelines recommend **_fluoxetine, citalopram, or sertraline_ as first-line treatments for moderate to severe depression** in children and adolescents. Escitalopram is also licensed for the treatment of depression in adolescents age 12 or older. **All antidepressants have a boxed warning regarding an increased risk of suicide; therefore, close monitoring is recommended to assess for suicidality and other adverse effects, such as GI effects, nervousness, HA, and restlessness.** TCAs were previously used to treat depression in children, but studies have shown little to no benefit in adolescents and children.

Answer 146

E hemoglobin A1c level ≥6.5% is diagnostic of diabetes mellitus. Other criteria include: * fasting plasma glucose level ≥126 mg/dL * random glucose leve l≥200 mg/dL in a patient with symptoms of diabetes * 2-hour glucose tolerance test value ≥200 mg/dL While a urine dipstick may be used to screen for diabetes, it is not a diagnostic test.

Answer 147

B This patient has mild persistent asthma, based on her symptoms occurring more than 2 days per week, but not daily, and use of her albuterol inhaler more than 2 days per week, but not daily.

Answer 148

D ## Footnote In patients who have symptoms of diarrhea-predominant IBS, the differential includes **celiac sprue, microscopic and collagenous colitis, atypical Crohn’s disease.** For those with constipation-predominant IBS, the differential is chronic constipation . If there are no warning signs, laboratory testing is warranted only if indicated by the history

Answer 149

D ## Footnote Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987, and sexual transmission. The mother should be offered testing and if she is seronegative, the children are at no risk. Maternal-fetal transmission is rare except in the setting of co-infection with HIV. Hepatitis C is insidious, and symptoms do not correlate with the extent of the disease. **Normal liver enzyme levels do not indicate lack of infectivity**. There is no risk to household contacts.,

Answer 150

D Delirium is common in the postoperative setting.

Answer 151

A ## Footnote This patient has brachial neuritis, which can be difficult to differentiate from cervical radiculopathy, shoulder pathology, and cerebrovascular accident. The **pain preceded the weakness, no trauma was involved, and the weakness is in a _nondermatomal_ distribution**, making brachial neuritis the most likely diagnosis. **Electromyography** is most likely to show this lesion, but only after 3 weeks of symptoms. MRI of the neck may show abnormalities, but not the cause of the current problem. Symptoms are not consistent with shoulder pathology, deep-vein thrombosis of the upper extremity, or cerebrovascular accident.

Answer 152

D ## Footnote **Thyroid function** must be evaluated in women with postpartum depression since both hyperthyroidism and hypothyroidism are more common postpartum. Postpartum depression may impair cognitive and behavioral development in the child. It is not related to the desired gender of the child, breastfeeding, or education level of the mother. It should be differentiated from the short-term “baby blues” that resolve within about 10 days. Sertraline is considered first-line treatment for postpartum depression in women who are breastfeeding.

Answer 153

C ## Footnote The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), left ventricular size, ventricular compliance, wall thickness, and valve function. The test should be performed during the initial evaluation. Radionuclide ventriculography can be used to assess LVEF and volumes, and MRI or CT also may provide information in selected patients. Chest radiography (posteroanterior and lateral) and 12-lead electrocardiography should be performed in all patients presenting with heart failure, but should not be used as the primary basis for determining which abnormalities are responsible for the heart failure.

Answer 154

A ## Footnote It is recommended that sexually active women under the age of 25 years be screened routinely for Chlamydia trachomatis. Treatment of asymptomatic infections in women reduces their risk of developing **pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and chronic pelvic pain**. A 1-gram dose of oral **azithromycin** is an appropriate treatment, including during pregnancy. Sexual contacts during the preceding 60 days should be either treated empirically or tested for infection and treated if positive. The patient should avoid sexual intercourse for 7 days after initiation of treatment. Consistent use of barrier methods for contraception reduces the risk of C. trachomatis genital infection.

Answer 155

A The DSM-IV categorizes Asperger’s syndrome and autism as pervasive developmental disorders. In both conditions, children have significant difficulties with social interactions, although the impairment is more severe and sustained in autism. Both Asperger’s and autism may be associated with symptoms of repetitive motor mannerisms, restricted patterns of interest (which are abnormal in focus or intensity), or preoccupation with parts of objects. However, unlike children with Asperger’s syndrome, autistic children have serious problems with communication skills, either in the development of speech itself or in the ability to carry on a conversation. It is an important distinction to make, as the prognosis for independent functioning in children with Asperger’s syndrome is significantly better than in children with autism. Ref

Answer 156

D This geriatric diabetic patient should be treated with insulin. Metformin is contraindicated in patients with renal insufficiency. Sitagliptin should not be added to a sulfonylurea drug initially, the dosage should be lowered in patients with renal insufficiency, and given alone it would probably not result in reasonable diabetic control. Pioglitazone can cause fluid retention and therefore would not be a good choice for a patient with cardiomyopathy.

Answer 157

A ## Footnote Skin tags, or acrochordons, are associated with DM and obesity. The onset often occurs in early adulthood, and the most common locations are the neck and axillae. These skin lesions are not associated with any significant cancer risk, and have not been associated with HIV infection.

Answer 158

C Bisphosphonates, including zoledronic acid, can reduce rates of clinical fractures among patients who have had a hip fracture. * Long-term use may increase the risk of **jaw osteonecrosis** and * **anemia**. Contraindications include **hypocalcemia** and a **creatinine clearance or other evidence of acute renal impairment.**

Answer 159

D ## Footnote This patient manifests a rapid onset of preeclampsia at term. The symptoms of epigastric pain and headache categorize her preeclampsia as severe. These symptoms indicate that the process is well advanced and that convulsions are imminent. Treatment should focus on rapid control of symptoms and delivery of the infant.

Answer 160

E Even though the patient’s DEXA has improved and she is technically osteopenic, she still has risk factors for osteoporosis, including recent smoking, low BMI, and a prior fragility fracture. She should continue her current regimen.

Answer 161

B ## Footnote Clinical clues to the diagnosis of malaria in this case include an appropriately targeted recent travel history, a prodrome of delirium or erratic behavior, unarousable coma following a generalized convulsion, fever, and a lack of focal neurologic signs in the presence of a diffuse, symmetric encephalopathy. The peripheral blood smear shows normochromic, normocytic anemia with **Plasmodium falciparum** trophozoites and schizonts involving erythrocytes, diagnostic of **cerebral malaria.** Treatment of this true medical emergency is **IV quinidine gluconate.** Vitamin B 12 deficiency is a predominantly peripheral neuropathy seen in older adults. Ehrlichiosis causes thrombocytopenia but not hemolytic anemia. Sickle cell disease presents with painful vaso-occlusive crises in multiple organs. Coma is rare.

Answer 162

C ## Footnote Childhood bullying has potentially serious implications for bullies and their targets. The target children are typically quiet and sensitive, and may be perceived to be weak and different. The presenting symptoms are not temporary, and in fact can progress to more serious problems such as suicide, substance abuse, and victim-to-bully transformation. Children who say they are being bullied must be believed and reassured that they have done the right thing in acknowledging the problem. Parents should be advised to discuss the situation with school personnel.

Answer 163

C ## Footnote 1%–2% of significantly injured patients develop acute respiratory failure in the post-injury period. Theory that the lung has a limited number of ways of reacting to injury and that several different types of acute, diffuse lung injury result in a *similar pathophysiologic response*. The common denominator of this response appears to be **injury at the alveolar-capillary interface, with resulting leakage of proteinaceous fluid from the intravascular space into the interstitium and subsequently into alveolar spaces**. It has become acceptable to describe this entire spectrum of acute diffuse injury as ARDs The syndrome of ARDS can occur under a variety of circumstances and produces a spectrum of clinical severity from mild dysfunction to progressive, eventually fatal, pulmonary failure. Fortunately, with proper management, pulmonary failure is far less frequent than milder abnormalities.

Answer 164

C ## Footnote When a properly collected, acceptable specimen is found to contain drugs or metabolites that would be expected based on a review of confirmed prescribed use of medications, the test is reported as negative. **Morphine is a metabolite of codeine** that may be found in the urine of someone taking a codeine-containing medication; morphine is not a metabolite of methadone. Oxazepam is a metabolite of diazepam but the reverse is not true. Tetrahydrocannabinol would not be found in the urine as a result of tramadol use.

Answer 165

E ## Footnote The anterior fontanelle closes at 3 months in 1% of cases, and by 1 year, 38% are closed. While early closure of the anterior fontanelle may be normal, the head circumference must be carefully monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development. When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation, and if present, a CT scan should be obtained.

Answer 166

C Penicillin is an effective treatment.

Answer 167

D his constellation of symptoms strongly suggests celiac disease, which typically present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.

Answer 168

E ## Footnote **Dribbling** + **increased post-void residual volume (\>100 mL)** **are signs of overflow incontinence -** can be caused by outflow obstruction (e.g., prostate hypertrophy, urethral constriction, fecal impaction) or, as in this case, by **detrusor muscle denervation caused by diabetic or other neuropathie**s. Excess urine output from hyperglycemia would result in frequent urination, but not urinary retention. Atrophic vaginitis and cystoceles are usually associated with stress incontinence. Asymptomatic bacteriuria is unlikely because the patient does not have any evidence of infection.

Answer 169

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.

Answer 170

A Family-based treatment for the adolescent with anorexia nervosa has been found to provide superior results when compared with individual adolescent-focused therapy (SOR B). Antidepressants have not been successful. They may be indicated for coexisting conditions, but this is more common with bulimia.

Answer 171

E ## Footnote When a patient presents with sudden hearing loss it is important to distinguish between sensorineural vs. conductive hearing loss. Patients should be asked about previous episodes, and the workup should include both an assessment for bilateral hearing loss and a neurologic examination. Sudden sensorineural hearing loss is diagnosed by audiometry demonstrating a 30-decibel hearing loss at three consecutive frequencies, with no other cause indicated from the physical examination. Evaluation for retrocochlear pathology may include auditory brainstem response, MRI, or follow-up audiometry. **Oral corticosteroids** may be offered as initial therapy, and hyperbaric oxygen therapy may be helpful within 3 months of diagnosis. Routinely prescribing antiviral agents, thrombolytics, vasodilators, vasoactive substances, or antioxidants is not recommended. The guidelines also strongly recommend against routine laboratory tests or CT of the head as part of the initial evaluation.

Answer 172

C ## Footnote In patients with severe pneumonia, the urine should be tested for antigens to **Legionella and pneumococcus**. Two blood cultures should also be drawn, but these are positive in only 10%–20% of all patients with CAP

Answer 173

D ## Footnote In a patient-centered approach to communication regarding end-of-life care, a patient’s wishes to not know about a diagnosis or prognosis should be respected. However, it is reasonable to ask the patient to name a proxy with whom you may discuss the issues. The other options listed do not respect the patient’s desire to not know her diagnosis or prognosis.

Answer 174

D Patients with borderline personality disorder often demonstrate instability in interpersonal relationships and self-image, and may be impulsive. They can present with a wide range of symptoms, including depression, anger, paranoia, extreme dependency, self-mutilation, and alternating idealization and devaluation of their physicians. Their lives are often chaotic. Treatment strategies include maintaining a caring but somewhat detached professional stance. A close personal relationship is typically not therapeutic for these patients. Angry outbursts will often have to be tolerated, but limit-setting is necessary with respect to appropriate behaviors. SSRIs, atypical antipsychotics, and mood stabilizers may be of help at times, but anxiolytics are often abused and may be associated with self-mutilating behaviors. These patients tend to respond best to clear, simple, non-technical explanations related to their medical care.

Answer 175

A ## Footnote Permission for the release of patient information should always be in writing. Although the actual medical record is the property of the physician, the information in the chart is the property of the patient. Ethically and legally, patients have a right to the information in their medical records, and it cannot be withheld from the patient or a third party (at the request of the patient), even if medical bills are unpaid or the physician is concerned about the patient.

Answer 176

B The most common pathogens in previously untreated acute superficial foot infections in diabetic patients are aerobic gram-positive **Staphylococcus aureus** and **β-hemolytic streptococci** (groups A, B, others). Previously treated and deep infections are often polymicrobial

Answer 177

A ## Footnote Antiandrogens such as **spironolactone**, along with **oral contraceptives**, are recommended for treatment of hirsutism in premenopausal women

Answer 178

E ## Footnote **Plantar fasciitis** - overuse injury due to microtrauma of the plantar fascia where it attaches at the medial calcaneal tubercle -\> heel or arch pain, which often is worse upon arising and ***pain with first few steps*** ***of the morning***. Examination reveals tenderness at the site and pain with dorsiflexion of the toes. treatment includes rest, ice, NSAIDs, and shoe inserts with arch support, heel cord and plantar fascia stretching. Currently, there is evidence against the use of extracorporeal shockwave therapy. If conservative therapy fails, a corticosteroid injection may be useful. Surgery is reserved for patients refractory to 6-12 months of uninterrupted conservative therapy. **Stress fractures** - pain at rest that intensifies with weight bearing; treatment includes rest, ice, NSAIDs, and shoe inserts with arch support, heel cord and plantar fascia stretching.

Answer 179

A ## Footnote An **unenhanced helical CT scan of the abdomen and pelvis** is the best study for confirming the diagnosis of a urinary tract stone in a patient with acute flank pain. A CT scan may also reveal other pathology, such as appendicitis, diverticulitis, or abdominal aortic aneurysm. Although abdominal ultrasonography has a very high specificity, it is still not better than CT, and its sensitivity is much lower; thus, its use is usually confined to pregnant patients with a suspected stone. Plain abdominal radiographs may show the stone if it is radiopaque, and are useful for following patients with radiopaque stones. CT will reveal a radiopaque stone. While most patients with stones will have hematuria, its absence does not rule out a stone.

Answer 180

E USPSTF) recommends daily aspirin use for * **males 45–79** years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage * **females 55–79** years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage The USPSTF has concluded that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in **men and women 80 years of age or older**. It recommends against the use of aspirin for **stroke prevention in women younger than 55**, and for **myocardial infarction prevention in men younger than 45**

Answer 181

E ## Footnote Acne neonatorum occurs in up to 20% of newborns. It typically consists of **closed** comedones on the forehead, nose, and cheeks, and is thought to result from stimulation of sebaceous glands by maternal and infant androgens. Parents should be counseled that lesions usually resolve spontaneously within 4 months without scarring. Findings in erythema toxicum neonatorum include **papules, pustules**, and erythema. Candida and herpes lesions usually present with **vesiculopustular** lesions in the neonatal period. Milia consists of 1- to 2-mm pearly **keratin plugs without erythema**, and may occur on the trunk and limbs.

Answer 182

C ## Footnote Clozapine is a second-generation antipsychotic, which are believed to be less likely to cause extrapyramidal side effects than the first-generation drugs such as haloperidol or the phenothiazines (e.g., fluphenazine). It is generally considered second-line therapy, to be used in cases unresponsive to other drugs. A 2003 meta-analysis concluded that clozapine was the **most efficacious second-generation antipsychotic**, followed by risperidone and olanzapine. However, clozapine use is associated with an approximately 1% incidence of **granulocytopenia / agranulocytosis**. Early detection by monitoring CBCs every 1–2 weeks has led to a reduction in agranulocytosis-related death.

Answer 183

C ## Footnote This patient has bipolar II disorder. She has a history of hypomanic episodes as well as major depression, with no history of a manic or mixed episode. Among the pharmacologic options listed, only divalproex and lithium are indicated for treating bipolar depression or acute mania, and for maintenance. They should be given as single agents, however, not in combination with other drugs, as studies have shown that initially adding paroxetine or bupropion to the mood stabilizer was no more effective than using lithium or valproate.

Answer 184

B ## Footnote All patients who present with palpitations should be evaluated for a cardiac cause, since this is the etiology in 43% of cases. A standard 12-lead EKG is the initial test of choice and, along with a history and physical examination, can determine the cause in 40% of cases. A normal resting EKG does not exclude a cardiac arrhythmia. Therefore, if the EKG is normal, palpitations of suspected arrhythmic etiology may require further investigation with ambulatory EKG monitoring. Echocardiography is helpful in evaluating patients for structural heart disease and should be performed when the initial history, physical examination, and EKG are unrevealing, or in patients with a history of cardiac disease or more complex signs and symptoms. This patient’s family history, along with the fact that she takes no medications, suggests the possibility of familial long QT syndrome, which often can be diagnosed from a resting EKG. Diagnosing long QT syndrome is important, since it is associated with an increased risk of sudden cardiac death. Based on the patient’s clinical presentation and evaluation, hospital admission is not warranted prior to obtaining a standard 12-lead EKG.

Answer 185

A ## Footnote Delayed gastric emptying may be caused or exacerbated by medications for diabetes, including **amylin analogues (e.g., pramlintide)** and **glucagon-like peptide 1 (e.g., exenatide)**. In a clinical trial of exenatide, nausea occurred in 57% of patients and vomiting occurred in 19%, which led to the cessation of treatment in about one-third of patients. Delayed gastric emptying has a direct effect on glucose metabolism, in addition to being a means of reducing the severity of postprandial hyperglycemia. The other medications listed do not cause delayed gastric emptying

Answer 186

D ## Footnote Cat bites that become infected with **Pasteurella multocida** can be complicated by cellulitis, which may form around the wound within 24 hours. The use of **prophylactic antibiotics** is associated with a statistically significant reduction in the rate of infection in hand bites. If infection develops and is left untreated, the most common complications are **tenosynovitis and abscess formation;** however, local complications can include **septic arthritis** and **osteomyelitis**. Fever, regional adenopathy, and lymphangitis are also seen.

Answer 187

A 2 doses of influenza vaccine are recommended for children **unless they have been vaccinated previously. Children 3–8 years of age should receive one or two 0.5-mL doses of split-virus vaccine intramuscularly.**

Answer 188

E ## Footnote There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica. Joint swelling occurs occasionally, but neither swelling nor early morning stiffness is necessary to make the diagnosis. Polymyalgia rheumatica does not respond to NSAIDs. The erythrocyte sedimentation rate should be ≥40 mm/hr.

Answer 189

C ## Footnote Although essential hypertension is most common in adolescents and adults, it is rarely found in children less than 10 years old and should be a diagnosis of exclusion. The most common cause of hypertension is renal parenchymal disease, and a urinalysis, urine culture, and renal ultrasonography should be ordered for all children presenting with hypertension. Other secondary causes, such as pheochromocytoma, hyperthyroidism, and excessive caffeine use, are less common, and further testing and/or investigation should be ordered as clinically indicated.

Answer 190

D ## Footnote Inhaled corticosteroids improve asthma control more effectively in children and adults than any other single long-term controller medication (SOR A). This patient has mild persistent asthma and should be treated with a low-dose inhaled corticosteroid.

Answer 191

E ## Footnote **Nonalcoholic steatohepatitis** (NASH) is the most common cause of abnormal liver tests in the developed world. Its prevalence increases with age, BMI, and triglyceride concentrations, and in patients with DM, HTN, or insulin resistance. **There is a significant overlap between metabolic syndrome and diabetes mellitus, and NAFLD is regarded as the liver manifestation of insulin resistance.** Statin therapy is considered safe in such individuals and can improve liver enzyme levels and reduce cardiovascular morbidity in patients with mild to moderately abnormal liver tests that are potentially attributable to NAFLD.

Answer 192

D The cardiac toxicity of methadone is related to QT prolongation and torsades de pointes

Answer 193

A ## Footnote The majority of patients who are latex-allergic are believed to develop IgE antibodies that cross-react with some proteins in plant-derived foods (**bananas, avocadoes, and kiwi**). These food antigens do not survive the digestive process, and thus lack the capacity to sensitize after oral ingestion in the traditional food-allergy pathway. Antigenic similarity with proteins present in latex, to which an individual has already been sensitized, results in an indirect allergic response limited to the exposure that occurs prior to alteration by digestion, localized primarily in and around the oral cavity. The frequent association with certain fruits has been labeled the “**latex-fruit syndrome**.”

Answer 194

B ## Footnote Celiac sprue is a condition of acquired malabsorption where children develop inflammation and destruction of the microvilli in the small intestine as a result of an immune response to gluten. Patients with celiac sprue often present as this child has, between **4 and 24 months of age** with impaired growth, diarrhea, and abdominal distention. An iron deficiency anemia can occur with impairment of iron absorption from the small intestine. Lesser cases of malabsorption are common, and this condition often goes unrecognized into adolescence or adulthood. Serologic tests, and ultimately a biopsy of the small intestine, can confirm the diagnosis

Answer 195

C ## Footnote melanosis coli - black or brown discoloration of the _mucosa_ of the colon; results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa; most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron. Ectopic endometrial tissue (endometriosis) most commonly involves the serosal layer of those parts of the bowel adjacent to the uterus and fallopian tubes, particularly the rectosigmoid colon. Collagenous colitis does not cause mucosal pigmentary changes. Melanoma rarely metastasizes multicentrically to the bowel wall. Multiple arteriovenous malformations are more common in the proximal bowel, and would not appear as described.

Answer 196

A ## Footnote The p-value is a level of statistical significance, and characterizes the likelihood of achieving the observed results of a study by chance alone, and in this case that likelihood is 5%. (In this case, 5% or less of the results can be achieved by chance alone and still be significant.) The confidence interval is a measure of variance and is derived from the test data. The p-value in and of itself says nothing about the truth or falsity of the null hypothesis, only that the likelihood of the observed results occurring by chance is 5%. The a or type I error is akin to the error of false-positive assignment; the B or type II error is analogous to the false-negative rate, or 1 - specificity, and cannot be calculated from the information given.

Answer 197

D ## Footnote Snuffbox tenderness and tenderness over the scaphoid tubercle are very sensitive for fracture of the scaphoid, but their specificity is only 40% and 60% respectively. Therefore, while the lack of tenderness at these sites almost rules out fracture, further imaging is needed in positive cases. A follow-up films after immobilization for 2 weeks should be done if the initial films are negative.

Answer 198

B ## Footnote A history of a first degree relative diagnosed with colon cancer before age 60 predicts a higher lifetime incidence of colorectal cancer (CRC) and a higher yield on colonoscopic screening. The overall colon cancer risk for these persons is three to four times that of the general population. Screening should consist of colonoscopy**, beginning at age 40** or **10 years before the age at diagnosis of the youngest affected relative**, whichever comes first. Earlier screening is no longer recommended for patients who have a single first degree relative with CRC diagnosed at 60 years of age or after, or if there is a family history of adenomas in a first-degree relative

Answer 199

B ## Footnote **Primary hyperaldosteronism** is the most common cause of secondary HTN in the middle-aged population, and can be diagnosed with a **renin/aldosterone ratio**. This diagnosis is further suggested by the finding of **hypokalemia --\> suggests hyperaldosteronism** even though it is not present in the majority of cases. An echocardiogram would help make a diagnosis of coarctation of the aorta, but this is more common in younger patients. Renal MRA may demonstrate renal artery stenosis, but this condition is more common in older patients. Sleep apnea is increasing in prevalence along with the rise in obesity, but it is not suggested by this case. A 24-hour urine catecholamine test is used to diagnose pheochromocytoma, which is not suggested by this patient’s findings. Pheochromocytoma is also less common than aldosteronism.

Answer 200

D Signs of fetal distress has proven to be the most reliable clinical symptom of uterine rupture. The “classic” signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases. Even ruptures monitored with an IUPC fail to show loss of uterine tone.

Answer 201

D ## Footnote This patient has **gestational HTN -** diagnosed when **elevated** **BP _without_ proteinuria** develops after 20 weeks' gestation and BP returns to normal within 12 weeks of delivery. The new criteria for preeclampsia - new onset of HTN (SBP \>140 mm Hg or DBP \>90 mm Hg) after 20 weeks' gestation, along with 300 mg protein in a 24-hour urine specimen. A certain amount of increase in blood pressure is no longer a criterion. Edema is also no longer a criterion. Elevated uric acid levels are no longer considered necessary for the diagnosis of preeclampsia. Chronic hypertension can only be diagnosed if present before pregnancy, or if it does not resolve by 12 weeks post partum. Essential hypertension is the most common cause of chronic hypertension. HELLP syndrome is a serious, but relatively rare, form of pregnancy-related hypertension associated with hemolysis, elevated liver enzymes, and low platelets

Answer 202

E ## Footnote Randomized, placebo-controlled trials have shown that isolated systolic hypertension in the elderly responds best to **diuretics** and to a lesser extent, **β-blockers**. Diuretics are preferred, although long-acting dihydropyridine calcium channel blockers may also be used. In the case described, β-blockers or clonidine may worsen the depression. **Thiazide diuretics may also improve osteoporosis**, and would be the most cost-effective and useful agent in this instance.

Answer 203

A ## Footnote Intranasal glucocorticoids are the most efficacious treatment for allergic rhinitis. They are far superior to oral preparations in terms of safety. Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if _started prior_ to the season of peak symptoms. Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis. Azelastine, an intranasal antihistamine, is effective for controlling symptoms but can cause _somnolence_ and a bitter taste. Oral antihistamines are not as useful for congestion as for sneezing, pruritus, and rhinorrhea

Answer 204

A ## Footnote Treatments available for childhood nocturnal enuresis include nonpharmacologic and pharmacologic treatments. Compared to other techniques and pharmacologic treatments, the **bed-wetting alarm** has a higher success rate (75%) and a lower relapse rate (41%).

Answer 205

C ## Footnote An **elevated parathyroid hormone** (or a level that is in an unexpected “normal” range) + **elevated calcium** generally indicates a diagnosis of primary hyperparathyroidism. However, these laboratory findings may also occur with **lithium or thiazide** use, tertiary hyperparathyroidism associated with **end-stage renal failure**, or **familial hypocalciuric hypercalcemia**, and a medical and family history should be obtained to assess these possibilities. The other medications listed do not cause hypercalcemia.

Answer 206

E ## Footnote This patient’s symptoms and laboratory findings suggest a significant lack of TSH despite low levels of circulating thyroid hormone. This is diagnostic of secondary hypothyroidism. Such findings should prompt a workup for a pituitary or hypothalamic deficiency that is causing a lack of TSH production. Primary hypothyroidism, such as Hashimoto’s thyroiditis, would be evidenced by an elevated TSH and low (or normal) T4 . Graves’ disease is a cause of hyperthyroidism, which would be expected to increase T4 levels, although low TSH with a normal T4 level may be present. The patient does not have the thyroid gland enlargement seen with goiter. Some nonthyroid conditions such as malnutrition may suppress T4 . In such cases the TSH would be elevated or normal. This patient has gained weight, which does not coincide with malnutrition.

Answer 207

E ## Footnote In breastfeeding women, **bilateral** nipple pain with and between feedings after initial soreness has resolved is usually due to _Candida_. Pain from engorgement typically resolves after feeding. _Mastitis_ is usually **unilateral** and is associated with **systemic symptoms** and **wedge-shaped erythema** of the breast tissue. Improper latch-on is painful only during feedings. Eczema isolated to the nipple, while a reasonable part of the differential, would be much more unusual.

Answer 208

E ## Footnote The hallmark of DRESS syndrome is **erythroderma** accompanied by **fever, lymphadenopathy, elevation of liver enzymes,** and **eosinophilia**. The offending medication should be discontinued immediately and **_treatment with corticosteroids_** should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine, and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS syndrome has the highest mortality rate.

Answer 209

D ## Footnote This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules states that ankle radiographs should be done if the patient has pain at the **medial or lateral malleolus** and either bone tenderness at the **back edge or tip of the lateral or medial malleolus,** or an **inability to bear weight** immediately after the injury or in the emergency department, or both. Sprains can be differentiated from major partial or complete ligamentous tears by AP, Lat, and 30˚ internal oblique (mortise view) xrays. If the joint cleft between either malleolus and the talus is \>4 mm, a major ligamentous tear is probable. Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph. Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should not be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.

Answer 210

B Uterine rupture occurs in 0.2%–1.0% of women in labor after one previous low transverse cesarean section. Uterine pain, cessation of contractions, vaginal bleeding, failure of labor to progress, or fetal regression may occur, but none of these are as consistent as **fetal bradycardia** in cases of uterine rupture during labor for VBAC patients.

Answer 211

E ## Footnote An acute rupture of any major tendon should be repaired asap. Acute tears of the rotator cuff should be repaired within 6 weeks of the injury if possible. Nonsurgical management is not recommended for active persons. Observing for an extended period will likely lead to retraction of the detached tendon, possible resorption of tissue, and muscle atrophy

Answer 212

A Cilostazol is a drug with phosphodiesterase inhibitor activity introduced for the symptomatic treatment of arterial occlusive disease and intermittent claudication. Cilostazol should be avoided in patients with CHF. There are no limitations on its use in patients with previous stroke or a history of diabetes. It has been found to have beneficial effects on HDL cholesterol levels and in the treatment of third degree heart block.

Answer 213

A ## Footnote **Melasma -** due to hyperpigmentation related to normal hormonal changes that accompany pregnancy; can also be caused by oral contraceptives and is more common in dark-skinned persons. **High-potency broad-spectrum sunscreens may help prevent melasma**, or at least prevent worsening of the condition. **Topical retinoids, hydroquinone, and corticosteroids can also be helpful, but are usually reserved for postpartum use and require months of treatment.** Other treatments include azelaic acid, chemical peels, kojic acid, cryosurgery, and laser treatment. Melasma usually improves spontaneously after delivery, but it may be prolonged or worsened by oral contraceptive use. It does not increase the risk of developing skin malignancies.

Answer 214

E ## Footnote A number of medications can cause thrombocytopenia, but heparin is a more likely cause than enalapril, furosemide, labetalol, or insulin. Even the small doses of heparin used to flush intravenous lines can be a source of thrombocytopenia

Answer 215

E ## Footnote Nipple pain with breastfeeding is extremely common, with some studies reporting a prevalence of up to 96%. The best intervention for nipple pain is **education on proper positioning and attachment of the infant.** Topical remedies may also be effective, although no one topical agent has been shown to be clearly superior, and none is as effective as education on positioning and latch-on.

Answer 216

A ## Footnote Croup is a viral illness and is not treated with antibiotics. Oral or intramuscular dexamethasone, 0.6 mg/kg as a single dose, and nebulized budesonide have been shown to reduce croup scores and shorten hospital stays. Racemic epinephrine may be used acutely, but rebound can occur. Albuterol has not been shown to be helpful.

Answer 217

D ## Footnote COPD diagnosis is made by documenting airflow obstruction in the presence of symptoms and/or risk factors. Airflow limitation cannot be accurately predicted by the history and examination. The USPSTF concluded that there is “moderate certainty” that screening asymptomatic patients for COPD using spirometry has **little or no benefit** and is not recommended.

Answer 218

E ## Footnote Genital warts are typically caused by HPV types 6 / 12, which are rarely associated with **invasive squamous cell carcinoma**. In general, chemical treatments are more effective on soft, moist, nonkeratinized genital lesions, while physical ablative treatments are more effective for keratinized lesions. Diagnosis by biopsy and viral typing is no longer recommended. Acetowhite staining has not been shown to favorably affect the course or treatment of HPV-associated genital warts. Topical 5% fluorouracil cream has been associated with severe local reactions and teratogenicity, and is no longer recommended. Treatment of genital warts has not been shown to reduce the incidence of cervical or genital cancer.

Answer 219

A Several clinical trials suggest that 7-day regimens of **erythromycin** or **amoxicillin**, or single-dose regimens of **azithromycin**, are effective for treating chlamydial infections during pregnancy. Doxycycline and levofloxacin are contraindicated during pregnancy due to potential ill effects on the fetus, metronidazole is not effective for the treatment of chlamydial infections.

Answer 220

D ## Footnote Of the options listed, treatment with bisphosphonates to prevent osteoporotic hip and vertebral fractures is the only one supported by consistent patient-oriented, high-quality clinical evidence. While each of the other recommendations has merit, the overall level of evidence for effectiveness is less compelling for these treatments than for treatment with bisphosphonates

Answer 221

D The treatment of choice for acute herpes zoster is oral antiviral agents. Acyclovir, valacyclovir, and famciclovir have all been shown to be efficacious with 7 days of oral treatment. Studies suggest that valacyclovir may be superior to acyclovir in decreasing both acute and postherpetic pain. Famciclovir appears to be equal in efficacy to valacyclovir. Topical acyclovir may be effective for more limited forms of herpes simplex, but is usually not effective for herpes zoster.

Answer 222

B ## Footnote Meniere’s disease, which is characterized by multiple episodes of vertigo lasting for 20–120 minutes, accompanied by a fluctuating hearing loss, tinnitus, and a sense of aural fullness. Audiograms will reveal a low-frequency hearing loss with an upsloping curve, which can become flattened over the years. Most patients develop unilateral symptoms, with progression to bilateral disease after many years after the onset of the unilateral symptoms. There is often a family history of Meniere’s disease, and there is frequently an association with allergies. The condition can also get worse with caffeine use. Benign positional vertigo is very common, and hearing loss could be an incidental finding. However, the most common form of age-related hearing loss is seen at the higher frequencies. Positional vertigo like this patient has is common between attacks of Meniere’s disease.

Answer 223

D ## Footnote The patient has paroxysmal ***supra***ventricular tachycardia (PSVT) with a heart rate of approximately 170 beats/min. **IV adenosine** **is the treatment of choice for PSVT**. Because the patient is hemodynamically stable, DC cardioversion is not indicated. Metoprolol may slow the heart rate but likely will not convert it to sinus rhythm. **Amiodarone is indicated for hemodynamically stable ventricular tachycardia**. Atropine is contraindicated in this or any other tachyarrhythmia.

Answer 224

D ## Footnote **Pulse oximetry** should be obtained on **ALL** pediatric patients with significant tachypnea, pallor, or respiratory distress. It has been found that CBCs, CRP, and ESR are not effective in differentiating between viral and bacterial pneumonia. CXR are also ineffective in distinguishing viral and bacterial pneumonia, and should be obtained in cases of ambiguous clinical findings, prolonged pneumonia, and pneumonia that is unresponsive to antibiotic therapy, as well as when there is the possibility of complications such as pleural effusions.

Answer 225

E Nicotine causes both physical dependence and tolerance. Withdrawal from nicotine can last several weeks or months. Physicians’ advice to stop smoking increases the rate of stopping smoking by about 30%. Bupropion is no more or less effective than other products for smoking cessation. Nicotine replacement therapy is safe in patients with stable angina.

Answer 226

D ## Footnote This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. **For patients with a history of previous stroke, combination therapy with a diuretic and an ACE inhibitor** is indicated, as this combination has been clinically shown to reduce the risk of recurrent stroke.

Answer 227

A ## Footnote Cardiovascular changes associated with aging include **_decreased_ CO, maximum HR, and SV,** as well as **_increased_ SBP and DBP**. Respiratory changes include an _increase_ in residual lung volume and a decrease in vital capacity. Other changes include _decreases_ in nerve conduction, proprioception and balance, maximum O2 uptake, bone mass, muscle strength, and flexibility. Most of these changes, however, can be reduced in degree by a regular aerobic and resistance training program.

Answer 228

E ## Footnote Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other drugs listed may cause renal injury, but not acute interstitial nephritis.

Answer 229

D With subclinical thyroid dysfunction, TSH is either below or above the normal range, free T3 or T4 levels are normal, and the patient has no symptoms of thyroid disease. * Subclinical hyp**O**thyroidism (TSH \>10 µU/mL) is likely to progress to overt hypothyroidism, and is associated with increased LDL cholesterol. * Subclinical hyp**ER**thyroidism (TSH Neither type of subclinical thyroid dysfunction is associated with diabetes mellitus. There is insufficient evidence of benefit to warrant early treatment of either condition.

Answer 230

A In the geriatric population, presbycusis is the most common cause of hearing loss. Patients typically have the most difficulty hearing higher-frequency sounds such as consonants. Lower-frequency sounds such as vowels are preserved.

Answer 231

E ## Footnote **Malathion** is currently the most effective treatment for head lice and is less toxic than lindane. Permethrin and pyrethrins are less effective than malathion, although they are acceptable alternatives. These insecticides, as well as lindane, are not recommended in children 2 years of age or younger. Wet combing may be effective, but is less than half as effective as malathion. Head shaving is only temporarily effective and is traumatic. Petrolatum is not proven to be effective.

Answer 232

B The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase. **Sounds from the vocal cords can be very INSPIRING, but if there is vocal cord dysfunction, the INSPIRATORY effect is gone**

Answer 233

A ## Footnote Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non–group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery. Pneumococcus is more frequently a cause of periorbital cellulitis. It is also seen in patients who have bacteremia with immunocompromised status. Immunocompromising conditions would include diabetes mellitus, alcoholism, lupus, nephritic syndrome, and some hematologic cancers. Clostridium and Escherichia coli are more frequently associated with crepitant cellulitis and tissue necrosis. Pasteurella multocida cellulitis is most frequently associated with animal bites, especially cat bites.

Answer 234

B ## Footnote The patient has **Waldenström’s macroglobulinemia** - due to an uncontrolled proliferation of lymphocytes and plasma cells, which produce **IgM proteins with kappa light chains**. The average age at the time of diagnosis is 65 years. Weakness, fatigue, weight loss, bleeding, and recurrent infections are common presenting symptoms. Physical findings include pallor, hepatosplenomegaly, and lymphadenopathy. Typical laboratory findings include moderate anemia and monoclonal IgM peaks on serum electrophoresis. Bence-Jones protein is seen in 80% of cases, but is typically *absent* in MGUS. Unlike in multiple myeloma, lytic bone lesions are not seen, and marrow biopsy reveals mostly lymphocytes. Sarcoidosis usually presents with hilar lymphadenopathy and a polyclonal gammopathy. Non-Hodgkin’s lymphoma presents with similar symptoms, lymphadenopathy, and hepatosplenomegaly, but generally lacks a monoclonal gammopathy and Bence-Jones proteinemia, and has distinctive malignant lymphocytes on bone marrow biopsy.

Answer 235

D ## Footnote IV **zoledronic acid** has been shown to reduce both hip fracture risk and vertebral fracture risk. Teriparatide reduces vertebral fracture risk but not hip fracture risk. The same is true for raloxifene and calcitonin salmon.

Answer 236

E ## Footnote Patients with a PE should be treated with LMWH, unfractionated heparin, or fondaparinux for **at least 5 days**, and then **can be stopped if the INR has been ≥2.0 for at least 24 hours**. Warfarin reduces the activity of coagulation factors II, VII, IX, and X produced in the liver. Coagulation factors produced _prior_ to initiating warfarin remain active for their usual several-day lifespan, which is why **_LMWH and warfarin must be given concomitantly for at least 5 days._** The INR may reach levels \>2.0 before coagulation factors II and X have reached their new plateau levels, accounting for the need for an additional 24 hours of combined therapy before stopping LMWH.

Answer 237

C ## Footnote Severe type I hypersensitivity reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little warning. Anaphylactic reactions result from a massive release of histamine and **start with pruritus around the mouth, on the scalp, and on the palms and soles**; flushing of the face and neck, with rhinitis and conjunctivitis; angioedema of the oral mucosa, especially of the pharynx and larynx; severe urticaria; dyspnea and bronchospasm (especially in known asthmatics); and hypotension. A delay in lifesaving therapy during this phase will result in full shock, hypotension, and death. Type IV reactions usually result in benign, diffuse erythematous macules on the trunk and proximal extremities, often referred to as a drug rash. These reactions infrequently become more severe and rarely are life threatening. In severe cases the lesions become painful and palpable, and may involve blistering, mucositis, and ecchymosis.

Answer 238

B Asymptomatic patients in excellent health often present with this characteristic chest radiograph pattern, which is usually due to histoplasmosis infection, especially if the patient has been in the midwestern United States. Exposure to bird or bat excrement is a common cause, and **treatment is usually not needed.** This pattern is not characteristic of the other infections listed, although miliary tuberculosis is a remote possibility in spite of the negative PPD skin test.

Answer 239

A ## Footnote A number of pretest probability scoring systems are available for assessing venous thromboembolism (VTE), which includes DVT and PE. **Wells Rule** divides patients suspected of having a DVT into low, intermediate, and high-risk categories, with a 5%, 17%, and 53% prevalence of DVT, respectively. This patient has a Wells score of 0 (+1 for calf circumference increase \>3 cm, +1 for pitting edema, –2 for a likely alternative diagnosis of gastrocnemius strain) and is therefore at low risk. **A negative D-dimer assay has a high negative predictive value for DVT**, so the diagnosis can be ruled out in a patient who has a low pretest probability and a negative D-dimer result. A negative D-dimer assay does not rule out DVT in a patient with a moderate to high pretest probability

Answer 240

E . Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. Combination therapy consisting of an * antipseudomonal cephalosporin such as cefepime or ceftazidime * antipseudomonal carbapenem such as imipenem or meropenem * extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam PLUS * antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin * aminoglycoside such as gentamicin, tobramycin, or amikacin PLUS * anti-MRSA agent (vancomycin or linezolid) Ceftriaxone and azithromycin or levofloxacin alone would be reasonable treatment options for a patient with nursing home–acquired pneumonia who does not require hospitalization.

Answer 241

A ## Footnote A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. IVDU is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include **Candida, herpes simplex virus, and cytomegalovirus.** Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy

Answer 242

C While it is certainly appropriate for the nurse practitioner or physician who ordered the test to notify the patient of mammography results, the facility performing the test is legally responsible.

Answer 243

A ## Footnote The current management of methanol intoxication, depending on its severity, includes ethanol administration to inhibit the metabolism of methanol, hemodialysis to remove alcohol and its toxins, and vigorous management of metabolic acidosis with bicarbonate therapy. Ethanol is a competitive inhibitor of toxin metabolism and slows the formation of toxic metabolites, formaldehyde, and formic acid from methanol, permitting these products to be disposed of by ordinary metabolic or excretory pathways. It has a similar effect in ethylene glycol poisoning, slowing the formation of glycoaldehyde and glycolic, glyoxylic, and oxalic acids.

Answer 244

C Development of pleural plaques is the most common pathologic pulmonary response to asbestos inhalation. Over time, collagen is deposited in the pleura and may calcify. Most plaques are asymptomatic, and there is no evidence that plaques transform into malignant lesions. This should alert the physician to follow the patient for development of more serious asbestos-related diseases (e.g., lung cancer and mesothelioma).

Answer 245

B Enlarging postpartum hematomas adjacent to an episiotomy are best treated by removing the sutures and ligating the specific bleeding sites. A perineal pad and cold compresses are inadequate for an enlarging lesion, and hypogastric artery ligation and hysterectomy are indicated only with supravaginal hematomas.

Answer 246

E ## Footnote Prophylaxis is generally recommended for patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially \>75 years), recent surgery or trauma, immobility or paresis, obesity (BMI \>30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy. Pharmacologic therapy with an anticoagulant such as enoxaparin is clearly indicated in the 67-year-old who has limited mobility secondary to hemiparesis and is being admitted for an acute infectious disease. The patient on chronic anticoagulation, the patient with severe thrombocytopenia, and the patient with coagulopathy are at high risk for bleeding if given anticoagulants, and are better candidates for nonpharmacologic therapies such as foot extension exercises, graduated compression stockings, or pneumatic compression devices. Although the 22-year-old is obese and recently had surgery, his young age and ambulatory status make anticoagulant prophylaxis less necessary.

Answer 247

C ## Footnote Studies have shown that the treatment of systolic and diastolic hypertension, especially with thiazide diuretics, with or without an ACE inhibitor, reduces stroke, heart failure, and death from all causes. Such treatment is effective in both sexes.

Answer 248

B ## Footnote Metformin is the only hypoglycemic agent shown to **reduce mortality rates** in patients with type 2 DM. A recent systematic review concluded that cardiovascular events are neither increased nor decreased with the use of _sulfonylureas_. The effect of _incretin mimetics/enhancers_ on cardiovascular events has not been determined. The STOP-NIDDM study suggests that _α-glucosidase inhibitors_ reduce the risk of cardiovascular events in patients with impaired glucose tolerance.

Answer 249

B ## Footnote have shown that patients who had hemoglobin levels targeted to normal ranges did worse than patients who had hemoglobin levels of 10–12 g/dL. The incidence of stroke, heart failure, and death increased in patients targeted to normal hemoglobin levels, and there was no demonstrable decrease in cardiovascular events

Answer 250

D ## Footnote In the figure shown, only one of the listed conclusions can be inferred: 100% of the sample selected reached menopause by age 60. This does not imply that all women reach menopause by age 60. No conclusions regarding the plausible causes of menopause, surgical or hormonal, are valid on the basis of this graph. This graph illustrates a skewed, or asymmetric, distribution. Therefore, the mean (arithmetic average) age of menopause is different from the median age or middle value in the sequence from highest to lowest. Whereas the median age of menopause is approximately 50, the mean age is closer to 45, due to the skewing effect of the younger age groups represented.

Answer 251

D ## Footnote A medial meniscus tear is the most likely diagnosis in a patient **\> 40** who was **bearing weight when the injury occurred**, was **unable to continue the activity**, and has a **positive Thessaly test** (patient stands on one leg and flex the knee to 20°, then internally and externally rotate the knee. The presence of swelling immediately after the injury makes an internal derangement of the knee more likely) This patient is able to bear weight, so a fracture is also not likely. Either a collateral ligament tear or an anterior cruciate ligament tear is possible, but these are not as common in this situation.

Answer 252

E ## Footnote Hoarseness most commonly affects teachers and older adults. The cause is usually benign, but extended symptoms or certain risk factors should prompt evaluation; specifically, **laryngoscopy is recommended when hoarseness does not resolve within 3 months** or when a serious underlying cause is suspected. The American Academy of Otolaryngology/Head and Neck Surgery Foundation guidelines state that **antireflux medications should not be prescribed for patients with hoarseness without reflux symptoms**

Answer 253

B Herpes zoster can occur from either a wild strain or a vaccine strain of varicella-zoster virus in vaccinated children, but the incidence is low. All cases are mild and uncomplicated.

Answer 254

E ## Footnote Most varicoceles appear in adolescence, occur on the left side, and are asymptomatic. About 10% are bilateral. Surgical repair of large varicoceles can reverse testicular growth arrest, with catch-up growth occurring within 1–2 years. Varicoceles are the most common surgically correctable cause of subfertility in men and the goal of surgery is to maximize chances for fertility

Answer 255

B ## Footnote The blood smear shows a **hypersegmented polymorphonuclear neutrophil PMN**, typical of **vitamin B12 deficiency with pernicious anemia**. The anemia is of the **macrocytic** type (MCV \>100 μ m ). There is no evidence of hemolysis or leukemia. While IDA can be a coexisting problem, the hypersegmented PMN is classic for vitamin B12 deficiency. It is important to note that elderly patients with vitamin B12 deficiency may have neurologic signs and symptoms before developing hematologic abnormalities.

Answer 256

A ## Footnote Constipation is one adverse effect of opioid treatment that does not diminish with time. Thus, this effect should be anticipated, and recommendations for prevention and treatment of constipation should be discussed when initiating opioids. Nausea and vomiting, mental status changes, sedation, and pruritus are also common with the initiation of opioid treatment, but these symptoms usually diminish with time, and can be managed expectantly.

Answer 257

C Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A **neutrophil count \>250/mL** is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately **without** waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level \>1 g/dL is actually evidence *against* spontaneous bacterial peritonitis.

Answer 258

D Nonverbal communication is important for identifying issues that a patient may be hiding or be unwilling to divulge. Some nonverbal clues, however, are culturally biased. * Many older or less-educated Mexican-Americans consider direct eye contact to be disrespectful. Because a physician is held in high regard, these patients will often either look down or look at another, more equal person in the room while being interviewed. * Many Americans, on the other hand, may consider a lack of eye contact to be negative, implying that a patient is unsure of the information they are providing, has poor self-esteem, or is hiding something.

Answer 259

C ## Footnote After a hysterectomy for documented benign disease, cytologic screening may be discontinued. Pap smears in this population are low yield and may cause unnecessary testing due to false-positives. Pap smears may be continued if the reason for the hysterectomy is uncertain. If there is a history of invasive cervical cancer or DES exposure, screening should be continued, although there is not a great deal of data to support this practice

Answer 260

B ## Footnote Acute interstitial nephritis (AIN) is often drug-induced. Of the medications listed, **ibuprofen** is the most likely offending agent. Development of AIN usually becomes evident approximately 2 weeks after starting a medication and is not dose-related. Other medications strongly associated with AIN include various antibiotics (particularly cephalosporins, penicillins, sulfonamides, aminoglycosides, and rifampin), diuretics, and miscellaneous medications such as allopurinol.

Answer 261

E The AHA-ACLS guidelines state that intraosseous access can be obtained in almost all age groups rapidly, and is preferred over the endotracheal route. **Any drug that can be administered IV can be administered intraosseously.** Many drugs administered via an endotracheal tube are poorly absorbed, and drug levels vary widely.

Answer 262

C Studies show that few residents have an advance directive at the time of admission to a nursing home. Studies also show that residents with advance directives are more likely to die in a nursing home with hospice care, are less likely to have a feeding tube or ventilator in the last month of life, require fewer resources, and are hospitalized less

Answer 263

C ## Footnote Routine exercise up to near-maximal pain on a regular basis has been shown to be one of the most effective treatments for symptoms of PAD. Smoking cessation and aspirin are also standard recommendations, and can both prevent CVEs and slow the rate of progression of PAD symptoms. **Statin** **drugs** (specifically simvastatin and atorvastatin) have been shown to be beneficial for treatment of PAD symptoms and prevention of CVEs through the reduction of cholesterol, but they also appear to have other properties that help reduce leg pain in patients with PAD. Although lowering abnormally high blood pressure is recommended in PAD patients, only **ACEi** have been shown to reduce symptoms of PAD directly.

Answer 264

D ## Footnote **Childhood obstructive sleep apnea** **syndrome** has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities. Ade**notonsillectomy** is the treatment of choice. Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment. Intranasal corticosteroids may also be helpful, but the benefit appears small.

Answer 265

D When trimethoprim/sulfamethoxazole is contraindicated, a 3-day course of ciprofloxacin, levofloxacin, norfloxacin, lomefloxacin, or gatifloxacin is a reasonable alternative. **Moxifloxacin attains inadequate urinary concentrations and should not be used in the management of urinary tract infections.**

Answer 266

C ## Footnote **Keratoacanthoma** is a relatively common lesion in the elderly, but is difficult to distinguish from squamous cell carcinoma. Most keratoacanthomas undergo a **benign self-healing course** but may leave a large, unsightly scar. Treatment is almost always preferred, both for cosmetic reasons and to prevent the rare case of malignant transformation. Proper treatment for a lesion with this appearance is excisional biopsy in order to distinguish between keratoacanthoma and squamous cell carcinoma.

Answer 267

D ## Footnote Because this dermatitis is recurrent and symmetric, contact dermatitis should be suspected. Rhus dermatitis is a contact dermatitis, but it is more acute and presents with *bullae and vesicles* that are more *linear* than those seen in this patient. MRSA usually presents as a unilateral cellulitis, or more commonly as inflammatory nodules or pustules. This dermatitis is not scaling and does not have a distinct border that would suggest tinea.

Answer 268

D ## Footnote NSAIDs should be avoided in patients with heart failure. They cause sodium and water retention, as well as an increase in systemic vascular resistance which may lead to cardiac decompensation. Patients with heart failure who take NSAIDs have a tenfold increased risk of hospitalization for exacerbation of their CHF. NSAIDs alone in patients with normal ventricular function have not been associated with initial episodes of heart failure. NSAIDs, including high-dose aspirin (325 mg/day), may decrease or negate entirely the beneficial unloading effects of ACE inhibition. They have been shown to have a negative impact on the long-term morbidity and mortality benefits that ACE inhibitors provide. Sulindac and low-dose aspirin (81 mg/day) are less likely to cause these negative effects.

Answer 269

E ## Footnote Hydroxychloroquine, originally developed as an antimalarial drug, is a well-known DMARD that can slow the progression of rheumatoid arthritis. Aspirin, indomethacin, and ibuprofen are anti-inflammatory agents. They relieve pain and improve mobility, but do not alter the progression of the disease. Capsaicin, a topical substance-P depleter, can relieve pain symptoms.

Answer 270

A ## Footnote Vitreous detachment = separation of the posterior aspect of the vitreous from the retina, which exerts traction on the retina and can result in a retinal tear and detachment. Symptoms of retinal detachment may include **light flashes** (photopsia), a sudden appearance or increase in **“floaters**” or **peripheral visual field loss**, any of which should prompt an ophthalmology referral. Cataract surgery can result in premature shrinkage of the vitreous and thereby poses an increased risk, but vitreous detachment resulting from other processes is more common. Hyphema, glaucoma, and diabetic retinopathy are not specific risk factors for retinal detachment.

Answer 271

C ## Footnote Rotavirus vaccine (RotaTeq) vaccination is given at 2, 4, and 6 months of age; all three doses should be administered by 32 weeks of age. Unlike the vaccine RotaShield, which was marketed in 1999, RotaTeq is not known to increase the risk for intussusception.

Answer 272

A Because the risk of developing active disease is highest in patients within 2 years after conversion, recent converters should generally be treated regardless of age. BCG vaccination has a limited effect on PPD reactivity; tests should not be interpreted any differently in patients who have previously received BCG. The use of a two-step approach (i.e., retesting 1–4 weeks later in patients who initially test negative) is designed to decrease the false-negative rate of PPD testing. The significance of a positive result on either phase of the test is the same. Patients who are HIV positive are at higher risk for false-negative PPDs and active disease, but PPD testing is not contraindicated.

Answer 273

A ## Footnote There has been an increase in vulvar cancer in women 35–65 years of age over the last decade. This increase is associated with HPV, particularly subtypes 16 and 18. Lichen sclerosus is associated with vulvar cancer in older women.

Answer 274

A Heart disease is the leading cause of death in the U.S., and this holds true for both men and women. Among men the only ethnicity for which heart disease is not the most common cause of death is Asian/Pacific Islander.

Answer 275

D Myelodysplastic syndrome is a hematologic malignancy with a predisposition to leukemic transformation. It can present with findings of anemia, thrombocytopenia, neutropenia, or any combination of these. Anemia occurs in 80%–85% of patients and is typically **MACROcytic.**

Answer 276

E Varicella vaccination is contraindicated during pregnancy. The patient should avoid contact with infected individuals until safe postpartum immunization is possible. Maternal varicella infection is esp. problematic during **weeks 13–20 of pregnancy** and when the onset of maternal symptoms occurs from **5 days before until 2 days after delivery**. Varicella Ig should be given to pregnant women following a known exposure, term infants born within the 7-day window described above and preterm infants. Those who develop any signs of varicella infection also be given IV acyclovir. Term infants delivered more than 5 days after the onset of maternal varicella are thought to have adequate passive immunity for protection and the expected benign course generally requires only observation.

Answer 277

E ## Footnote Basic ADLs, such as dressing, eating, toileting, and grooming, are generally intact in early dementia. In contrast, IADLs, such as managing money and medications, shopping, cooking, housekeeping, and transportation, which often require calculation or planning, are frequently impaired in early dementia.

Answer 278

A The major indication for joint replacement is **severe joint pain**. **Loss of joint function** and **radiographic** **evidence of severe destruction of the joint** may also be considered in the decision. The appearance of the joint and the status of the contralateral joint may be minor considerations. Surgical insertion of a foreign body into an infected joint is contraindicated.

Answer 279

A ## Footnote Intact parathyroid hormone (PTH) will be **suppressed** in cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma. Thyrotoxicosis-induced bone resorption elevates serum calcium, which also results in suppression of PTH. Patients with **familial hypocalciuric hypercalcemia (FHH)** have moderate hypercalcemia but relatively *_low_* urinary calcium excretion, PTH levels can be normal or only mildly elevated despite the hypercalcemia. This mild elevation can lead to an erroneous diagnosis of primary hyperparathyroidism. **The conditions can be differentiated by a 24-hour urine collection for calcium**; calcium levels will be high/normal in patients with primary hyperparathyroidism and low in patients with FHH.

Answer 280

E ## Footnote According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not decrease intraoperative or postoperative complications. The American Heart Association recommends against routine preoperative testing in asymptomatic patients undergoing low-risk procedures, since the cardiac risk associated with such procedures is less than 1%.

Answer 281

E ## Footnote Panic disorder typically presents with the symptoms described, in late adolescence or early adulthood. The attacks are sporadic and last 10–60 minutes. Generalized anxiety disorder is more common, and common symptoms include restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance. Patients with mitral valve prolapse usually have an abnormal cardiac examination. Pheochromocytoma is associated with headache and hypertension, and usually occurs in thin patients. Paroxysmal supraventricular tachycardia is usually not associated with gastrointestinal distress or paresthesias.

Answer 282

A ## Footnote Good Samaritan laws apply to situations in which the physician does not have a preexisting duty to provide care to the patient. On an airplane, there is no preexisting duty for a physician to attend to a fellow passenger who becomes ill. In addition, a specific federal law, the Aviation Medical Assistance Act, ensures that physicians have Good Samaritan protection if they provide medical assistance while in flight over the United States. A physician who volunteers at an event assumes a duty to care for illness or injury in the participants. Likewise, physicians have a duty to provide emergency care to a person in need within a facility where they are working, such as a medical office or an emergency department.

Answer 283

A ## Footnote Current American Heart Association guidelines for blood pressure control in stroke patients advise monitoring with no additional treatment for patients with a systolic blood pressure

Answer 284

A ## Footnote Symptoms of congestive heart failure in infants are often related to feedings. Only small feedings may be tolerated, and dyspnea may develop with feedings. Profuse perspiration with feedings, is characteristic, and related to adrenergic drive, as feeding is the infants greatest exertion Fever and nasal congestion are more suggestive of infectious problems. Noisy respiration or wheezing does not distinguish between congestive heart failure, asthma, and infectious processes. A staccato cough is more suggestive of an infectious process, including pertussis.

Answer 285

B ## Footnote Paget’s disease of bone is a focal disorder of skeletal metabolism in which **_all elements of skeletal remodeling_ (resorption, formation, and mineralization) are _increased_.** There is no known relationship between Paget’s disease and multiple myeloma, although most cases of sarcoma in patients over 50 arise in pagetic bone. **The preferred treatment for nearly all patients with symptomatic disease is one of the newer bisphosphonates.** Treatment of bone pain resulting from Paget’s disease is generally **very satisfactory**, and in fact, relief may continue for many months or years after treatment is stopped, lending support for intermittent symptomatic therapy. Finally, despite the massive bone turnover, **extracellular calcium homeostasis is almost always _normal_.**

Answer 286

E The most common adverse event attributed to varenicline at a dosage of 1 mg twice a day is **nausea**, occurring in approximately 30%–50% of patients. Taking the drug with food lessens the nausea.

Answer 287

C ## Footnote Slipped capital femoral epiphysis (SCFE) typically occurs in young adolescents during the growth spurt. Physical activity, obesity, and male gender are predisposing factors for the development of this condition, in which the femoral head is displaced posteriorly through the growth plate. There is pain with physical activity, most commonly in the upper thigh anteriorly, but one-third of patients present with referred lower thigh or knee pain, which can make accurate and timely diagnosis more difficult. The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding, which makes the maneuver very useful in children with lower extremity pain. Orthopedic consultation is advised if SCFE is suspected. Hip extension and abduction are also limited in SCFE, but these findings are nonspecific. The knee findings in this patient are not associated with SCFE.

Answer 288

C ## Footnote In the neurologically intact individual the most common subtypes are stress incontinence, which occurs with coughing or lifting; urge incontinence, which occurs when patients sense the urge to void but are unable to inhibit leakage long enough to reach the toilet; and overflow incontinence, which occurs when the bladder cannot empty normally and becomes overdistended. The term functional incontinence is applied to those cases where lower urinary tract function is intact but other factors such as immobility and severe cognitive impairment lead to incontinence. For mild urge incontinence, as in this patient, the approach to this problem should be behavioral. For more severe cases, various pharmacologic agents, including anticholinergics are useful. Failure of these modalities should lead to urodynamic testing and consideration of surgery.

Answer 289

D ## Footnote This patient most likely is suffering from recurrent migraine headaches; at the described frequency and intensity, he meets the criteria for prophylactic medication. Ibuprofen or acetaminophen could still be used as rescue medications, but a daily agent is indicated and propranolol is the best choice for this patient. Sumatriptan is not approved for children under the age of 12 years. Carbamazepine has significant side effects and requires monitoring. Amitriptyline is a commonly used agent, but it could worsen his constipation.

Answer 290

B Studies have shown that PEG tubes do not improve nutritional status or quality of life for residents with dementia, nor do they decrease the risk of aspiration pneumonia, although aspiration risk may possibly be decreased if the feeding tube is placed below the gastroduodenal junction. Feeding tubes can also cause discomfort and agitation, leading to an increased use of restraints.

Answer 291

A ## Footnote **Anemia of chronic disease** is characterized by the underproduction of red cells due to low serum iron caused by the *uptake of iron by the reticuloendothelial system.* Total-body iron stores are increased but the iron in storage is not available for red cell production. This anemia is normochromic and normocytic, and is associated with a reduction in iron, _transferrin_, and transferrin saturation. Ferritin is either normal or increased, reflecting both the increased iron within the reticuloendothelial system and increases due to immune activation (acute phase reactant). In **iron deficiency anemia**, total-body iron levels are low, leading to hypochromia and microcytosis, low iron levels, increased _transferrin_ levels, and reduced ferritin levels. This patient’s anemia is most likely multifactorial, with anemia of chronic disease and drug effects playing a role. However, she also has iron deficiency, and searching for a source of blood loss would be important. With thalassemia, marked microcytosis is seen, and with hemolysis, slight macrocytosis and an increased reticulocyte count would be expected.

Answer 292

E ## Footnote Tarsal coalition is the fusion of two or more tarsal bones. Pain occurs around the ankle, and there is decreased ROM of the hindfoot and pain on foot inversion on examination. Os trigonum results from non-ossification of cartilage. It usually is unilateral and causes palpable tenderness of the heel. Sever’s apophysitis is inflammation of the calcaneal apophysis, and causes pain in the heel. Plantar fasciitis causes tenderness over the anteromedial heel. Navicular stress fractures are tender over the dorsomedial navicular

Answer 293

C ## Footnote Initial exercise routines for the elderly can be as short as 6 minutes in duration. Even 30 minutes per week of exercise has been shown to be beneficial. Graded exercise testing need not be done, especially if low-level exercise is planned. A target heart rate of 60%–75% of the predicted maximum should be set as a ceiling. Patients with peripheral neuropathy should not perform treadmill walking or step aerobics because of the risk of damage to their feet.

Answer 294

D The treatment of acute and significant diarrhea often requires a specific diagnosis. Epidemiologic studies have shown that Campylobacter infections are the leading cause of bacterial diarrhea in the U.S.

Answer 295

E Most patients with **somatoform disorder** are F and are of **low socioeconomic status**. They have **high utilization** **of medical services**, usually reflected by a thick medical chart, and are often **single parents**. Many of these patients **seek and are ultimately granted surgical procedures**, and it is not uncommon for them to have multiple procedures, especially involving the pelvic area. Often there are associated psychiatric symptoms such as **anxiety, depression, suicidal threats, alcohol or drug abuse, interpersonal or occupational difficulties, and antisocial behavior**. A background of a **dysfunctional family unit** in which one or both parents abused alcohol or drugs or were somatically preoccupied is also quite common. Unfortunately, these individuals **tend to marry alcohol abusers**, and thus continue the pattern of dysfunctional family life. Treatment should be by one primary physician where an established relationship and regular visits can curtail the dramatic symptoms that many times lead to hospitalization. The family physician is in a position to monitor family dynamics and provide direction on such issues as alcoholism and child abuse. Each office visit should be accompanied by a physical examination, and the temptation to tell the patient that the problem is not physical should be avoided. Knowing the patient well helps to avoid unnecessary hospitalization, diagnostic procedures, surgery, and laboratory tests. These should be done only if clearly indicated. Psychotropic medications should be avoided except when clearly indicated, as medications reinforce the sick role, may be abused, and may be used for suicidal gestures. Following these recommendations significantly decreases the cost of care for the patient.

Answer 296

D The U.S. Preventive Services Task Force recommends: * routine physical examination every 3–5 years for young adults until the age of 40. * Mammograms are not recommended until age 40. * Lead screening is recommended for at-risk individuals between 6 mo and 6 yo. * Colorectal cancer screening for average-risk individuals is recommended at age 50. * **Counseling on tobacco/substance abuse is recommended as part of _all_ routine preventive care.**

Answer 297

B ## Footnote Fibroadenoma is the most common benign breast mass, accounting for approximately two-thirds of all adolescent breast masses. It is characterized by a slow growing, nontender, rubbery, well-defined mass, most commonly located in the UOQ. Size varies, and is most commonly in the range of 2–3 cm. Fibrocystic disease is found in older adolescents and is characterized by bilateral nodularity and cyclic tenderness. Benign breast cysts are characterized by a spongy, tender mass with symptoms exacerbated by menses. Cysts are frequently multiple, and spontaneous regression occurs in 50% of patients. Cystosarcoma phyllodes is a rare tumor with malignant potential, although most are benign. It presents as a firm, rubbery mass that may enlarge rapidly. Skin necrosis is usually associated with the tumor. Intraductal papillomas are usually benign but do have malignant potential. They are commonly subareolar and are associated with nipple discharge. These tumors are rare in the adolescent population.

Answer 298

C ## Footnote **Permethrin** and **lindane** are the two most studied topical treatments for scabies, though studies have shown that permethrin to be more effective than lindane. However, the potential neurotoxicity of lindane, especially with repeated applications, has limited its use. Other topical treatments include benzoyl benzoate and crotamiton. Crotamiton has significantly less efficacy than permethrin at 4 weeks (61% vs 89%). Several controlled trials have assessed the efficacy of a single dose of ivermectin (200 g/kg) for the treatment of scabies. In one placebo-controlled trial, 37 of 50 patients treated with ivermectin (74%) were cured.

Answer 299

E ## Footnote Patients orthostatic proteinuria. This benign condition occurs in about 3%–5% of adolescents and young adults. It is characterized by increased protein excretion in the upright position, but normal protein excretion when the patient is supine. It is diagnosed using split urine collections as described in the question. The daytime specimen has an increased concentration of protein, while the nighttime specimen contains a normal concentration. Since this is a benign condition with normal renal function, no further evaluation is necessary.

Answer 300

A ## Footnote Although dietary management may be appropriate, a weight reduction diet is not likely to improve this patient’s cardiovascular outcome. In fact, even if this person were obese, there is insufficient evidence that weight reduction would decrease his cardiovascular mortality. There is good evidence that the other options, even β-blockers in a patient with normal blood pressure, are indicated. All of these measures have evidence to support their usefulness for secondary prevention of coronary artery disease.

Answer 301

E Low-dose topical, oral, nasal, and intra-articular corticosteroids are not immunosuppressive and do not contraindicate administration of any vaccine. Influenza vaccine and pneumococcal vaccine can be given together. Neither is a live vaccine.

Answer 302

B ## Footnote Running injuries are primarily caused by overuse due to training errors. Runners should be instructed to increase their mileage gradually. A stress fracture causes localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg. Plantar fasciitis causes burning pain in the heel and there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.

Answer 303

A Classic clinical clues that suggest renal-artery stenosis include the * **onset of stage 2 HTN (blood pressure \>160/100 mm Hg) _after_ 50 yo** or in the absence of a family history of HTN * **HTN associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the RAAS (ie lisinopril)** * **HTN** with repeated hospital admissions for heart failure * **drug-resistant HTN** (defined as BP above the goal despite treatment with 3 drugs from different classes at optimal doses). The other conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE inhibitor.

Answer 304

D ## Footnote Chronic hepatitis B has three major phases: **immune-tolerant, immune-active,** and **inactive-carrier.**There usually is a linear transition from one phase to the next, but reactivation from immune-carrier to immune-active phase also can be seen. Active viral replication occurs during the **_immune-tolerant phase_** when there is little or no evidence of disease activity, and this can last for many years before progressing to the **_immune-active phase_ (evidenced by elevated AST/ALT and HBeAg** (indicating high levels of HBV DNA)). Most patients with chronic hepatitis B eventually transition to the **_inactive-carrier phase_**, which is characterized by the clearance of HBeAg and the development of anti-HBeAg, accompanied by normalization of liver enzymes and greatly reduced levels of hepatitis B virus in the bloodstream.

Answer 305

B ## Footnote Solitary pulmonary nodules ≥8 mm in diameter with a “ground-glass” appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should *also* be evaluated, especially in a patient with a history of smoking. CT is the imaging modality of choice to reevaluate pulmonary nodules seen on a xray. PET is an appropriate next step when the cancer pretest probability and imaging results are discordant. Patients with notable nodule growth during follow-up should undergo a biopsy.

Answer 306

E Of the biochemical markers listed, the most clinically useful test to differentiate women who are at high risk for impending preterm delivery from those who are not is the fetal fibronectin in cervical or vaginal secretions. In symptomatic women, this is most accurate in predicting spontaneous preterm delivery within 7–10 days. It is less accurate in those who are asymptomatic. If the fetal fibronectin is negative, it may be possible to avoid interventions such as hospitalization, tocolysis, and corticosteroid administration.

Answer 307

B ## Footnote This patient has **melanosis coli**, which is a benign condition resulting from abuse of **anthraquinone laxatives such as cascara, senna, or aloe**. The condition resolves with discontinuation of the medication.

Answer 308

B ## Footnote When proteinuria is noted on a dipstick and the history, examination, full urinalysis, and serum studies suggest no obvious underlying problem or renal insufficiency, a urine protein/creatinine ratio is recommended, as the test correlates well with 24-hour urine protein, which is particularly difficult to collect in a younger patient. Renal ultrasonography is appropriate once renal insufficiency or nephritis is established. If pathogenic proteinuria is confirmed, an antinuclear antibody and/or complement panel may be indicated. A nephrology referral is not necessary until the presence of kidney disease or proteinuria from a cause other than benign postural proteinuria is confirmed.

Answer 309

E ## Footnote This presentation is typical of pityriasis rosea - **mild prodrome** (thought to be jet lag by this patient) followed by the development of an ovoid salmon-colored, slightly raised **herald patch** (commonly on the trunk), followed by an **outbreak of smaller, similar lesions that trend along Langer’s lines**. In this case, clear evidence of the herald patch remains visible in the left interscapular region, which is helpful in confirming the diagnosis. Guttate psoriasis shares some features with pityriasis rosea in that it can appear suddenly and often follows a triggering incident such as a streptococcal infection, which could be confused with a prodromal phase; however, the absence of a herald patch and the smaller but thicker erythematous lesions differentiate psoriasis from pityriasis rosea. Tinea versicolor often involves the upper trunk and may appear as a lightly erythematous, scaling rash, but the onset is more gradual than in this case. Although this patient may be exposed to low levels of radiation in her job, radiation dermatitis requires doses such as those administered in cancer treatment protocols and would generally be limited to the field of exposure. Cutaneous T-cell lymphoma usually presents as a nonspecific dermatitis, most commonly in men over the age of 50. An infectious etiology for pityriasis rosea is strongly suspected, although none has been identified. There is some evidence that the agent may be human herpesvirus 6. The illness generally resolves within 2 months, leaving no residual signs other than postinflammatory hyperpigmentation.

Answer 310

A ## Footnote The patient has instituted a legal advance directive and his proxy’s request should be respected as his own and the care withdrawn. If there were no advance directive the decision in this case would become more difficult, and might require a family conference or the involvement of an ethics committee. A patient’s condition does not need to be terminal or irreversible to allow the removal of life-sustaining therapy. Legal involvement is rarely required in situations where advance directives are already available and valid.

Answer 311

B **Thalamotomy** (partial removal of thalamus) and **pallidotomy** (destruction of the globus pallidus), contralateral to the side of the body that is most affected, are most effective for the treatment of disabling unilateral tremor and dyskinesia from **Parkinson’s disease.**

Answer 312

B ## Footnote Comedones are noninflammatory acne lesions. Inflammatory lesions include papules, pustules, and nodules. Grading acne based on the type of lesion and severity helps guide therapy. **Topical retinoids** prevent the formation of comedones and reduce their number, and are indicated as monotherapy for _noninflammatory acne_. **Topical antibiotics** are used primarily for the treatment of _mild to moderate inflammatory or mixed acne._ **Oral antibiotics** are effective for the treatment of _moderate to severe acne._ **Oral isotretinoin** is reserved for treatment of _severe, recalcitrant acne_.

Answer 313

D ## Footnote Serum antibody testing, especially IgA antiendomysial antibody, is highly sensitive and specific and readily available at a cost of about $100 to $200. Definitive diagnosis generally requires EGD with a biopsy of the _distal duodenum_ to detect characteristic villous flattening

Answer 314

D ## Footnote Midshaft posteromedial tibial stress fractures are common and are considered low risk. Management consists of relative rest from running and avoiding other activities that cause pain. Once usual daily activities are pain free, low-impact exercise can be initiated and followed by a gradual return to previous levels of running. A **pneumatic stirrup leg brace** has been found to be helpful during treatment. Non–weight bearing is not necessary, as this patient can walk without pain. Casting is not recommended. Ultrasonic pulse therapy has helped fracture healing in some instances, but has not been shown to be beneficial in stress fractures.

Answer 315

A Buspirone is indicated for the treatment of anxiety - It is not an established antidepressant. Its advantages include the absence of addictive potential and sedation; like antidepressants, the onset of benefit is often delayed for several weeks.

Answer 316

E ## Footnote **GI transit times are slower in women** than in men, which can diminish the absorption of medications such as metoprolol, theophylline, and verapamil. In addition, women should wait longer after eating before taking medications that should be administered on an empty stomach, such as ampicillin, captopril, levothyroxine, loratadine, and tetracycline. **Women also secrete less gastric acid** than men, so they may need to drink an acidic beverage to aid in absorption of medications that require an acidic environment, such as ketoconazole. **Women usually have lower BMIs than men**, and may need smaller loading or bolus dosages of medications to avoid unnecessary adverse reactions. **Women typically have higher fat stores** than men, so lipophilic drugs such as benzodiazepines and neuromuscular blockers have a longer duration of action. **Women also have lower GFR** than men, resulting in slower clearance of medications that are eliminated renally, such as digoxin and methotrexate.

Answer 317

C meperidine should not be used in the elderly because its metabolite can accumulate and cause seizures

Answer 318

C ## Footnote PA and lateral CXR are still valuable in the early evaluation of patients with chest pain. While they do not confirm or rule out the presence of myocardial ischemia, other causes of chest pain may be evident, such as **pneumothorax, pneumonia,** or **heart failure**. The CXR may also provide clues about other possible diagnoses, such as **pulmonary embolism, aortic disease,** or **neoplasia**. The other tests listed often have a role in the evaluation of chest pain, but none has supplanted the plain chest film as the best initial imaging study.

Answer 319

A ## Footnote The U.S. Preventive Services Task Force makes no specific recommendations for vitamins or antioxidants to prevent cancer or cardiovascular disease. Moreover, it makes no specific recommendations for vitamin supplements for any condition.

Answer 320

B This patient has a clinical presentation consistent with **acute sinusitis**. **Failure to respond to adequate antibiotic therapy suggests either a complication, progression to chronic sinusitis, or a different, confounding diagnosis.** The diagnostic procedure of choice in this situation is coronal CT of the sinuses, due to its increased sensitivity and competitive cost when compared with standard radiographs. Cultures of the nasal discharge give unreliable results because of bacterial contamination from the resident flora of the nose. The other options listed do not contribute to the diagnosis and treatment of sinusitis.

Answer 321

B When _straw-colored_ or _grey-green_ fluid is obtained by FNA of a breast nodule and the lesion completely disappears, the diagnosis is simple cyst. The fluid should _not_ be sent for analysis because the risk for cancer is exceedingly small. If the fluid is _bloody_ or otherwise unusual, it should be sent for cytologic examination because about 7% of bloodstained aspirates are associated with cancer

Answer 322

D ## Footnote Sensitivity is the percentage of patients **with** a disease who have a positive test result. Specificity is the percentage of patients **without** the disease who have a negative test result. Pretest probability is the probability of disease before a test is performed. Posttest probability is the probability of disease after a test is performed. Positive predictive value is the percentage of patients with a positive test result who are confirmed to have the disease.

Answer 323

D patients with one or two small (

Answer 324

A After vagal maneuvers are attempted in a stable patient with supraventricular tachycardia, the patient should be given a 6-mg dose of adenosine by rapid IV push. If conversion does not occur, a 12-mg dose should be given. This dose may be repeated once. If the patient is unstable, immediate synchronized cardioversion should be administered. svt**A**c = **s**tabilize **v**entricular **t**achycardias w/ **A**denosine then **C**ardioversion

Answer 325

A ## Footnote Osteoporosis is defined as a **fragility** or **low-impact fracture**, or as a **spine or hip bone mineral density** **\> 2.5 SD** **below** **the mean** for young, healthy women. A fracture of the radius caused by a fall from a standing position would be considered a low-impact fracture. A fracture resulting from a motor vehicle accident would be considered a high-impact fracture, which is not diagnostic for 11 osteoporosis. A T-score of –2.5 or less is considered osteoporosis, a T-score between –1.0 and –2.5 is considered osteopenia, and a T-score of –1.0 or higher is considered normal.

Answer 326

A Combination of an SSRI with a drug that increases serotonin concentrations may induce the potentially life-threatening serotonin syndrome, with mental status changes, agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever. These drugs include **MAOi****, tramadol, sibutramine, meperidine, sumatriptan, lithium, St. John’s wort, ginkgo biloba, and atypical antipsychotic agents.**

Answer 327

C ## Footnote Rubella has been directly responsible for inestimable pregnancy wastage, as well as for severe congenital malformations. **Identification and vaccination of unimmunized women immediately after childbirth or abortion is recommended. The vaccine should be avoided shortly before or during pregnancy since it is an attenuated live virus** The use of globulin to prevent viremia in nonimmune subjects exposed to rubella is not recommended. Because of herd immunity there is a very low likelihood that this patient will be exposed to rubella.

Answer 328

A One of the most characteristic findings in dermatomyositis is Gottron’s papules, which are flat-topped, sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal joints.

Answer 329

D ## Footnote Studies have demonstrated that bed rest is detrimental to recovery from low back pain. Patients should be encouraged to remain as active as possible. Exercises designed specifically for the treatment of low back pain have not been shown to be helpful. Neither opioids nor trigger-point injections have shown superiority over placebo, NSAIDs, or acetaminophen in relieving acute back pain. There is no good evidence to suggest that systemic corticosteroids are effective for low back pain with or without sciatica.

Answer 330

A ## Footnote All of the atypical antipsychotics are associated with some degree of weight gain. Of the choices listed, **aripiprazole is associated with the least amount of weight gain**, generally less than 1 kilogram. The other agents listed are likely to cause considerably more weight gain.

Answer 331

B Many infections of the respiratory tract have a viral etiology, and when this is the case early antibiotic treatment offers little to no benefit. Once the clinical course of a respiratory illness exceeds the expected length for a viral illness, it may be proper to initiate antibiotic treatment for a suspected atypical or secondary bacterial infection. **Epiglottitis** is one exception to this approach because of the possibility of a bacterial infection, particularly with **Haemophilus influenzae type b**, that can produce a rapidly worsening, potentially fatal airway compromise. When epiglottitis is suspected based on findings such as hoarseness, dysphagia, stridor, drooling, fever, chills, and respiratory distress, IV antibiotic treatment should be instituted immediately, ideally with a ß-lactam drug that exhibits activity against methicillin-resistant Staphylococcus aureus.

Answer 332

C ## Footnote The most common secretory pituitary adenomas are **prolactinomas**. They cause galactorrhea and hypogonadism, including amenorrhea, infertility, and impotence. **Growth hormone–secreting tumors**, which are the next most common secretory pituitary tumors, cause acromegaly or gigantism. Next in frequency are **corticotropic (ACTH-secreting) adenomas**, which cause cortisol excess (Cushing’s disease). **Glycoprotein hormone-secreting pituitary adenomas** (secreting TSH, LH, or FSH) are the least common. TSH-secreting adenomas are a rare cause of hyperthyroidism. Paradoxically, most patients with gonadotropin-secreting adenomas have hypogonadism.

Answer 333

D ## Footnote The **relative risk reduction (RRR)** is the proportional decrease in disease incidence in the treated group relative to the incidence in the control group. In this example the 3% incidence in the treated group is 40% less than the 5% incidence in the control group: (5%–3%)/5% = 40%. The **absolute risk reduction (ARR) is the difference between the incidence of disease in the treatment group and the incidence in the control group. In this example the ARR is 5% minus 3% = 2%. The number needed to treat (NNT) equals the reciprocal of the ARR: 1/.02 = 50.** The RRR is not a very useful statistic in clinical practice. It amplifies small differences and makes clinically insignificant findings appear significant because it essentially ignores the baseline risk of the outcome event. **The ARR provides a more useful measure of clinical effect. It answers the question “How much will I decrease my patient’s risk of an adverse outcome by this treatment?” The NNT is also very useful for clinicians, as it answers the question, “How many patients will I need to treat to prevent one adverse outcome?”**

Answer 334

C CT is the gold standard for the diagnosis of renal colic. Its sensitivity and specificity are superior to those of ultrasonography and intravenous pyelography. Noncalcium stones may be missed by plain radiography but visualized by CT. MRI is a poor tool for visualizing stones.

Answer 335

C ## Footnote Increasing prescription copayments results in a decrease in the number of prescriptions filled and worsening clinical outcomes for patients with heart failure, diabetes mellitus, hyperlipidemia, and schizophrenia. With each 10% increase in copayments, it is estimated that overall prescription spending decreases 2%–6%. The cited study found that up to 25% of Medicaid recipients, faced with a copayment, could not afford to fill at least one prescription in the previous year.

Answer 336

A ## Footnote Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area. Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.

Answer 337

E ## Footnote Syncope work-up begins with a H/P to identify those at risk for a poor outcome. Patients who have a **prodrome of have a cardiac arrhythmia. Patients with longer prodromes with N/V are likely to have vasovagal syncope, which is a benign process. Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension.** In most cases, the recommended test is an EKG. If the EKG is normal, dysrhythmias are not a likely cause of the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography are not necessary unless there are specific findings in either the history or the physical examination.

Answer 338

A ## Footnote This patient has **lichen planus -** pruritic, symmetrically distributed violaceous flat-topped papules, usually 3–6 mm in size. First-line treatment is with **high-potency topical corticosteroids /clobetasol**, as mid-potency topical agents such as triamcinolone are ineffective. Topical calcineurin inhibitors, including tacrolimus, can be used in cases not responding to topical corticosteroids. While scabies can masquerade as a variety of other dermatoses, retreatment with a scabicide is not indicated in this patient.

Answer 339

C ## Footnote The 1990 Patient Self-Determination Act (PSDA) requires hospitals, nursing homes, and health care programs to ask patients about advance directives and then incorporate the information into medical records

Answer 340

A ## Footnote Glipizide does not have an active metabolite, and is safe in patients with chronic renal disease. Metformin should be avoided in patients with a Cr \>1.5 mg/dL for men or \>1.4 mg/dL for women. Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia. Acarbose should be avoided in patients with chronic kidney disease, as it has not been evaluated in these patients.

Answer 341

D ## Footnote Factors associated with a higher risk of heat-related death include being confined to bed, not leaving home daily, and being unable to care for oneself. Among medical conditions, the highest risk is associated with preexisting psychiatric illnesses, followed by cardiovascular disease, use of psychotropic medications, and pulmonary disease.

Answer 342

A ## Footnote **Lumbar spine extension** increases lumbar lordosis, which decreases the cross-sectional area of the spinal canal, thereby compressing the spinal cord further. Walking **down**hill can cause this. Spinal flexion that decreases lordosis has the opposite effect, and will usually improve the pain, as will sitting. Pain with internal hip rotation is characteristic of hip arthritis and is often felt in the groin. Pain in the lateral hip is more typical of trochanteric bursitis. Increased pain walking uphill is more typical of vascular claudication.

Answer 343

B This patient has **delayed bone age + reduced growth velocity**, which suggests an underlying systemic cause, such as **growth hormone deficiency** Although bone age can be delayed with constitutional growth delay, after 24 months of age, growth curves are parallel to the 3rd percentile. Bone age would be normal with genetic short stature, Turner syndrome, skeletal dysplasia; but the latter two have dysmorphic features

Answer 344

C **Congenital adrenal hyperplasia** - caused by an inherited deficiency of any of the enzymes necessary for the biosynthesis of **cortisol**. In patients with the **salt-losing CAH variant**, symptoms begin shortly after birth with * failure to regain birth weight * progressive weight loss secondary to dehydration and vomiting * anorexia * Disturbances in cardiac rate and rhythm may occur due to electrolyte imbalances * cyanosis and dyspnea * in genetic males, various degrees of hypospadias may be seen, with or without a bifid scrotum or cryptorchidism.

Answer 345

D ## Footnote Nonalcoholic fatty liver disease is the most likely diagnosis in this patient, but hepatitis B and C should be ruled out. The patient's alcohol consumption of less than two drinks per week makes alcoholic fatty liver disease unlikely. A liver biopsy would not be appropriate at this time. Liver ultrasonography should be considered after hepatitis B and C are ruled out. The patient is younger than the recommended screening age for colonoscopy.

Answer 346

C ## Footnote viral laryngotracheobronchitis (croup) - cough, respiratory stridor, and distress result from edema of the **_sub_**glottic portion of the upper airway. Stridor + intercostal retractions are indications for **aerosolized epinephrine** + **intramuscular dexamethasone**, and hospitalization may be required for observation and continued treatment. Antibiotics do not have a role in the treatment of viral croup, and attempted visualization of the epiglottis is not indicated since it will increase the child’s anxiety and worsen the symptoms.

Answer 347

C ## Footnote Patients who have one first degree relative diagnosed with colorectal cancer or adenomatous polyps before age 60, or at least two second degree relatives with colorectal cancer, are in the highest risk group. They should start colon cancer screening at **age 40,** or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years.

Answer 348

D proctalgia fugax - episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination

Answer 349

C Causes of low back pain include vertebral disk herniation and spinal stenosis. Numbness and muscle weakness may be present in both. Pain from spinal stenosis is **relieved by sitting** and aggravated by standing, whereas the opposite is true for pain from a herniated disk.

Answer 350

C ## Footnote Chronic paronychia is a common condition in workers whose hands are exposed to **chemical irritants** or are wet for long periods of time. This patient is an otherwise healthy hairdresser, with frequent exposure to irritants. The patient should be advised to avoid exposure to harsh chemicals and water. In addition, the use of strong topical corticosteroids over several weeks can greatly reduce the inflammation, allowing the nail folds to return to normal and helping the cuticles recover their natural barrier to infection. Soaking in iodine solution would kill bacteria, but would also perpetuate the chronic irritation. Because the condition is related to chemical and water irritation, a prolonged course of antibiotics should not be the first treatment step, and could have serious side effects. There is no need to explore less likely autoimmune causes for nail changes at this time.

Answer 351

E This patient has pneumonia, sepsis, and suspected coinfection with influenza. Although the rapid antigen-based nasal swab was negative, false-negative rates may be as high as 70% and this test should not be relied upon to rule out influenza. Treatment should include both antiviral and antibacterial agents that include coverage against MRSA, the most common bacterial pathogen isolated from critically ill patients with coinfection. Oseltamivir, ceftriaxone, azithromycin, and vancomycin should be initiated empirically for the pneumonia and sepsis. The criteria for sepsis are satisfied by a temperature \>38.3°C, a WBC count \>12,000/mm3, a respiratory rate \>20/min, and a source of probable infection.

Answer 352

E female athlete triad**: amenorrhea, osteoporosis, decreased energy availability** (dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian function) Athletes who have amenorrhea for 6 months, disordered eating, and/or a history of a stress fracture resulting from minimal trauma should have a bone density test. **Low bone mineral density** for age is the term used to describe at-risk female athletes with a **Z-score of –1 to –2.** * Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along with a Z-score

Answer 353

D Effects of epidural anesthesia * an increased duration of the second stage of labor * an increased rate of instrument-assisted vaginal deliveries * an increased likelihood of maternal fever Overall, there is no statistically significant difference in the duration of the first stage of labor, the incidence of low Apgar scores, or the incidence of maternal backache at 3 months or 12 months.

Answer 354

B ## Footnote Influenza - **very abrupt onset**, and a **fever** with a **nonproductive cough**. Patients tend to say they have never been so ill. Mycoplasma pneumonia can spread among family members, but it is **milder** and has a more **indolent onset** and a longer incubation period. Bacterial bronchitis is an overdiagnosed, supposed **complication of URI**, and is not contagious. While the phrase cold and flu is often used, URI are not so febrile or prostrating, and coryza is the dominant syndrome sooner or later. Legionella can have point-source epidemics, but the incubation period is longer, symptoms vary from mild illness to life-threatening pneumonia, and **diarrhea** is prominent in many cases.

Answer 355

C Most medications used for prophylaxis/abortive treatment of migraines in the nonpregnant patient can also be used in pregnant patients. Most ß-blockers and calcium channel blockers are safe. Acetaminophen and narcotics can be used for acute pain. Ibuprofen/NSAIDs can also be used but should be avoided late in pregnancy because it is associated with premature closure of the ductus arteriosus and oligohydramnios. **Ergotamines (Migergot)** are avoided as they are uterotonic and have abortifacient properties. They have also been associated with case reports of fetal birth defects **Triptans** have the potential to cause vasoconstriction of the placental and uterine vessels and should be used only if the benefit clearly outweighs the harm.

Answer 356

B ## Footnote Specific phobias respond moderately well to **β-blockers used prior to a performance**. Since the symptoms are due to catecholamine excess, these drugs block peripheral anxiety symptoms such as tachycardia and tremulousness that can escalate subjective anxiety and impair performance.

Answer 357

B ## Footnote **Calcaneal apophysitis**, also known as Sever disease, is the most _common cause of heel pain in children_, usually occurring between 5 and 11 years of age. It is thought that in these children the **bones grow faster than the muscles and tendons**. A tight Achilles tendon then pulls on its insertion site at the posterior calcaneus with repetitive running or jumping activities, causing microtrauma to the area. There may be swelling and tenderness in this area and passive dorsiflexion may increase the pain. Radiography is usually normal and therefore does not often aid in the diagnosis, but it may reveal a **fragmented or sclerotic calcaneal apophysis.**Treatment involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and the use of orthotic devices. Plantar fasciitis and heel pad syndrome cause pain on the plantar surface of the heel rather than posteriorly. Achilles tendinopathy causes tenderness to palpation of the Achilles tendon. Tarsal tunnel syndrome related to compression of the posterior tibial nerve causes neuropathic pain and numbness in the posteromedial ankle and heel.

Answer 358

D CT urography or intravenous pyelography is recommended by the American College of Radiology as the most appropriate imaging procedure for hematuria in all patients, with the exception of those with generalized renal parenchymal disease, young women with hemorrhagic cystitis, children, and pregnant females.

Answer 359

B Metformin is contraindicated in patients with renal dysfunction, because it is associated with an increased incidene of lactic acidosis

Answer 360

A ## Footnote USPSTF and the CDC recommend that all adults age 65 years and under be screened for HIV regardless of risk factors. The USPSTF does not recommend routine screening for ovarian cancer with a bimanual examination, transvaginal ultrasonography, or CA-125 testing. The USPSTF recommends that women age 65 and older be screened for osteoporosis with a DXA scan. Women younger than age 65 should be screened only if their risk of fracture is equal to or greater than a 65-year-old white female with no additional risk factors. The USPSTF recommends that women age 50–75 be screened for colorectal cancer with colonoscopy every 10 years OR with flexible sigmoidoscopy every 5 years plus fecal occult blood testing (FOBT) every 3 years OR with FOBT annually.

Answer 361

D ## Footnote Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk

Answer 362

A Rheumatoid arthritis is most often _symmetric_ at presentation and particularly affects the wrists and other extremity joints that have a high ratio of synovium to articular cartilage. **Rheumatoid factor is often negative in the early months of the disease**, although it may be positive later. Radiographs and laboratory tests are helpful, but the diagnosis is primarily clinical. Osteoarthritis of the wrists usually involves the carpal-metacarpal joint of the thumb primarily, and the joint would be red if there were an injury. Fibromyalgia usually involves the soft tissue of the trunk, and there is no evidence of inflammation. Lyme disease can cause a variety of joint diseases, but not chronic symmetric arthritis.

Answer 363

D ## Footnote **Morphine** effectively decreases the feeling of SOB 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/vomiting 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 not manage the sensation of shortness of breath in a dying patient.

Answer 364

C ## Footnote This patient has **exercise-related oligomenorrhea,** but does not have the eating disorder that characterizes the female athlete triad. Menstrual problems in athletes do correlate with **bone density loss** and **impaired recovery from exercise**. The main issue in well-nourished female athletes seems to be that **energy intake is not increased to match energy expenditures at high levels of training.** Unlike those with the female athlete triad, there is little evidence that athletes without eating disorders suffer substantial harm from exercise-induced menstrual problems. Hormonal manipulation has not been shown to affect bone density, though it may produce withdrawal bleeding. Bisphosphonate therapy has been shown to be ineffective, and is not recommended in women of child-bearing age.

Answer 365

D ## Footnote This patient has classic symptoms of allergic rhinitis. Intranasal corticosteroids are considered the mainstay of treatment for mild to moderate cases. In multiple studies, intranasal corticosteroid sprays have proven to be more efficacious than the other options listed, even for ocular symptoms. Air filtration systems and bedding covers have not been shown to reduce symptoms.

Answer 366

E ## Footnote This patient has hypoactive sexual desire disorder (HSDD); the diagnosis includes 2 components: (1) recurrent deficiency/absence of sexual desire or receptivity to sexual activity, and (2) distress about such a deficiency. In menstruating women, oral estrogen and oral sildenafil have not been shown to be superior to placebo. CBT has been shown to be helpful for other sexual dysfunctions, but not with HSDD. **Topical testosterone**, in either patch or gel form, has shown consistent improvements in arousal, desire, fantasy, orgasm, and overall satisfaction in cases of HSDD.

Answer 367

A ## Footnote This patient has a low pretest probability of PE based on the Wells criteria. She would be a good candidate for a high-sensitivity D-dimer test, with a negative test indicating a low probability of venous thromboembolism. In patients with a low pretest probability of venous thromboembolism, ultrasonography or helical CT would not be the recommended initial evaluation. Neither troponin I nor an ANA level would be part of the recommended initial evaluation.

Answer 368

E ## Footnote Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are **LMWH** and **adjusted-dose warfarin**. These may be augmented by intermittent pneumatic compression.

Answer 369

A ## Footnote Intoeing, as described, is usually caused by internal tibial torsion. This problem is believed to be caused by sleeping in the prone position, and sitting on the feet. In 90% of cases, internal tibial torsion **gradually** **resolves without intervention by the age of 8.** Avoiding prone sleeping enhances resolution of the problem. Night splints, orthotics, and shoe wedges are ineffective. Surgery (osteotomy) has been associated with a high complication rate, and is therefore not recommended in mild cases before the age of 8.

Answer 370

E ## Footnote According to the American Geriatrics Society 2002 guidelines for management of persistent pain in older persons, tramadol has efficacy and safety similar to those of equianalgesic doses of codeine and hydrocodone. However, because of the threat of seizures (rare but potential), tramadol should be used with caution in patients with a history of seizure disorder or those taking other medications that lower seizure thresholds.

Answer 371

A The criteria for diagnosing diabetes mellitus include any one of the following: * symptoms of diabetes (polyuria, polydipsia, weight loss) PLUS one of the following * random glucose level ≥200 mg/dL * fasting plasma glucose level ≥126 mg/dL * a 2-hour postprandial glucose level ≥200 mg/dL after a 75 g glucose load. In the absence of unequivocal hyperglycemia the test must be repeated on a different day. The criteria for impaired glucose homeostasis include either * a fasting glucose level of 100-125 mg/dL (impaired fasting glucose) or * a 2-hour glucose level of 140-199 mg/dL on an oral glucose tolerance test. Normal values are now considered

Answer 372

B ## Footnote Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or rheumatologic condition and requires further workup. CBC, CRP, and ESR can help assess for these conditions, even though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence of a joint effusion. If the hip were painful or had decreased ROM, then US could help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient, but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first step toward identifying the source of his pain and fever.

Answer 373

E ## Footnote If a metal foreign body is present on the cornea for more than 24 hours a rust ring will often be present in the superficial layer of the cornea. This material is toxic to the cornea and should be removed as soon as possible, but it is not an emergency. The proper removal of a rust ring requires the use of a slit lamp and specialized ophthalmic equipment. Referral to an eye specialist within 24–48 hours is the best management in this case.

Answer 374

B First-line agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS) include **metformin** and **clomiphene**, alone or in combination, and **rosiglitazone**

Answer 375

A Most cases of nephrotic syndrome are caused by **primary kidney disease**, the most common secondary cause of nephrotic syndrome in adults is **diabetes mellitus**. Other secondary causes include systemic lupus erythematosus, hepatitis B, hepatitis C, NSAIDs, amyloidosis, multiple myeloma, HIV, and preeclampsia. Primary causes include membranous nephropathy and focal segmental glomerulosclerosis, each accounting for approximately one third of cases.

Answer 376

A ## Footnote This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Septic arthritis is considered highly likely in a child who has a fever over **38.7°C (101.7°F),** refuses to bear weight on the leg, has a **WBC \>12,000** cells/mm , and **ESR \>40** mm/hr. If several or all of these conditions exist, aspiration 3 of the hip guided by US or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful in cases that are unclear based on standard data, or if other etiologies need to be excluded.

Answer 377

D ## Footnote HIV screening is recommended as part of routine prenatal care, even in low-risk pregnancies. Counseling about cystic fibrosis carrier testing is recommended, but not routine testing. Hepatitis C and parvovirus antibodies are not part of routine prenatal screening. Routine screening for bacterial vaginosis with a vaginal smear for clue cells is not recommended.

Answer 378

C ## Footnote The preferred method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small margin of normal-appearing skin. Mohs surgery is sometimes used to treat melanomas, but is not used for the initial diagnosis. The depth of the lesion is crucial to staging and prognosis, so shave biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an appropriate treatment for melanoma.

Answer 379

E ## Footnote The pain from infiltration of local anesthetics can be decreased by using a warm solution, using small needles, and performing the infiltration slowly. It is also helpful to add sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life. An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate. It also helps to inject the agent through the edges of the wound (assuming the wound is not contaminated) and to pretreat the wound with topical anesthetics.

Answer 380

A ## Footnote The most common presenting symptom of obstructive sleep apnea is excessive daytime sleepiness (SOR A). Other symptoms include snoring, unrefreshing or restless sleep, witnessed apneas and nocturnal choking, morning headache, nocturia or enuresis, gastroesophageal reflux, and reduced libido

Answer 381

A ## Footnote **Duplex Doppler US** is the preferred initial test for renovascular hypertension in patients with impaired renal function. Tests involving intravenous radiographic contrast material may cause deterioration in renal function. Captopril renography is not reliable in the setting of poor renal function. Magnetic resonance angiography also could be considered, but the association between the use of gadolinium contrast agents and nephrogenic systemic fibrosis in patients with renal dysfunction would be a concern.

Answer 382

E ## Footnote Patients at the end of life have five main areas of concern: control of pain and other symptoms; avoiding a prolongation of the dying process; having a sense of control; relieving burdens on family and loved ones; and strengthening relationships with family and friends.

Answer 383

C Postdate and post-term pregnancy are terms that are used interchangeably. The postdate pregnancy is defined as a pregnancy that has reached **42 weeks** of amenorrhea. This is important because perinatal mortality doubles at 42 weeks gestational age. The diagnosis of postdate pregnancy depends heavily on accurate dating methods.

Answer 384

D ## Footnote USPSTF recommends one-time screening for AAA by US in men age 65–75 who have ever smoked (Grade B recommendation). The USPSTF recommends against routine screening for AAA in women (Grade D recommendation).

Answer 385

C ## Footnote The diagnosis of any STI in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common STI. **Gonorrhea, Chlamydia, Syphilis, HIV** are virtually diagnostic of _sexual abuse_, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2–3 years. **Genital herpes, genital warts, hepatitis B** should raise a strong suspicion of _possible inappropriate contact_. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. **Bacterial vaginosis** provides only _inconclusive evidence for sexual contact_, and is the only one of the options listed for which reporting is neither required nor strongly recommended.

Answer 386

A ## Footnote **Strabismus** is an ocular misalignment that can be diagnosed on a cover/uncover test when the corneal light reflex is deviated from its normal position slightly nasal to mid-pupil. The misaligned eye then moves to fixate on a held object when the opposite eye is covered. The eye drifts back to its original position when the opposite eye is uncovered. **Amblyopia** is cortical visual impairment from abnormal eye development-most often as a result of strabismus. Cataract is a less frequent cause of amblyopia. Esotropia is a type of strabismus with an inward or nasal deviation of the eye that would be evidenced by a corneal light reflex lateral to its normal position. (The outward eye deviation seen in this patient is exotropia.) Heterophoria, or latent strabismus, does not cause eye deviation when both eyes are uncovered.

Answer 387

E ## Footnote The **most common cause of pneumonia in children age** **4 mo - 4 yrs is RSV**. Other viruses may cause pneumonia as well. The peak incidence of respiratory syncytial virus is between 2 and 7 months of age. Wheezing and profuse rhinorrhea are characteristic and the disease typically occurs in mid-winter or early spring epidemics. Parainfluenza 3 typically affects older infants and is not common in winter. Mycoplasma tends to affect older children and children with bacterial illnesses; those infected with this organism generally appear more acutely ill.

Answer 388

E ## Footnote This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the organism are known, treatment should include IV antibiotic coverage for **Enterococcus, Streptococcus, MSSA and MRSA**. A patient who does _not_ have a prosthetic valve should be started on **vancomycin and gentamicin**, with monitoring of serum levels. Enterococcus and MRSA are often resistant to cephalosporins. If the organism proves to be Staphylococcus sensitive to nafcillin, the patient can be switched to a regimen of **nafcillin and gentamicin.**

Answer 389

D The primary distinguishing feature of delirium is a course that is typically acute, with rapid deterioration over hours or days, rather than months as with dementia. Also, the severity of delirium tends to fluctuate over the course of hours, with patients appearing quite normal at times and wildly agitated with hallucinations at others. Frequently, extreme changes in psychomotor activity are noted with delirium; although this may also be seen with dementia, it is typically not seen until the latter stages.

Answer 390

A ## Footnote The most common symptom of vulvar cancer is longstanding pruritis. The other symptoms mentioned occur less frequently

Answer 391

E A well-known use of IV magnesium is for correcting the uncommon ventricular tachycardia of torsades de pointes, and acute management of rapid a-fib.

Answer 392

A ## Footnote **β-Agonists** activate potassium uptake by the cells. This includes bronchodilators and tocolytic agents. Other agents that can induce hypokalemia include **pseudoephedrine** and **insulin**. **Thiazides**, can also cause hypokalemia as a result of the renal loss of potassium.

Answer 393

D ## Footnote Somatization disorders should be considered in patients who have a history of various complaints over a several-year period that involve multiple organ systems. There is no test to confirm this diagnosis. It is often intertwined in other psychiatric problems, including anxiety disorder, personality disorder, and depression. Treatment includes testing to make sure that there is nothing physically wrong, while building a trusting relationship with the patient. Once this is accomplished, it is reasonable to discuss the disorder with the patient. Cognitive therapy has been shown to be of value, as well as regularly scheduled office visits for monitoring and support. Medicines for coexisting psychiatric problems also are of benefit. In addition, referral for psychiatric consultation may be worthwhile. Food allergies can cause a variety of symptoms, but usually not to the extent seen with this patient, and testing for this might confuse the issue. Lorazepam may help the symptoms if there is a coexisting anxiety disorder, but it will not address the underlying problem. Laryngeal esophageal reflux can cause hoarseness and will respond to proton pump inhibitors, but given the repetitive nature of her symptoms and the previous negative workups, it is not consistent with the whole picture.

Answer 394

E ## Footnote The diagnosis of CAP is mostly based on the H&P. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the H&P. Children under 2 years of age who are in day care are at higher risk for developing CAP. Laboratory tests are rarely helpful in differentiating viral versus bacterial etiologies and should not be routinely performed. **Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration**. **Streptococcus pneumoniae** is one of the most common etiologies in this age group, and **high-dose amoxicillin** is the drug of choice.

Answer 395

B ## Footnote The parallelogram shape of this infant’s head is typical of positional skull deformity aka benign positional molding or occipital plagiocephaly. The incidence of positional skull deformity is increased in children who sleep in the supine position, but switching to prone sleeping is not recommended because this would increase the risk of SIDS. The deformity can be prevented by routine switching of the dependent side of the infant’s head. Supervised “tummy time” for 30–60 minutes each day can also decrease the amount of flattening and can increase the child’s motor development. This condition can prevent correct positioning and is remedied with physical therapy techniques and most infants with positional skull deformity improve within 2–3 months with the institution of positional changes and tummy time. If the condition does not significantly improve after this amount of time, referral to a pediatric neurosurgeon with expertise in craniofacial malformations would be appropriate. Cranial synostosis is the result of abnormal fusion of one or more of the sutures between the skull bones. Ipsilateral frontal bossing and ear advancement are not seen, resulting in a trapezoid-shaped head.

Answer 396

A ## Footnote The herpes zoster vaccine is the only live-attenuated virus vaccine listed, and is therefore the one contraindicated in immunodeficient patients. HPV, Tdap, meningococcal, and pneumococcal polysaccharide vaccines are not live or live-attenuated vaccines, and may be given to immunocompromised patients

Answer 397

E ## Footnote Topical **mupirocin** is as effective as cephalexin or amoxicillin/clavulanate in the treatment of impetigo, which is most often caused by Staphlococcal species. Oral penicillin V, oral erythromycin, and topical bacitracin are less effective than mupirocin. Topical disinfectants such as hydrogen peroxide are no more effective than placebo.

Answer 398

B ## Footnote Thyroid hormone requirements increase during pregnancy. Most women with hypothyroidism who become pregnant require an increased levothyroxine dosage. A common recommendation is to have women begin taking nine doses weekly (one extra dose on 2 days of the week) as soon as the pregnancy is confirmed. Thyroid function tests should be repeated regularly throughout the pregnancy to guide additional dosage adjustments.

Answer 399

C ## Footnote SIADH - can be caused by CNS/lung tumors, infections such as meningitis/pneumonia, medications such as amiodarone, carbamazepine, SSRIs, and chlorpromazine. In this fairly asymptomatic patient, **initial management should be free water restriction**. As she is hemodynamically stable, she does not need normal saline. Moreover, administration of normal saline may exacerbate the hyponatremia, as the sodium may be rapidly excreted while the water is retained. **If she had a rapid onset and neurologic symptoms such as seizures, hypertonic saline could be given**. Correction should be slow, with a goal of no more than a **1-2 mmol/L/hr** increase in the sodium level; a normal sodium level should not be reached within the first 48 hours of treatment. Demeclocycline is appropriate for patients who cannot adhere to the requirement for fluid restriction, or who have recalcitrant hyponatremia despite restriction.

Answer 400

B Coral-red fluorescence on Wood’s light examination is typical of infection with **Corynebacterium minutissimum**, a condition known as erythrasma. This organism commonly complicates intertrigo, often in the groin or interdigital spaces. Erythromycin is the most effective treatment for this bacterial infection.

Answer 401

B This patient’s EKG demonstrates a RBBB and a L anterior hemiblock. This **“trifascicular block”** puts the patient at risk for tachyarrhythmias and bradyarrhythmias. Given the patient’s complaint of near-syncope, a heart monitoring study would be most appropriate. An echocardiogram may be helpful eventually to assess cardiac function. Although the patient is at risk for heart block, immediate hospitalization is not indicated.

Answer 402

B ## Footnote OSA is increasingly recognized in children. Peak incidence is in the preschool-age range of 2–5 years when adenotonsillar tissue is greatest in relation to airway size. It is associated with obesity in older children. Common clinical manifestations include snoring with sleep interruptions and respiratory pauses. **Polysomnography** is the gold standard for the diagnosis. Although the child has inattention, excessive drowsiness is not seen in attention-deficit/hyperactivity disorder (ADHD) and medications for that condition are not indicated. None of his symptoms suggests a seizure disorder, so an EEG would not be helpful.

Answer 403

B ## Footnote The combination of the vasodilators **hydralazine + isosorbide dinitrate** has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and ACEi/ARB are insufficient to control symptoms or cannot be tolerated. This combination is **particularly effective in African-Americans with NYHA class III or IV heart failure**, with advantages including reduced mortality rates and improvement in quality-of-life measures. Digoxin, a long-time standard for the treatment of heart failure, is useful in reducing the symptoms of heart failure but has not been shown to improve survival. Amlodipine and other calcium channel blockers do not have a direct role in the treatment of heart failure.

Answer 404

C ## Footnote Psychomotor agitation is experienced by most patients during alcohol withdrawal. Benzodiazepines are clearly the drug class of choice. Providing medication on an as-needed basis rather than on a fixed schedule is generally preferred. Antipsychotics and butyrophenones (including haloperidol) lower the seizure threshold and should not be used. For short-term management of status epilepticus, anticonvulsants may be used in conjunction with benzodiazepines. The vast majority of seizures from withdrawal are self-limited and do not require anticonvulsant treatment. Clonidine and other α2-agonists do reduce minor symptoms of withdrawal, but have not been shown to prevent seizures. The effectiveness of baclofen in acute alcohol withdrawal is unknown.

Answer 405

D ## Footnote TMJ occur in a large number of adults. The etiology is varied, but includes dental malocclusion, bruxism (teeth grinding), anxiety, stress disorders, and, rarely, rheumatoid arthritis. While dental splints have been commonly recommended, the evidence for and against their use is insufficient to make a recommendation either way. Physical therapy modalities such as iontophoresis or phonophoresis may benefit some patients, but there is no clearly preferred treatment. Radiologic imaging is unnecessary in the vast majority of patients, and should therefore be reserved for chronic or severe cases. In fact, the majority of patients with TMJ disorders have spontaneous resolution of symptoms, so noninvasive symptomatic treatments and tincture of time are the best approach for most.

Answer 406

C Even a temporary reduction in renal function, such as occurs after pyelography or angiography, can cause lactic acidosis in patients taking metformin. The drug should be discontinued 48 hours before such procedures and restarted 48 hours after the procedure if renal function is normal.

Answer 407

C ## Footnote Also known as **erythema infectiosum** or **fifth disease**, **parvovirus B19** is a fairly common cause of an **exanthematous rash + arthritis** in younger women. This infection should be particularly suspected in health-care workers who have frequent contact with children. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.

Answer 408

A ## Footnote Pulmonary emboli, anastomotic leaks, and respiratory failure are responsible for 80% of deaths in the 30 days following bariatric surgery, with death from pulmonary embolism being the most frequent cause. Wound infections and marginal ulcers are common complications of this type of surgery.

Answer 409

B The exposed person should be tested for hepatitis B antibodies; *_if antibody levels are inadequate (_* An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months).

Answer 410

D ## Footnote Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. The cough is thought to be triggered by microaspiration of acidic gastric contents into the larynx and upper bronchial tree. Aggressive acid reduction using a proton pump inhibitor twice daily before meals for 3–4 months is the best way to demonstrate a causal relationship between GERD and extra-esophageal symptoms. Methacholine inhalation testing is not necessary in this patient, since symptomatic asthma has been ruled out by the lack of response to bronchodilator therapy. Chest CT and pulmonary function tests are not indicated given the lack of findings from the history, physical examination, and chest film to suggest underlying pulmonary disease. An initial therapeutic trial of proton pump inhibitors is favored over 24-hour pH monitoring because it is less uncomfortable to the patient and has a better clinical correlation.

Answer 411

D ## Footnote Mild acne is limited to a few to several papules and pustules without any nodules. Moderate acne have several to many papules and pustules with a few to several nodules. Severe acne have many or extensive papules, pustules, and nodules. The patient has mild acne according to the classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to topical agents and as first-line therapy in more severe acne. Caution must be used to avoid tetracycline in pregnant females. Oral isotretinoin is used in severe nodular acne, but also must be used with extreme caution in females who may become pregnant. Special registration is required by physicians who use isotretinoin, because of its teratogenicity.

Answer 412

A The patient described has a life expectancy that makes the risk-benefit ratio for the detection of asymptomatic prostate cancer extremely unfavorable. In addition, a mildly elevated PSA in a 78-year-old with a large prostate is most likely due to benign prostatic hypertrophy.

Answer 413

C ## Footnote **S. pneumoniae, H. influenzae, and M. catarrhalis** are the most common bacterial isolates from the middle ear fluid of children with acute otitis media. **Penicillin-resistant S. pneumoniae** is the most common cause of **recurrent and persistent** acute otitis media.

Answer 414

D "Baby blues" begin during the first 2–3 days after delivery and resolve within 10 days; symptoms include brief crying spells, irritability, poor sleep, nervousness, and emotional reactivity. Roughly 8%–10% will progress to a major postpartum depression. A previous history of MDD significantly increases the risk of developing postpartum depression (RR = 4.5), and a prior episode of postpartum depression is the strongest risk factor for postpartum depression in subsequent pregnancies. Prenatal and obstetric complications and socioeconomic status have not consistently been shown to be risk factors. First pregnancy is also not a significant risk factor.

Answer 415

A ## Footnote In multiple studies, angiotensin receptor blockers (ARBs) have been shown to be less likely to cause a chronic cough when compared with ACE inhibitors. Although this is not a life-threatening danger, it is a side effect that can be persistent and lead to discontinuation of medication. Angioedema, a more dangerous side effect, is thought to be ACE-inhibitor specific, though there have been case reports of angioedema associated with ARB use.

Answer 416

E ## Footnote Amiodarone - antiarrhythmic useful in the acute management of **sustained ventricular tachyarrhythmias, _regardless_ of hemodynamic stability**. It is **first-line treatment for symptomatic a-fib in patients with LV dysfunction and heart failure**. It has a very limited role in the treatment of atrial flutter. The only role for prophylactic amiodarone is in the **peri**operative period of cardiac surgery. The use of prophylactic antiarrhythmic agents in the face of “warning dysrhythmias” or after MI is no longer recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with nonischemic cardiomyopathy.

Answer 417

B ## Footnote The history and physical findings in this patient are consistent with all of the conditions listed. However, the elevated FSH and LH indicate an ovarian problem, and this case is consistent with ovarian failure or premature menopause. Most pituitary tumors associated with amenorrhea produce hyperprolactinemia. Polycystic ovary syndrome usually results in normal to slightly elevated LH levels and tonically low FSH levels. Hypothalamic amenorrhea is a diagnosis of exclusion, and can be induced by weight loss, excessive physical exercise (running, ballet), or systemic illness. It is associated with tonically low levels of LH and FSH.

Answer 418

C ## Footnote **Trismus (difficulty opening mouth)** is almost universally present with peritonsillar abscess, while voice changes, otalgia, and odynophagia may or may not be present. Pharyngotonsillitis and peritonsillar cellulitis may also be associated with these complaints. **Otalgia** is common with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of other conditions. Peritonsillar abscess is rarely found in patients who do not have **at least a 3-day** history of progressive sore throat.

Answer 419

B Patients with carbon monoxide poisoning should be treated immediately with normobaric oxygen, which speeds up the excretion of carbon monoxide.

Answer 420

E Patients with low-risk peptic ulcer bleeding based on clinical and endoscopic criteria can be discharged from the hospital on PO PPI thearpy on the same day as endoscopy. Routine second-look endoscopy is not recommended in patients with upper gastrointestinal bleeding who are not considered to be at high risk for rebleeding. Arteriography with embolization is indicated only in patients with persistent bleeding.

Answer 421

D ## Footnote Body dysmorphic disorder is an increasingly recognized somatoform disorder where patients have a preoccupation with imagined defects in appearance, which causes emotional stress. Body dysmorphic disorder may coexist with anorexia nervosa, atypical depression, obsessive-compulsive disorder, and social anxiety. Cosmetic surgery is often sought. SSRIs and behavior modification may help, but cosmetic procedures are rarely helpful.

Answer 422

A ## Footnote First-line treatment for diabetic peripheral neuropathy is tricyclic antidepressants. Anticonvulsants are second line and opioids are third line. Many medications have been found to be effective, including the **tricyclics, duloxetine, pregabalin, oxycodone, and tramadol.** Among the tricyclics, amitriptyline, imipramine, and nortriptyline have been found to be the most effective. For an uninsured patient, the tricyclics are also the most affordable.

Answer 423

B ## Footnote All patients who are found to have a thyroid nodule should have their TSH measured. Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed. For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant.

Answer 424

A CDC Centor Criteria for predicting streptococcal pharyngitis. These include * tonsillar exudates * tender anterior cervical lymphadenopathy * absence of cough * history of fever Patients with four positive criteria should be treated with antibiotics those with three positive criteria should be tested and treated if positive those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and according to the panel should not be tested or treated with antibiotics.

Answer 425

A ## Footnote In patients with fatigue, laboratory studies should include ESR, CMP, TSH level, CBC and a UA. A pregnancy test should be ordered for women of childbearing age. A baseline cortisol level would be valuable only in patients with significant findings of Addison’s disease. No other tests have been shown to be useful unless a specific medical condition is suspected.

Answer 426

C ## Footnote It has been recognized that **patients suffering from a critical illness with an exaggerated inflammatory response often have a relative cortisol deficiency**. Clinically, this can cause **hypotension that is resistant to IV fluid resuscitation**. Evidence is mounting that **survival is increased if these patients are treated with IV corticosteroids** during acute management. Cortisol levels can be assessed with a single serum reading, or by the change in the cortisol level after stimulation with cosyntropin (referred to as Δcortisol). The other hormones listed are not important for the acute management of a critically ill patient.

Answer 427

E ## Footnote This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90°; flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain. Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.

Answer 428

D Domestic violence cuts across all racial, socioeconomic, religious, and ethnic lines. The only consistent risk factor for being a victim is female gender.

Answer 429

A Like all drugs, SSRIs have significant side effects, including inhibition of the cytochrome P-450 system. However, **citalopram is least likely to inhibit this system**, making it a preferred SSRI for patients taking multiple medications for other illnesses.

Answer 430

A ## Footnote The initial workup for urethritis in men includes G+C testing of the penile discharge/urine _or_ UA with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment for men with a purulent urethral discharge or a positive urine test (+leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes azithromycin OR doxycycline **_PLUS_** ceftriaxone OR cefixime If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine should be obtained. Treatment should include azithromycin OR doxycycline **_PLUS_** metronidazole

Answer 431

D **Antibiotics** treatment for pertussis is effective for eradicating bacterial infection, which is important for disease control because it reduces infectivity. However, it is not for reducing the duration or severity of the disease. Azithromycin for 3–5 days or clarithromycin for 7 days Children under 1 month of age should be treated with azithromycin, as there is an **association between erythromycin and hypertrophic pyloric stenosis** in young infants. TMP/SMX can be used in patients who are unable to take macrolides or where macrolide resistance may be an issue, but should not be used in children

Answer 432

D ## Footnote The most useful findings for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, abnormal respiratory pattern, and low serum bicarb ( Unlike in adults, calculation of the BUN/creatinine ratio is not useful in children. Although the normal BUN level is the same for children and adults, the normal serum creatinine level changes with age in children.

Answer 433

E ## Footnote This patient has symptoms that suggest **acute coronary syndrome**, which includes chest pain with activity that radiates to the shoulder. An **EKG** is essential early in the evaluation of a patient with chest pain, and the initial evaluation should also include a **troponin I** measurement. The patient should neither be admitted nor given a benzodiazepine until the EKG is performed. The diagnosis of acute coronary syndrome should be established prior to heart catheterization. Other laboratory tests may be appropriate, but they are not the most important initial tests.

Answer 434

D ## Footnote Certain drugs can affect taste more than smell, but this does not include the bisphosphonates. Olfactory disorders may be associated with deficiencies of vitamins A, B6, B12, and trace metals, but not with vitamin D deficiency. Celiac disease is not known to cause a decreased ability to smell. **Rare tumors involving the olfactory region of the brain can affect smell, and are best detected by MRI.**

Answer 435

E ## Footnote Each of the individuals listed is at increased risk for hepatitis A infection or its complications, except for the Indian immigrant. Hepatitis A is so prevalent in developing countries such as India that virtually everyone is infected by the end of childhood, and therefore immune. Infection with hepatitis A confers lifelong immunity, so an adult from a highly endemic area such as India has little to gain from vaccination.

Answer 436

C Recent reports of epidemics of gastroenteritis on cruise ships are consistent with **Norwalk virus infections due to waterborne or foodborne spread.** In the United States, these viruses are responsible for about 90% of all epidemics of nonbacterial gastroenteritis. The Norwalk-like viruses 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 is usually appropriate.

Answer 437

B ## Footnote This patient has heart failure with a bronchospastic component. The S3 gallop occurs with a dilated LV and a R-sided pleural effusion, which are common in heart failure. **A BNP level is useful in differentiating cardiac vs pulmonary diseases, while a troponin I level is helpful in assessing for cardiac ischemia.** Arterial blood gasses are not useful in confirming the diagnosis. A CT angiogram of the chest would be useful for diagnosing pulmonary embolism. A d-dimer test is helpful to rule out venous thromboembolic disease.

Answer 438

E ## Footnote Although most patients will not have a palpably enlarged spleen on examination, it is likely that all, or nearly all, patients with mononucleosis have splenomegaly. In a small study, 100% of patients hospitalized for mononucleosis had an enlarged spleen by US exam, whereas only 17% of patients with splenomegaly have a palpable spleen. Patients should be advised to avoid contact- or collision-type activities for 3–4 weeks because of the increased risk of rupture. The cornerstone of treatment for mononucleosis is supportive, including hydration, NSAIDs, and throat sprays or lozenges.

Answer 439

A ## Footnote **Oral iron is absorbed better with an acidic gastric environment, which can be accomplished with the concomitant administration of _vitamin C_**. Oral iron absorption is improved if the iron is taken on an empty stomach, but this may not be well tolerated because gastric irritation is a frequent side effect. Constipation also is common with oral iron therapy. Iron therapy should be continued for several months after the hemoglobin reaches a normal level, in order to fully replenish iron stores. Sustained-release oral iron products provide a decreased amount of iron for absorption. Agents that raise gastric pH, such as antacids, proton pump inhibitors, and H2 blockers, should be avoided if possible.

Answer 440

A Patients with mental illness may have decision-making capacity if they are able to understand and communicate a rational decision. The key factors to consider in determining decision-making capacity include whether the patient can express a choice, understand relevant information, appreciate the significance of the information and its consequences, and engage in reasoning as it relates to medical treatment.

Answer 441

A ## Footnote This patient most likely has **preeclampsia**, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes hemoglobin, hematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid. A peripheral smear and coagulation profiles also may be obtained. Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

Answer 442

A ## Footnote The key indicator of postherpetic neuralgia is **persistent pain 3–6 months after an episode of herpes zoster.** Studies show that patients who present for treatment of herpes zoster within 72 hours will benefit from **antiviral therapy such as famciclovir to reduce the pain and decrease the risk of postherpetic neuralgia.** Treating zoster pain with tricyclic antidepressants in low dosage (10–25 mg amitriptyline) may also decrease risk. While steroids added to antiviral therapy may be of benefit in short-term therapy, they do not reduce pain at 6 months.

Answer 443

A ## Footnote The recycling of scalp hair is an ongoing process, with the hair follicles rotating through three phases. The actively growing **anagen**-phase hairs give way to the **catagen** phase, during which the follicle shuts down, followed by the resting **telogen** phase, during which the hair is shed. This patient most likely has a **_telogen effluvium_,** a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the **shift of large numbers of anagen-phase hairs to the telogen phase**. Telogen-phase hairs are **easily shed.** Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger. **_Anagen effluvium_** is the diffuse hair loss that occurs when **chemotherapeutic** medications cause rapid destruction of anagen-phase hair. **_Alopecia areata_** **-** causes round patches of hair loss, is felt to have an autoimmune etiology. **_Female-pattern hair loss_** affects the central portion of the scalp, and is not associated with an inciting trigger or shedding. **_Discoid lupus erythematosus_** causes a scarring alopecia.

Answer 444

B ## Footnote oral fluoride supplementation at currently recommended dosages to preschool-aged children older than 6 months of age whose primary water source is deficient in fluoride.

Answer 445

E * Cluster headache features * male * severe, sharp, continuous unilateral pain that lasts from 15 minutes to 3 hours; generally incapacitating * headaches are associated with at least one of the following ipsilateral signs: conjunctival injection, lacrimation, nasal congestion, miosis or ptosis, eye edema, and forehead and facial sweating. * can occur from every other day up to 8 times a day, often in cycles for 4–12 weeks. * respond to most of the same medications as migraine **(DHE, ergotamines, triptans)** and **100% oxygen therapy.** * Paroxysmal hemicranias * very unusual * present with a similar type of pain as cluster HA, but the attacks are usually short * more common in women * Medication rebound headaches * diffuse, bilateral, almost daily headaches. * occur in people who are overusing medications, and they tend to get worse with physical or mental exertion. * Temporal arteritis * usually occurs in older adults * Migraines * often unilateral but they are usually pulsatile * associated with nausea and vomiting or photophobia and phonophobia.

Answer 446

B placental abnormalities and obstetric complications were the largest category of causes of stillbirth in white women, and this was even more true after 32 weeks gestation. Other important causes included infection and fetal defects. More than one cause was found in one-third of cases.

Answer 447

C ## Footnote **Cilostazol** has been shown to help with intermittent claudication.

Answer 448

C Patients with chronic mild liver disease may take **NSAIDs**, but they should be **avoided in all patients with cirrhosis**, due to the **risk of precipitating hepatorenal syndrome**. Pregabalin and gabapentin are not metabolized by the liver and can be quite helpful. Acetaminophen, while toxic in high doses, can be used safely in dosages of 2–3 g/day. Tramadol is also safe in patients with cirrhosis.

Answer 449

A ## Footnote Varenicline works by binding to nicotine receptors in the brain, providing much lower stimulation than nicotine itself would. This has the effect of reducing the reinforcement and reward that smoking provides to the brain. However, **varenicline also blocks the benefit a patient would receive from nicotine replacement products**. Studies have shown that using nicotine replacement products concurrently with varenicline leads to an increase in nausea, headaches, dizziness, and fatigue.

Answer 450

A ## Footnote All persons between the ages of 19 and 64 who smoke should receive this vaccine. One-time revaccination after 5 years is recommended for persons with chronic renal failure, asplenia (functional or anatomic), or other immunocompromising conditions.

Answer 451

A ## Footnote SSRIs/ sertraline - broadest range of efficacy in treating PTSD since they are able to reduce all three clusters of PTSD symptoms (re-experiencing, numbing, hyperarousal) TCAs/amitriptyline - modest lessening of the symptoms of reexperiencing, with minimal or no effect on avoidance or arousal symptoms. MAOi/ phenelzine have shown moderate to good improvement in reexperiencing and avoidance symptoms, but little improvement in hyperarousal. Benzodiazepines/ alprazolam have been used to treat PTSD, but their efficacy against the major symptoms has not been proven in controlled studies.

Answer 452

C Ferritin and serum iron levels fall with iron deficiency. Total iron binding capacity rises, indicating a greater capacity for iron to bind to transferrin (the plasma protein that binds to iron for transport throughout the body) when iron levels are low.

Answer 453

D ## Footnote There is no specific therapy for anemia of chronic disease except to manage or treat the underlying disorder. Iron therapy is of no benefit, but erythropoietin may be helpful in some patients. There is no available data to suggest that combination therapy or prednisone is beneficial for this disorder.

Answer 454

D BNP is synthesized, stored, and released by the ventricular myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes.

Answer 455

D ## Footnote Psoriasis is a **genetic** inflammatory condition that has been associated with a **significant risk of cardiovascular morbidity and mortality**. Children of patients with the disorder are at increased risk, especially if both parents have the disorder. **Life expectancy is somewhat reduced** in patients with severe psoriasis, particularly if the disease had an early onset. Plaque psoriasis is usually a lifelong disease; this is in contrast to guttate psoriasis, which may be self-limited and never recur. **Cigarette smoking** may increase the risk of developing psoriasis. Psoriasis is also associated with an increased likelihood of obesity, diabetes mellitus, and metabolic syndrome.

Answer 456

A ## Footnote Patients often welcome spiritual discussion, depending on the situation. The percentage that welcome this discussion increases with the severity of illness, and is greatest among those who are very seriously ill with a potentially fatal disease. Spiritual inquiry during medical care should focus on understanding, compassion, and hope, and should be directed toward individuals who suffer from serious illness.

Answer 457

B ## Footnote Acid laryngitis is a group of respiratory symptoms related to gastroesophageal reflux disease. The symptoms of hoarseness (especially in the morning), a repeated need to clear the throat, and nocturnal or early morning wheezing may occur singly or in varying combinations, and are believed to be caused by gastric contents irritating the larynx and hypopharynx. Thyroid disease, sinusitis, and tracheal stenosis can produce one or more of the symptoms described, but not all of them.

Answer 458

B ## Footnote Spironolactone is recommended for treating **resistant** **HTN**, even when hyperaldosteronism is not present. A longer-acting diuretic such as **chlorthalidone** is also recommended for treating resistant HTN, particularly in cases with normal renal function. There is no benefit to switching from an ACE inhibitor to an ARB. Nitrates have some effect on blood pressure but are recommended only for patients with coronary artery disease.

Answer 459

D Cluster headache can be removed from the differential because it is always unilateral, although the affected side can vary. The remainder of these headache types can be bilateral, frontal, and nonthrobbing. Brain tumor headaches may be similar in character to previous headaches, but are often more severe or frequent.

Answer 460

C TIBC is elevated in IDA. Serum Fe may be decreased in response to inflammation (secondary to hepcidin) even when total body stores of iron are not decreased. Microcytosis and hypochromia are both features of IDA occurring late in its development, but both can also be seen in the thalassemias. Serum ferritin is also an acute-phase reactant but is normal or elevated in the face of an inflammatory process. A low serum ferritin is diagnostic for iron deficiency even in its early stages.

Answer 461

A ## Footnote The initial evaluation for chronic pelvic pain should include a UA/UC, cervical swabs for G/C, CBC, ESR, β-hCG, and pelvic US. CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic US. Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would be indicated if the history or examination suggests a GI source for the pain after the initial evaluation.

Answer 462

A Lights criteria use ratios of fluid/serum values for protein and LDH. Pleural fluid/serum ratios greater than 0.6 for LDH and 0.5 for protein are indicative of exudates. In the scenario presented, both ratios are approximately 0.3; therefore, the fluid is a transudate. The list of causes for transudates is much shorter than for exudates. The vast majority of transudates are due to heart failure, with cirrhosis being the next most common cause. Once there is reasonable certainty that the fluid is a transudate, additional studies usually are not necessary. The other conditions listed result in exudative pleural effusions.

Answer 463

B The attending physician is responsible for determining capacity and incapacity for decision making. The extent, cause, and probable duration of any incapacity should be documented in the clinical record.

Answer 464

E ## Footnote Calcium oxalate stones are the most common of all renal calculi. A low-sodium, restricted-protein diet with increased fluid intake reduces stone formation. A low-calcium diet has been shown to be ineffective. Oxalate restriction also reduces stone formation. Oxalate-containing foods include spinach, chocolate, tea, and nuts, but not yellow vegetables. **Potassium citrate should be taken at mealtime to increase urinary pH and urinary citrate**

Answer 465

C ## Footnote Anaerobic lung abscesses are most often found in a person predisposed to aspiration who complains of a productive cough associated with fever, anorexia, and weakness. Physical examination usually reveals poor dental hygiene, a fetid odor to the breath and sputum, rales, and pulmonary findings consistent with consolidation. Patients who have sarcoidosis usually do not have a productive cough and have bilateral physical findings. A persistent productive cough is not a striking finding in disseminated tuberculosis, which would be suggested by miliary calcifications on a chest film. The clinical presentation and physical findings are not consistent with a simple mass in the right hilum nor with a right pleural effusion.

Answer 466

B ## Footnote Pneumonia caused by **Legionella pneumophila** is commonly preceded by nonspecific systemic symptoms that may lead a clinician to consider other diagnoses. Symptoms may include high-grade fever, malaise, myalgias, anorexia, and headache. Gastrointestinal and neurologic symptoms are also common and include nausea, vomiting, abdominal pain, **diarrhea**, and **confusion**. Focal neurologic signs are less common, but have been reported. Localizing respiratory symptoms will typically develop later, most often a dry cough and dyspnea. From this point on the illness resembles a typical pneumonia with fever, productive cough, pleuritic pain, and breathlessness.

Answer 467

C ## Footnote Hiccups are caused by a respiratory reflex that originates from the phrenic and vagus nerves, as well as the thoracic sympathetic chain. Hiccups that last a matter of hours are usually benign and self-limited, and may be caused by **gastric distention**. Treatments usually focus on interrupting the reflex loop of the hiccup, and can include mechanical means (e.g., stimulating the pharynx with a tongue depressor) or medical treatment, although only **chlorpromazine** is FDA-approved for this indication. If the hiccups have lasted more than a couple of days, and especially if they are waking the patient up at night, there may be an underlying pathology causing the hiccups. Identifying and treating the underlying disorder should be the focus of management for intractable hiccups.

Answer 468

E Treatment of hypoxemia is critical in the management of COPD and trials have shown a reduction in mortality with the use of oxygen for 15 or more hours daily.

Answer 469

D Parvovirus B19 is associated with erythema infectiosum, or fifth disease. It is also associated with nonspecific fever, arthropathy, chronic anemia, and transient aplastic crisis.

Answer 470

D Contraindications to insertion of the levonorgestrel intrauterine system (LNG-IUS) include **uterine anomalies, postpartum endometritis, untreated cervicitis, and current PID**. Nulliparity may increase discomfort during insertion but is not a contraindication. Levonorgestrel is a synthetic progestin and is not associated with an increased risk of deep vein thrombosis. It also is not associated with any adverse effect on quantity or quality of milk in breastfeeding women, and has no adverse effects on the infant. The LNG-IUS is not contraindicated in patients with endometriosis, and there is some evidence that it may improve symptom scores in these women.

Answer 471

B ## Footnote **Acute glomerulonephritis (AGN)** in children manifests as **brown/ cola-colored urine**, which may be painless _or_ associated with mild flank/abdominal pain. There are many etiologies of AGN but the most common in children are **IgA nephropathy** (which may directly follow an acute upper respiratory tract infection) and **acute poststreptococcal glomerulonephritis** **following a streptococcal throat or skin infection (usually 7–21 days later)**. In cases with more severe renal involvement, patients may develop **HTN, edema, and oliguria**. **RBC casts** are the classic finding on urinalysis in a patient with AGN. W BC casts are seen in acute pyelonephritis, often manifested by high fever, and costovertebral angle or flank pain and tenderness. Patients may also appear septic. Positive serum antinuclear antibodies are associated with lupus nephritis. Urine eosinophils are seen in drug-induced tubulointerstitial nephritis. Serum complement levels are reduced, not elevated, in various forms of acute glomerulopathies, including poststreptococcal AGN.

Answer 472

D ## Footnote **Patellofemoral pain syndrome** - characterized by anterior knee pain, particularly with activities that overload the joint, such as stair climbing, running, and squatting. Patients complain of popping, catching, stiffness, and giving way. On examination there will be a positive J sign, with the patella moving from a medial to a lateral location when the knee is fully extended from the 90° position. This is caused by an imbalance in the medial and lateral forces acting on the patella. Locking is not characteristic of patellofemoral pain syndrome, so a loose body or meniscal tear should be considered if this is reported.

Answer 473

D The CXR of a child with meconium aspiration syndrome will show patchy atelectasis or consolidation. If the child has a normal chest film and respiratory distress, a noncardiopulmonary source should be considered (i.e., a neurologic or metabolic etiology). The chest film of a child with transient tachypnea of the newborn will show a wet silhouette around the heart, diffuse parenchymal infiltrates, or intralobar fluid accumulation. Homogeneous opaque infiltrates with air bronchograms on a CXR are seen with hyaline membrane disease.

Answer 474

E Ibandronate, raloxifene, denosumab, and etidronate have been shown to reduce new vertebral fractures, but are not proven to prevent hip fracture. Only **zoledronic acid, risedronate,** and **alendronate** have been confirmed in sufficiently powered studies to prevent hip fracture, and these are the anti-osteoporosis drugs of choice.

Answer 475

A ## Footnote Recent American Society of Anesthesiologists guidelines recommend the following restrictions on diet prior to surgery for pediatric patients: **8 hours for solid food, 6 hours for formula, 4 hours for breast milk, and 2 hours for clear liquids.** These changes have resulted in decreased numbers of canceled cases and pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction.

Answer 476

D ## Footnote Indications for laparoscopic bariatric surgery include a BMI \>40 kg/m2 or a BMI of 35-40 kg/m2 with significant obesity-related comorbidities. Weight loss by nonoperative means should be attempted before surgery, and patients should be evaluated by a multidisciplinary team that includes a dietician and a mental health professional before surgery.

Answer 477

E ## Footnote **Postpartum urinary retention** (PUR) - defined as a post-void bladder residual of at least **150 cc present** **6 hours or more after delivery**. This condition is more likely to occur in patients who are primiparous, have a prolonged first or second stage of labor, have instrumented vaginal deliveries, or require a cesarean section for failure to progress. Most cases will **resolve 2–6 days after delivery**, but some can take up to several weeks. The use of intermittent self-catheterization or a transurethral catheter is recommended until the patient’s ability to spontaneously micturate returns.

Answer 478

E ## Footnote Delirium is a frequent complication of hospital admission in older patients, especially those with preexisting dementia. Orientation and reassurance in a quiet environment will usually be effective in treating the confusion and agitation, once serious causes of the delirium have been ruled out. Benzodiazepines and meperidol have been reported to cause delirium. Physical restraints and restrictive environments (e.g., intensive-care units) can predispose to delirium and are best avoided if possible.

Answer 479

E ## Footnote **Perinephric abscess** - collection of pus in the tissue surrounding the kidney, generally in the space enclosed by Gerota’s fascia. Clinical features may be quite variable, and the most useful predictive factor in distinguishing uncomplicated pyelonephritis from perinephric abscess is **persistence of fever for more than 4 days after initiation of antibiotic therapy.** The radiologic study of choice is **CT,** as this can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of the diagnosis), and perirenal gas (which is diagnostic). Most perinephric infections occur as an extension of an ascending urinary tract infection, commonly in association with renal calculi or urinary tract obstruction. Patients with anatomic urinary tract abnormalities or diabetes mellitus have an increased risk.

Answer 480

D ## Footnote A patient with a recurrent kidney stone and an elevated serum calcium level most likely has hyperparathyroidism, and a parathyroid hormone (PTH) level would be appropriate. Elevated PTH is caused by a single parathyroid adenoma in approximately 80% of cases. The resultant hypercalcemia is often discovered in asymptomatic persons having laboratory work for other reasons. An elevated PTH by immunoassay confirms the diagnosis.

Answer 481

E ## Footnote An adult patient with a confirmed SBP \>139 mm Hg or DBP \>89 mm Hg is hypertensive. JNC-7 guidelines recommend the adoption of healthy lifestyles for all patients, especially those with HTN, and the addition of pharmacologic treatment as necessary to reach a goal BP

Answer 482

A This patient presents with a history of snakebite, swelling of an entire extremity, weakness, and ecchymosis. This is consistent with a grade III envenomation and merits antivenin therapy. Antivenin is indicated before any consideration of compartment syndrome. Pressure measurements would be required because of the clinical similarities between envenomation injury and compartment syndrome.

Answer 483

A ## Footnote Any child **younger than 29 days old** with a _fever_ or any child who _appears toxic_, regardless of age, should undergo a **complete sepsis workup** and be **admitted to the hospital** for observation until culture results are known or the source of the fever is found and treated. Observation only, with close follow-up, is recommended for nontoxic infants **3 - 36 months** of age with a temperature Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and UA, can be sent home with precautions and with follow-up in 24 hours. Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics

Answer 484

B Nitrofurantoin for 5 days is an appropriate treatment for an uncomplicated UTI, but not for pyelonephritis. **Fluoroquinolones**, such as ciprofloxacin, are the preferred empiric antibiotic treatment for outpatient treatment of pyelonephritis, as long as the local prevalence of resistance to community-acquired Escherichia coli is ≤10%. Amoxicillin is generally not considered first-line treatment for pyelonephritis because of a high prevalence of resistance to oral β-lactam antibiotics, and it should only be chosen if susceptibility results for the urinary isolate are known and indicate likely activity.

Answer 485

A ## Footnote The abrupt discontinuation of **venlafaxine**, or a reduction in dosage, is associated with withdrawal symptoms much more severe than those seen with other SSRIs. These symptoms include agitation, anorexia, confusion, impaired coordination, seizures, sweating, tremor, and vomiting. To avoid this withdrawal symptom, dosage changes should be instituted gradually. Abrupt discontinuation of mood stabilizers such as divalproex, and atypical antipsychotics such as olanzapine, can result in the return of psychiatric symptoms, but not severe physiologic dysfunction. Similarly, stopping anticholinesterase inhibitors such as donepezil will not cause a withdrawal syndrome.

Answer 486

E ## Footnote Methamphetamine dependence is very difficult to treat. No medications have been approved by the FDA for the treatment of this problem, nor have any studies shown consistent benefit to date. The standard therapy for methamphetamine dependence is outpatient behavioral therapies, especially with case management included. Therapy must be individualized. Support groups and 12-step drug-treatment programs may be helpful

Answer 487

E ECT can be used safely in elderly patients and in persons with cardiac pacemakers or implantable cardioverter-defibrillators. ECT also can be used safely during pregnancy, with proper precautions and in consultation with an obstetrician. There are no absolute contraindications to electroconvulsive therapy (ECT), but persons who may be at increased risk for complications include those with unstable cardiac disease such as ischemia or arrhythmias, cerebrovascular disease such as recent cerebral hemorrhage or stroke, or increased intracranial pressure

Answer 488

A ## Footnote Clostridium difficile infection is more common with aging and can be treated with either metronidazole or vancomycin daily. For mild recurrent disease, repeating the course of the original agent is appropriate. Multiple recurrences or severe disease warrants the use of both agents.

Answer 489

D Myalgias and noninflammatory arthralgias are more likely with aromatase inhibitors. Endometrial cancer may occur with long-term use of tamoxifen.

Answer 490

C ## Footnote The U.S. Preventive Services Task Force has concluded that the net benefit of daily aspirin is substantial in women 55–79 years of age for whom the benefit of **ischemic stroke** prevention exceeds the harm of an increased risk for gastrointestinal bleeding. Aspirin use is recommended in men 45–79 years of age for prevention of **myocardial infarction** when the potential benefit outweighs the potential harm of gastrointestinal hemorrhage. _Net benefit of aspirin_ **W** **5**5-79 **S**troke **M** **4**5-79 **M**I

Answer 491

E Of the several drugs studied for the treatment of dependence, the evidence of efficacy is strongest for **naltrexone** (opioid antagonist) and **acamprosate** (NMDA antagonist and GABA analog)

Answer 492

E ## Footnote Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder except Down syndrome; about one in 4000–6000 males is affected. Down syndrome, Klinefelter’s syndrome, and homocystinuria do not present with the described findings. Asperger’s syndrome is a variant of autism in people of normal to high intelligence. Patients with Klinefelter’s syndrome usually have small testicles.

Answer 493

E Doxylamine (Unisom) and vitamin B6 is associated with a 70% reduction in N/V, with no evidence of teratogenicity.

Answer 494

E Myasthenia gravis is a neuromuscular illness with an underlying immune-related cause. Corticosteroids and anticholinesterase medications such as oral pyridostigmine can be helpful, but thymectomy may be appropriate for patients with generalized disease not responding to medication. Thymectomy increases the remission rate and improves the clinical course.

Answer 495

E Bupropion can lower the seizure threshold and should not be used in patients who have a history of a seizure disorder or who drink heavily. A history of the other medical conditions listed does not contraindicate the use of bupropion.

Answer 496

e ## Footnote In patients with systolic heart failure, the usual management includes an ACE inhibitor and a ß-blocker. Since this patient had angioedema with an ACE inhibitor, an angiotensin receptor blocker may cause this side effect as well. Adding metolazone is generally not necessary unless the patient has volume overload that does not respond to increased doses of furosemide. Digoxin may improve symptoms, but has not been shown to increase survival. **For patients who cannot tolerate an ACE inhibitor, especially African-Americans, a combination of direct-acting vasodilators such as isorbide and hydralazine is preferred.** Verapamil has a negative inotropic effect and should not be used.

Answer 497

D ## Footnote Deceleration-type blows to the chest can produce partial or complete transection of the aorta. A CXR shows an acutely widened mediastinum and/or a pleural effusion when the condition is severe. The other conditions listed would produce mediastinal emphysema (esophageal or bronchial rupture), a widened heart, or pulmonary edema (acute heart failure, myocardial contusion).

Answer 498

D ## Footnote Whole cow’s milk does **not supply enough vitamin E, iron, and essential FA,** and **overburdens their system with too much protein, Na, and K**. Skim and low-fat milk lead to the same problems as whole milk, and also **fail to provide adequate calories for growth.** For these reasons cow’s milk is not recommended for children under 12 months of age. Human breast milk or iron-fortified formula, with introduction of solid foods after 4-6 months of age if desired, is appropriate for the first year of life.

Answer 499

C ## Footnote **AKI** is currently defined as either a rise in serum Cr or a reduction in urine output. Cr 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 sterile pyuria may also be seen in addition to eosinophiluria. Discontinuation of the offending drug is the cornerstone of management.

Answer 500

A ## Footnote It is important to screen for anemia during late infancy. Iron deficiency is the most common cause of anemia in this age group. There is evidence that persistent iron deficiency in childhood may have a negative impact on cognitive development. A therapeutic trial of iron is the best approach to the treatment of iron deficiency in late infancy. If the anemia fails to respond, investigating other causes of anemia is indicated

Answer 501

B This patient most likely has ischemic colitis, given the abdominal pain, bloody diarrhea, and cardiovascular risks. Peptic ulcer disease is unlikely because the nasogastric aspirate was negative. Diverticular bleeding and angiodysplasia are painless. Infectious colitis is associated with fever.

Answer 502

D Because of the **risk of asthma exacerbation or asthma-related death,** the FDA has added a **warning against long-acting β2-agonists as monotherapy**. Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved and accepted for both monotherapy and combination therapy in the management of asthma.

Answer 503

A Fluoxetine has FDA approval for this indication.

Answer 504

A The patient described is likely suffering from bulimia. These patients use vomiting, laxatives, or diuretics to prevent weight gain after binge eating. This often causes a loss of potassium, leading to weakness, cardiac arrhythmias, and respiratory difficulty. The levels of other electrolytes are not as dramatically affected.

Answer 505

A Flexible flat feet as described are not pathologic unless painful, which is uncommon. Flexibility of the flat foot is determined by appearance of an arch when the feet are not bearing weight. No treatment is indicated for painless flexible flatfoot. Spontaneous correction is usually expected within 1 year of walking.

Answer 506

A TCA is acceptable for use on vaginal mucosa and is also acceptable for use when pregnancy is a possibility. Podofilox and podophyllin in alcohol are not safe for use on mucosa. Imiquimod cream is also not approved for mucosal use. Interferon requires injection.

Answer 507

D ## Footnote This is a classic presentation for intussusception, which usually occurs in children under the age of 2 years and is characterized by paroxysms of colicky abdominal pain. A mass is palpable in about two-thirds of patients. Pyloric stenosis presents with a palpable mass, but usually develops between 4 and 6 weeks of age. A choledochal cyst presents with the classic triad of RUQ pain, jaundice, and a palpable mass. Meckel’s diverticulum usually presents in this age group with painless lower gastrointestinal bleeding. Intestinal malrotation usually presents within the first 4 weeks of life and is characterized by bilious vomiting.

Answer 508

D ## Footnote **Delayed attainment of social skill milestones is the earliest and most specific sign of autism.** Delayed or odd use of language is a common, but less specific, early sign of autism. Compared with social and language impairments, restricted interests and repetitive behaviors are less prominent and more variable in young children. Self-injurious behaviors are associated with autism, but not specific for it. For example, new-onset head banging may be the way an autistic child attempts to deal with pain from a dental abscess, headache, sinusitis, otitis media, or other source of pain.

Answer 509

B ## Footnote Metformin is a biguanide; main advantages other oral anti-diabetic agents is that it **does not cause hypoglycemia**. **Lactic acidosis**, while rare, can occur in patients with renal impairment. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a **weight-neutral or even a weight loss** effect. **Gastrointestinal distress** is a common side-effect of metformin, particularly early in therapy.

Answer 510

A Patients must have 3 of 4 Amsel criteria to be diagnosed with bacterial vaginosis. These include * pH \>4.5 (most sensitive) * clue cells \>20% (most specific) * homogeneous discharge * positive whiff test (amine odor with addition of KOH)

Answer 511

C ## Footnote **Antiphospholipid syndrome** is due to the presence of lupus anticoagulant and anticardiolipin antibodies, which bind to negatively charged phospholipids. The antibodies are usually detected by a **false-positive serologic test for syphilis**. Clinical features include **venous + arterial thrombosis**, **fetal wastage**, **thrombocytopenia**, and the **presence of an activated partial thromboplastin time (aPTT) inhibitor**. It is an important diagnostic consideration in all patients with unexplained thrombosis or cerebral infarction, particularly in young patients. Although hemophilia would also be associated with a prolonged aPTT, the PTT would normalize when the patient’s serum was mixed with normal plasma. Neurosyphilis is excluded by the negative serum FTAABS result. Thrombotic thrombocytopenic purpura is not associated with prolongation of the aPTT and is associated with a hemolytic anemia. Although protein C deficiency is a hypercoagulable state that can lead to stroke, none of the laboratory abnormalities suggests this diagnosis.

Answer 512

A features of benign nodules: diameter * think of benign as s's: 5, smooth, solid, concentric calcifications, slow Features of malignant nodules: diameter \>10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year

Answer 513

D ## Footnote The most common presenting symptom of Hodgkin lymphoma is **painless lymphadenopathy**. Approximately one-third of patients with Hodgkin lymphoma present with **unexplained fever, night sweats, and recent weight loss**, collectively known as “B symptoms.” Other common symptoms include **cough, chest pain, dyspnea, and superior vena cava obstruction caused by adenopathy in the chest and mediastinum.**

Answer 514

D **Hypersensitivity pneumonitis** can present in acute, subacute, or chronic forms. * **Acute hypersensitivity pneumonitis -** symptoms resolve over several days, but will suddenly and violently recur with repeated exposure to the offending antigen. * **Subacute -** begins gradually over weeks or months, causing a cough and increasing SOB. * **Chronic -** develops over years of exposure, causing fibrotic changes to the lungs that will be evident on radiographs, as well as chronic crackles on auscultation. The case described includes two episodes of the acute form. The patient was exposed to mold antigens in his flooded home. Within 4-8 hours of exposure, chills, cough, and shortness of breath will be noted, and at times will be dramatic. A chest film can be normal, even with significant hypoxia. **PFTs show _restrictive_ changes**, compared obstructive changes in acute asthma. Blood tests often show an elevated erythrocyte sedimentation rate. Serum IgG tests for the probable antigen confirm the diagnosis. Asthma would be an unlikely diagnosis in this case, with the pulmonary function tests showing restrictive changes rather than obstructive changes, and little improvement with albuterol. Also, the lack of a previous history of asthma makes it less likely. Legionnaires’ disease is always possible, but is unlikely in this case given the sudden onset, quick recovery over several days, and sudden recurrence. Pulmonary embolism is ruled out by the negative D-dimer test.

Answer 515

C SSRIs such as fluoxetine and fluvoxamine are FDA-approved and considered first-line agents in the treatment of OCD

Answer 516

E ## Footnote Long-standing ulcerative colitis (UC) is associated with an increased risk of colon cancer. The greater the duration and anatomic extent of involvement, the greater the risk. Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission. All of the other options listed are features typically associated with Crohn’s disease. Virtually all patients with UC have rectal involvement, even if that is the only area affected. In Crohn’s disease, rectal involvement is variable. Noncontinuous and transmural inflammation are also more common with Crohn’s disease. Transmural inflammation can lead to eventual fistula formation, which is not seen in UC.

Answer 517

A ## Footnote The American College of Rheumatology recommends that patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day), or an equivalent, receive bisphosphonates in addition to calcium and vitamin D supplementation, regardless of their DEXA-scan T score. The other treatments are not recommended for prevention of glucocorticoid-induced osteoporosis.

Answer 518

B For the average adult over the age of 60, the normal time required for the Timed Up and Go test is 10 seconds. A time longer than 10 seconds may indicate weakness, a balance or gait problem, and/or an increased fall risk.

Answer 519

A **Rigidity, sialorrhea, and stooped posture** are parkinsonian ADRS of neuroleptic drugs. These are treated with anticholinergic drugs such as benztropine or amantadine. **Dystonia** also responds to anticholinergics. **Akathisia** (motor restlessness and an inability to sit still) can be treated with either anticholinergic drugs or beta-blockers.

Answer 520

A ## Footnote Occupational asthma is often preceded by the development of rhinitis in the workplace and should be considered in patients whose symptoms improve away from work. Reversibility with β-agonist use makes COPD less likely, in addition to the fact that the patient is a nonsmoker. CF is not a likely diagnosis in a patient this age with a long history of being asymptomatic. Sarcoidosis would be less likely to cause reversible airway obstruction and intermittent symptoms. Vocal cord dysfunction would not be expected to respond to bronchodilators.

Answer 521

D ## Footnote This patient has **severe hyponatremia** manifested by confusion and seizures, a life-threatening situation warranting **urgent treatment with hypertonic (3%) saline**. The serum sodium level should be **raised by only 1–2 mmol/L per hour,** to prevent serious neurologic complications. Saline should be used only until the seizures stop. Some authorities recommend concomitant use of furosemide, especially in patients who are likely to be volume overloaded, as this patient is, but *it should not be used alone.* The arginine vasopressin antagonist conivaptan is approved for the treatment of euvolemic or hypervolemic hyponatremia, but not in patients who are obtunded or in a coma, or who are having seizures.

Answer 522

E ## Footnote **Reflex syncope** is a strong diagnostic consideration for episodes of syncope associated with a characteristic precipitating factor (in this case, the half-time show). The 3 major categories of syncope include carotid sinus hypersensitivity, neurally mediated, and situational syncopes. The most common and benign forms of syncope are **neurally mediated** **syncope aka** **vasovagal syncope** with sudden hypotension, frequently accompanied by bradycardia. Most patients are young and otherwise healthy. **The mechanism of the syncope seems to be a period of high sympathetic tone (often induced by pain or fear), followed by sudden sympathetic withdrawal, which then triggers a paradoxical vasodilatation and hypotension. Attacks occur with upright posture, often accompanied by a feeling of warmth or cold sweating, lightheadedness, yawning, or dimming of vision. If the patient does not lie down quickly he or she will fall, with the horizontal position allowing a rapid restoration of central profusion.** Recovery is rapid, with no focal neurologic sense of confusion or headache. The **event can be duplicated with tilt table testing, demonstrating hypotension and bradycardia.**

Answer 523

C ## Footnote Avascular necrosis is the most serious complication of a slipped capital femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and total hip replacement early in adulthood.

Answer 524

E ## Footnote This patient presents with a classic description of supraventricular tachycardia (SVT). The initial management of SVT centers around stopping the aberrant rhythm. In the hemodynamically stable patient initial measures should include **vagal maneuvers, IV adenosine or verapamil, IV diltiazem or β-blockers, IV antiarrhythmics, or cardioversion in refractory cases**. While digoxin is occasionally useful in atrial fibrillation with a rapid ventricular rate, it is not recommended for SVT. **Radiofrequency ablation is fast becoming the first-line therapy for all patients with recurrent SVT and SVT that is refractory to suppressive drug therapies.**

Answer 525

C ## Footnote If a person is Rh(-), they do not have type D antigen on their RBCs. If a woman is exposed to D antigen (+) RBCs, she can have an immune response of variable strength. **If a maternal antibody screen for D antigen is (+), this indicates that the current fetus MAY be at risk for hemolytic disease.** The level of risk is determined by the antibody titer. For example, an antibody titer of 1:4 poses much less risk to the fetus than a titer of 1:64. Determination of the blood type of the father is helpful if paternity is certain. **If the father is homozygous Rh (-), there is no risk of alloimmunization to the fetus and the fetus is NOT at risk for hemolytic disease**. In this scenario, maternal sensitization occurred either from a prior pregnancy with a different partner or from another source (e.g., transfusion). **If the father is heterozygous or homozygous Rh positive, then the fetus IS at risk.** If paternity is uncertain, PCR can be performed on 2 mL of amniotic fluid or 5 mL of chorionic villi to accurately determine the fetal Rh status.

Answer 526

B ## Footnote The most reliable predictor of survival in breast cancer is the **stage at the time of diagnosis**, as **tumor size + lymph node involvement** are the main factors to take into account. Other prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been proposed as important variables, but most microscopic findings other than lymph node involvement correlate poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to be less aggressive than ER-negative tumors.

Answer 527

B ## Footnote Some patients with significant vitamin B12 deficiency have levels in the lower range of normal, as this patient does. Vitamin B12 is a cofactor in the synthesis of both methionine and succinyl coenzyme A, and **vitamin B12 deficiency leads to the accumulation of methylmalonic acid and homocysteine**, which are the precursors of these compounds. An elevated level of these substances is therefore more sensitive than a low vitamin B12 level for vitamin B12 deficiency. Homocysteine is also elevated in folic acid deficiency, however, so a methylmalonic acid level is recommended if vitamin B12 deficiency is a concern and serum vitamin B12 levels are 150–400 pg/mL. A reduced haptoglobin level is useful to confirm hemolytic anemia. An elevated free erythrocyte protoporphyrin level may occur in lead poisoning or iron deficiency. An elevated angiotensin converting enzyme level is found in sarcoidosis.

Answer 528

C ## Footnote This is a **classic** **incidentaloma**. Nodules are detected in up to 50% of thyroid sonograms and carry a low risk of malignancy (If the TSH level is normal, nuclear scanning and further thyroid studies are not necessary. Nodules smaller than 1 cm are difficult to biopsy and thyroid surgery is not indicated for what is almost certainly benign disease. It is reasonable to follow small nodules with clinical examinations and periodic sonograms.

Answer 529

B ## Footnote This patient most likely has Clostridium difficile colitis, suggested by semiformed rather than watery stool, fecal leukocytes (not seen in viral gastroenteritis or sprue), and a hospital stay greater than 2 weeks. **While this disease has traditionally been associated with antibiotic use, it is posing an increasing threat to patients in hospitals and chronic-care facilities who have not been given antibiotics.** The primary sources for infection in such cases have been toilets, bedpans, floors, and the hands of hospital personnel. Prompt recognition and treatment is essential to prevent patient relapse and to minimize intramural epidemics. The diarrhea of ulcerative colitis usually contains blood and occurs intermittently over a protracted course. Digoxin toxicity is likely to be accompanied by electrocardiographic and laboratory abnormalities, particularly hyper- or hypokalemia.

Answer 530

B ## Footnote The conditions listed are all causes of seizures. Of course, there are many other causes of seizures in the elderly, including primary and metastatic neoplasias (e.g., electrolyte disorders). However, in the geriatric population, cerebrovascular disease is the most common cause of seizures, with about 10% of stroke victims developing epileptic seizures. Seizures are more common following hemorrhagic strokes compared to nonhemorrhagic strokes.

Answer 531

C ## Footnote There is not a direct relation between daily calorie consumption and weight. An adult male consuming an extra 100 calories a day above his caloric need will not continue to gain weight indefinitely; rather, his weight will increase to a certain point and then become constant. Fat must be fed, and maintaining the newly created tissue requires an increase in caloric expenditure. An extra 100 calories a day will result in a weight gain of approximately 5 kg, which will then be maintained.

Answer 532

A This child had transient tachypnea of the newborn, the most common cause of neonatal respiratory distress. It is a benign condition due to residual pulmonary fluid remaining in the lungs after delivery. Risk factors include cesarean delivery (no vaginal squeeze to eliminate the lung fluid), macrosomia (increased likelihood of C-sections), male gender, and maternal asthma and/or diabetes mellitus.

Answer 533

D ## Footnote When draining a felon, a volar longitudinal incision or a high lateral incision is recommended. Incisions that are not recommended are the “fish-mouth” incision, the “hockey stick” (or “J”) incision, and the transverse palmar incision

Answer 534

E DMARDs such as methotrexate are the best initial therapy for RA. Aspirin and NSAIDs are no longer considered first-line treatment because of concerns about their limited effectiveness, inability to modify the long-term course of the disease, and gastrointestinal and cardiotoxic effects.

Answer 535

C ## Footnote Escherichia coli O:157 can cause serious GI illness; source is undercooked beef. Transmission is frequent, esp in children’s day-care facilities / nurseries. Patients present with bloody diarrhea. This patient has a 10%–15% risk of developing **hemolytic uremic syndrome** secondary to her E. coli O:157 infection, making close **monitoring of renal function** essential.

Answer 536

A When possible, it is important for the family physician to base clinical decisions on the best evidence. Strength-of-Recommendation Taxonomy (SORT) grades in medical literature are intended to help physicians practice evidence-based medicine. SORT grades are only A, B, and C. * SOR A - recommendation based on consistent, good-quality, patient-oriented evidence. * SOR B - recommendation based on limited-quality patient-oriented evidence. * SOR C - recommendation based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening. These should not be confused with the U.S. FDA labeling categories for the potential teratogenic effects of medications on a fetus: pregnancy categories A, B, C, D, and X.

Answer 537

A This patient has a microcytic, hypochromic anemia, which can be caused by iron deficiency, thalassemia, sideroblastic anemia, and lead poisoning. In a child with a microcytic anemia who does not respond to iron therapy, hemoglobin electrophoresis is appropriate to diagnose thalassemia. Hypothyroidism, vitamin B12 deficiency, and folate deficiency result in macrocytic anemias.

Answer 538

D ## Footnote In the US, deaths from pertussis increased from 4 deaths in 1996 to 17 deaths in 2001, and a total of 56 deaths from 2001 to 2003. Immunity has decreased in previously vaccinated adolescents and adults, and now they are a reservoir for infection. Tdap vaccine is recommended as a single booster for patients age 19–65, and those between the ages of 11 and 18 years should receive Tdap rather than a Td booster. The Tdap vaccine protects against pertussis, in addition to tetanus and diphtheria. Tetanus and rubella deaths are not increasing. There are no vaccines for hepatitis C or West Nile virus.

Answer 539

B ## Footnote In general, it is best to place a woman who is **\> 20 weeks pregnant** in the **left lateral decubitus position** because the uterus can compress the great vessels, resulting in decreased SBP and uterine blood flow. However, in the case of trauma where a spinal cord injury cannot be ruled out, the woman needs to be kept supine on a backboard. The **weight of the uterus can be shifted off the great vessels by either manual deflection laterally or by elevating the right hip 4–6 inches by placing towels under the backboard.** The Trendelenburg position does not relieve the weight of the uterus on the great vessels. The prone position does not provide adequate spinal cord protection, and would be extremely awkward in a large pregnant woman.

Answer 540

E ## Footnote To be eligible for Medicare hospice benefits, a patient must be eligible for Medicare Part **A** (hospital insurance). Although most hospice referrals come from physicians, nurses, and social workers, a patient’s family members can also make a hospice referral. The patient must sign a statement choosing hospice, and both the patient’s physician and the hospice medical director must certify that the patient has a terminal illness with an estimated life expectancy of less than 6 months. There is no requirement that the patient be debilitated or moribund.

Answer 541

A ## Footnote Maximal HR with exercise generally decreases with age. A frequently used formula for predicting maximal HR = (220 - age) x (0.85 if female) Myocardial collagen and mass both increase with age. The increase in collagen may play a role in decreasing left ventricular compliance. The resting heart rate, like the maximal exercising heart rate, decreases with normal aging. Tachycardia at rest may suggest a pathologic state.

Answer 542

E Community-acquired pneumonia in children \> 5 yo is commonly due to **Mycoplasma pneumo,** **Chlamydophila pneumo**, and **Strep pneumo**. Less common bacterial infections include **H. influenzae, Staph aureus**, and **group A Strep**. Initial treatment with antibiotics is empiric, as the pathogen is usually unknown at the time of diagnosis. The choice in children is based on age, severity of illness, and local patterns of resistance. Children age 5–16 years who can be treated as outpatients are usually treated with **oral azithromycin**. For patients requiring inpatient management, **IV cefuroxime PLUS** **IV erythromycin or azithromycin** is recommended

Answer 543

A ## Footnote Vasomotor symptoms slowly increase until perimenopause, at which time they peak. The symptoms then tend to diminish after menopause. Numerous other pathologic and functional vasomotor etiologies may mimic hot flashes. Estrogen is effective in treating hot flashes but generally should not be given alone, as it increases the risk for endometrial cancer.

Answer 544

B Rifaximin, a nonabsorbable antibiotic, has been shown to reduce the risk for traveler’s diarrhea by 77%.

Answer 545

C ## Footnote Patients with renal failure often have normal vitamin B12 levels despite an actual deficiency. In this situation, the clinician can order a methylmalonic acid (MMA) level to confirm the diagnosis. Vitamin B12 is the necessary coenzyme in the metabolism of MMA to succinyl-CoA. Thus, in the absence of vitamin B12, MMA levels increase. Additionally, homocysteine levels would be elevated in the presence of vitamin B12 deficiency

Answer 546

C ## Footnote Treatment of **cocaine-associated chest pain** is similar to that of acute coronary syndrome, unstable angina, or acute MI, but there are exceptions. **The hypertension, tachycardia, and chest pain will often respond to _IV benzodiazepines_ as early management**. While β-blockers are recommended for acute MI, they *can exacerbate coronary artery spasm in cocaine-associated chest pain*. Fibrinolytic therapy should be given only to patients who clearly have an STEMI and cannot receive immediate direct PCI. Calcium channel blocker use in the setting of cocaine-induced ischemia has not been studied, but may be considered if there is no response to benzodiazepines and NTG. There are no recommendations regarding the use of ACEi, but these agents would not address the tachycardia.

Answer 547

D ## Footnote Uric acid, cystine, and calcium oxalate stones tend to form in acidic urine, whereas struvite (magnesium ammonium phosphate) and calcium phosphate stones form in alkaline urine. Urine should be acidified for prevention of calcium phosphate and struvite stones. Cranberry juice or betaine can lower urine pH. Acidic = Uric, Cystine, Oxalate -\> treat with base Basic = mag ammonium phosphate, calcium phosphate (phosphate) -\> treat with acid

Answer 548

D Dehydroepiandrosterone (DHEA) is illegal under the Anabolic Steroid Control Act of 2004, and is prohibited by the NCAA and the International Olympic Committee. Like androstenedione, DHEA is a precursor to testosterone, but neither of these substances has been shown to enhance either performance or strength. In fact, they **increase serum estrogen and LH levels**.

Answer 549

C ## Footnote In the xray shown, there is a fracture of the fifth metacarpal head, commonly known as a boxer’s fracture. There is only slight volar angulation and no displacement. The proper treatment for this fracture is an **ulnar gutter splint**, which immobilizes the wrist, hand, and fourth and fifth digits in the neutral position. Generally, 3 or 4 weeks of continuous splinting is adequate for healing. Surgical pinning is indicated in cases of significant angulation (35°–40° or more of volar angulation) or in fractures with significant rotational deformity or displacement. The other options listed are not appropriate treatments for this injury. This injury most commonly results from “man-versus-wall” pugilistics, but other mechanisms of injury are possible.

Answer 550

A ## Footnote Aspirin is the only drug that interferes with platelet aggregation for the life of the platelet. It does this by **permanently acetylating cyclooxygenase, thus inhibiting prostaglandin synthesis.** This phenomenon is clinically helpful when an antithrombotic effect is desired, but it may **require that surgical procedures be delayed, as** **the effect of a single aspirin on bleeding times can persist for up to 5 days.** Other **_NSAIDs_** (i.e., indomethacin, sulfinpyrazone) also inhibit platelet activity, but their effect on prostaglandin synthesis is **_reversible_**. The anti-platelet effect of dipyridamole is less well understood. Warfarin is a biochemical antagonist of prothrombin and vitamin K-dependent coagulation factors, and therefore has no significant effect on platelet activity.

Answer 551

E ## Footnote Surgical procedures associated with a **_high (\>5%) risk_** of perioperative myocardial ischemia include **vascular surgery and emergent major operations**, especially in patients over 75 years of age. Head/neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery carry an **_intermediate risk (1%–5%)_** Endoscopic procedures and cataract and breast surgeries are considered low-risk (

Answer 552

C ## Footnote The patient exhibits signs of a moderate bleeding diathesis. Her **PT elevation**, without evidence of hepatocellular damage or hepatic dysfunction, is highly suspicious for **warfarin ingestion**. The normalization of the PT under observation in a hospital setting is consistent with this suspicion. Although accidental poisoning is a possibility, the mother’s affect is highly suspicious for Munchausen syndrome by proxy. The fact that her mother is a health-care worker and develops a close and appropriate relationship with the health-care team is consistent with this diagnosis. Acetaminophen toxicity of this degree would likely produce transaminase and bilirubin elevations, as well as mental status changes. Antiphospholipid syndrome produces a hypercoagulable state. Henoch-Schonlein purpura presents with purpura, joint pain, abdominal pain, and a normal PT. Traumatic injury would not result in PT elevations.

Answer 553

C These findings are consistent with alopecia areata, which is thought to be caused by a localized autoimmune reaction to hair follicles. It occasionally spreads to involve the entire scalp (alopecia totalis) or the entire body (alopecia universalis). Spontaneous recovery usually occurs within 6–12 months. The initial treatment of choice for patients \> 10 yo, in cases where alopecia areata affects less than 50% of the scalp, is **intralesional corticosteroid injections**. Minoxidil is an alternative for children

Answer 554

C ## Footnote Bedbug bites are difficult to diagnose due to the variability in bite response between people and the changes in a given individual’s skin reaction over time. It is best to collect and identify bedbugs to confirm bites. Cimex lectularius injects saliva into the bloodstream of the host to prevent coagulation. It is this saliva that causes the intense itching and welts.

Answer 555

A Two of the most important ethical principles in medicine are respect for autonomy and beneficence. * **Respect for autonomy** means regarding patients as rightfully self-governing in matters of choice and action. To make an autonomous decision, the patient must be *mentally sound, have knowledge and understanding of the facts, and be free of coercion.* * **Beneficence** means that physicians are motivated solely by what is good for the patient. There are often ethical conflicts between these two principles. This particular patient is clearly in need of further emergency treatment, but he refuses. He has had a significant head injury, is combative and possibly intoxicated, and therefore **is not considered mentally sound**. The physician should detain him for his own good and provide the appropriate care. Threatening the patient, having him sign out against medical advice, or encouraging him to return later is not appropriate because his mentation is impaired.

Answer 556

E ## Footnote Many medications require dosage adjustments in patients with chronic kidney disease. **Medications are adjusted based on the estimated GFR or creatinine clearance.** Most medication adjustments require a reduction in the dose, lengthening of the dosing interval, or both. Medication adjustments are divided into three groups, based on whether the GFR is **\>50** mL/min/1.73m2, **10-50** mL/min/1.73m2, or **mL/min/1.73m2.** Loading doses of medications usually do not need to be adjusted. The production and excretion of creatinine decreases in older patients, so a normal serum creatinine level does not always correlate with normal kidney function. Serum drug levels typically are not required for adjusting medications in patients with chronic kidney disease.

Answer 557

E ## Footnote Emerging data on low-carbohydrate diets is mostly encouraging, in that these diets do not seem to cause the expected increases in BP, LDL-cholesterol levels, or TG levels that the medical community had first assumed. Although low-carbohydrate diets have been shown to result in clinically meaningful weight loss, reduced-calorie diets appear to result in similar weight loss regardless of which macronutrients they emphasize. This patient has symptoms of metabolic syndrome and has a higher risk of glucose intolerance or diabetes mellitus. Low-carbohydrate diets have been shown to reduce insulin resistance at least as well as, if not better than, traditional diet plans.

Answer 558

B ## Footnote Regional analgesia in laboring patients increases the risk of vacuum-or forceps-assisted delivery (relative risk = 1.42; 95% confidence interval, 1.28–1.57; 23 trials; n = 735)

Answer 559

C ## Footnote A meta-analysis of six well controlled clinical trials of **aspirin prophylaxis showed a 32% decrease in _MIs in men and 24% decrease in ischemic stroke in women_** There was no decrease in cardiovascular mortality or all-cause mortality in either sex, and there was a trend toward increased risk of stroke, primarily hemorrhagic stroke. **The risk of major bleeding disorders was around 76% higher in aspirin users.** The analysis suggests that aspirin may do more harm than good in healthy persons without cardiovascular risk factors.

Answer 560

C **IGRA** is an **objective** test for screening latent TB infection. It targets **antigens specific to M. tuberculosis;** these proteins are *absent* from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. IGRAs are labor intensive, however, and the blood sample must be received by a qualified laboratory and incubated with the test antigens within 8-16 hours of the time it was drawn,depending upon the brand of cuurently available IGRAs

Answer 561

B ## Footnote Metformin is a biguanide used as an oral antidiabetic agent. One of its main advantages over some other oral agents is that it does not cause hypoglycemia. Side effects include: **lactic acidosis**, esp in patients with renal impairment, and **GI distress**, particularly early in therapy. In contrast to most other agents for the control of elevated glucose, which often cause weight gain, metformin reduces insulin levels and more frequently has a weight-maintaining or even a weight loss effect.

Answer 562

D ## Footnote Prostate-specific antigen (PSA) is a marker that is used to screen for prostate cancer. Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor CA-125 is a marker for ovarian cancer. A Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4–6 weeks after successful surgical resection. Cancer antigen 27.29 (CA 27-29) is a tumor marker for breast cancer. Some tumor markers, such as CEA, alpha-fetoprotein, and CA-125, may be more helpful in monitoring response to therapy than in detecting the primary tumor.

Answer 563

B Although malignant melanoma is the most serious condition of those listed, actinic keratosis may lead to squamous cell carcinoma with significant morbidity.

Answer 564

B This patient is suffering from severe COPD (stage III) and has a history of frequent exacerbations. The addition of a corticosteroid inhaler for patients with severe disease has been found to significantly **decrease the number of exacerbations, but has no effect on overall mortality.** Side effects of oral candidiasis and easy bruising of the skin are increased. Continuous oxygen has been shown to improve overall mortality and endurance in patients with an oxygen saturation of 88% or less, but has not been shown to improve quality of life in those with mild hypoxemia or if used only at night. Oral prednisone has been shown to be effective when used to treat acute exacerbations, but when used on a chronic basis it is no more effective than corticosteroid inhalers. Chronic oral prednisone is also associated with significant side effects, and therefore is not generally recommended. Oral theophylline has not been shown to be of benefit in either preventing exacerbations or improving quality of life, and has significant side effects of gastrointestinal toxicity, seizures, and arrhythmias. It should be reserved for carefully selected patients only.

Answer 565

A The diaphragm is an effective method of contraception if used correctly. A weight change of more than 15 lb, pregnancy, or pelvic surgery may necessitate refitting. If used with nonoxynol-9, a diaphragm may actually increase the risk of HIV transmission. Diaphragms are made of latex, but a wide seal rim model made of silicone is available for those who are latex sensitive. Diaphragm use is contraindicated in women with a history of toxic shock syndrome. The diaphragm should remain in place for 6–24 hours after intercourse.

Answer 566

E ## Footnote Verapamil, due to its negative inotropic effect, is associated with worsening heart failure and an increased risk of adverse cardiovascular events.

Answer 567

E Among the oral antiglycemic drugs, the sulfonylurea agents are the most likely to cause hypoglycemia, with glyburide \>\> glipizide. Glyburide should rarely be used in the elderly!

Answer 568

A CHADS₂ score: CHF, HTN, Age \>75, DM, and previous Stroke/TIA. Each of these is worth 1 point except for stroke worth 2 points. _\>_ 4 points = high risk; 2-3 points = moderate risk, ≤1 point = low risk, and this patient has 0 points. Low-risk patients should be treated with aspirin, 81–325 mg daily. Moderate-or high-risk patients should be treated with warfarin. Amiodarone is used for rate control, and clopidogrel is used for vascular events not related to atrial fibrillation.

Answer 569

D ## Footnote Torsades de pointes - wide QRS complexes with apices that are sometimes positive and sometimes negative; generally associated with QT prolongation. Anything that produces or is associated with a prolonged QT interval can cause torsades de pointes, including drugs (quinidine, procainamide, disopyramide, phenothiazines), electrolyte disturbances, insecticide poisoning, subarachnoid hemorrhage, and congenital QT prolongation. The the usual anti-arrhythmic drugs are not only useless but contraindicated, because they can make matters worse.

Answer 570

D ## Footnote Patients with **hyperplastic** polyps are considered to have normal colonoscopy findings and can be followed up in 10 years, unless they have hyperplastic polyposis syndrome. Patients with **1-2 small adenomas** ( Patients with **\>3 small adenomas**, or **one adenoma \>1 cm** should be followed up in 3 years if the adenomas are completely removed. Patients who have had a **sessile adenoma** removed piecemeal should have repeat colonoscopy in 2–6 months to make sure that the polyp has been completely removed. Other factors that influence the screening interval include the quality of the preparation and the ability of the physician to see the entire colon. Although this patient had three hyperplastic polyps removed, he is at low risk for colon cancer and should have repeat screening at the normal 10-year interval.

Answer 571

D ## Footnote MG is an autoimmune neuromuscular disease characterized by varying degrees of skeletal muscle weakness. Symptoms, which vary in type and severity, may include **ptosis** of one or both eyelids; **blurred vision**; **diplopia**; **unstable gait**; **weakness** in the arms, hands, fingers, legs, and neck; **difficulty swallowing**; **SOB**; and **impaired speech (dysarthria)**. In most cases, the first noticeable symptom is weakness of the eye muscles. Muscles that control respiration and neck and limb movements may also be affected. **Symptoms typically worsen through the day** or as the muscles are repetitively used, and improve with rest. Fibromyalgia does not produce objective neurologic findings, and Sheehan's syndrome would not cause a localized neurologic deficit. In addition, the TSH level would be low or zero, and the MRI of the brain would be abnormal. An MRI of the brain would also be abnormal if stroke symptoms had been present for 2 weeks. The patient is unlikely to have unilateral symptoms with polymyositis, and creatine kinase would be elevated.

Answer 572

D ## Footnote Pentoxifylline is a competitive non-selective phosphodiesterase inhibitor and works by improving RBC deformability (known as a haemorrheologic effect), reduces blood viscosity and decreases the potential for platelet aggregation and thrombus formation. It's primary use is to treat **intermittent claudication** resulting from peripheral artery disease. Pentoxifylline is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy in patients unable to tolerate compression therapy. Aspirin has also been shown to be effective.

Answer 573

B ## Footnote Quadriceps tendon rupture can be partial or complete. When complete, as in this case, the patient has no ability to straighten the leg actively. A similar pattern is seen with patellar tendon rupture, but in this situation the patella is retracted superiorly by the quadriceps.

Answer 574

D ## Footnote This patient most likely is **malingering**, which is to purposefully feign physical symptoms for external gain. Factitious disorder involves adopting physical symptoms for unconscious internal gain, such as deriving comfort from taking on the role of being sick. Somatization disorder is related to numerous unexplained physical symptoms that last for several years and typically begin before 30 years of age. Conversion disorder involves a single voluntary motor or sensory dysfunction suggestive of a neurologic condition, but not conforming to any known anatomic pathways or physiologic mechanisms.

Answer 575

E ## Footnote BV is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora. BV is considerably more common as a cause of vaginal discharge than C. albicans and T. vaginalis.

Answer 576

C Pulmonary AVMs are found in 15%–30% of patients with hereditary hemorrhagic telangiectasia (HHT) aka Osler-Weber-Rendu syndrome. **All patients with possible or confirmed HHT should be screened for pulmonary AVMs with contrast echocardiography**. While contrast echocardiography is used to detect ASD and VSD, neither of these conditions is particularly prevalent in HHT. Aortic aneurysms and myocardial perfusion defects are also not associated with HHT.

Answer 577

B ## Footnote Chlamydial pneumonia - usually seen in infants 3-16 weeks of age, and they frequently have been sick for several weeks. The infant appears **nontoxic, afebrile,** but is **tachypneic** with a prominent **cough**. Physical examination reveals **diffuse rales with few wheezes**. **Conjunctivitis** is present in about 50% of cases. The chest film shows **hyperinflation and diffuse interstitial or patchy infiltrates.**

Answer 578

A Certain classes of medications are frequently associated with falls in older adults. These classes include **benzodiazepines, antidepressants, antipsychotics, antiepileptics, anticholinergics, sedative hypnotics, muscle relaxants, and cardiovascular medications. Diphenhydramine** is an anticholinergic medications associated with falls in older adults. The other drugs listed are not in the higher-risk groups of medications.

Answer 579

E Empiric coverage for MRSA and double coverage for pseudomonal pneumonia should be prescribed in patients with nursing home–acquired pneumonia requiring intensive-care unit admission

Answer 580

B ## Footnote 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.

Answer 581

A ## Footnote Most tinea infections respond to topical therapy, but oral therapy is required for tinea capitis so that the drug will penetrate the hair shafts. Tinea corporis may require oral therapy in severe cases, but usually responds to topical therapy. Oral therapy has a higher likelihood of side effects. Erythrasma and mycosis fungoides are not fungal diseases.

Answer 582

D ## Footnote Heroin overdose is manifested by CNS depression and hypoventilation. Clinical clues include pupillary miosis and a decreasing respiratory rate in the presence of a semi-wakeful state. In addition to hypoventilation, a multifactorial acute lung injury occurs within 2–4 hours of the overdose resulting in noncardiogenic pulmonary edema. Findings include **hypoxia, crackles on lung auscultation, and pink, frothy sputum**. Treatment must include respiratory support with intubation, mechanical ventilation, and oxygen, as well as opiate reversal with naloxone

Answer 583

B ## Footnote Marfan's syndrome - AD. **Men \>72 in**, **women \>70** in who have two or more **skeletal, ophthalmologic,** or **cardiovascular** abnormalities should be screened by ECHO for associated cardiac abnormalities. Any of these athletes who have a family history of Marfan's syndrome should be screened, whether they have manifestations themselves or not. If there is no family history, echocardiography should be performed if two or more of the following are present: cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 standard deviation below the mean, myopia, or an ectopic lens. Patients with Marfan's syndrome who have ECHO evidence of aortic abnormalities should be placed on **ß-blockers** and **monitored with ECHO Q6M**

Answer 584

D Three trials have shown that neuromuscular training with plyometrics and strengthening reduces anterior cruciate ligament (ACL) tears. Females have a higher rate of ACL tears than males. Early-onset OA occurs in the affected knee in an ~50% of patients with ACL tears. The ACL typically pops audibly when it is torn, usually with no physical contact.

Answer 585

E ## Footnote For patients in a surgical ICU, using an insulin drip to maintain tight glucose control decreases the risk of sepsis but has no mortality benefit. Metformin should be stopped if the serum creatinine level is ≥1.5 mg/dL in men or ≥1.4 mg/dL in women, or if an imaging procedure requiring contrast is needed. I n patients who have not had their hemoglobin A 1c measured in the past 30 days, this could be done to provide a better indication of glucose control. If adequate control has been demonstrated and no contraindications are noted, the patient’s usual medication regimen should be continued

Answer 586

C ## Footnote Chronic paronychia (\> 6 weeks) is often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking. Findings on examination are similar to those of acute paronychia, with tenderness, erythema, swelling, and retraction of the proximal nail fold. Often the adjacent cuticle is absent. In addition to medication, basic treatment principles for the condition include avoidance of contact irritants, avoiding immersion of the hands in water, and use of an emollient. Topical corticosteroids have higher efficacy for treating chronic paronychia compared to oral antifungals

Answer 587

C Treatments likely to be beneficial for essential tremor of the hands include **propranolol** and **topiramate**. Topiramate has been shown to improve tremor scores after 2 weeks of treatment, but is associated with appetite suppression, weight loss, and paresthesias. Medications with unknown effectiveness include benzodiazepines, ß-blockers other than propranolol, calcium channel blockers, clonidine, gabapentin, and isoniazid.

Answer 588

A ## Footnote Extracorporeal shock wave therapy is effective for calcific tendinitis of the rotator cuff. Side effects include bruising and pain. Needling and irrigation, physical therapy, and cortisone injections are sometimes used in patients with acute symptoms. Endoscopic and open surgical treatments are alternatives to extracorporeal shock wave therapy in refractory cases. Extracorporeal shock wave therapy does not have an established role in gout, rotator cuff tear, frozen shoulder, or hooked acromion.

Answer 589

A **IV Insulin + glucose** will provide the fastest and most consistent early lowering of serum potassium. Calcium is important for arrhythmia prevention, but does not lower the potassium level. Sodium polystyrene sulfonate given orally or rectally will only lower potassium in a delayed fashion.

Answer 590

B ## Footnote Workers and children at child care centers should receive postexposure prophylaxis if one or more cases of hepatitis A is found in a child or worker. Hepatitis A vaccine is preferred over immunoglobulin because of its long-lasting effect, ease of administration, and efficacy. Children younger than 1 year of age should receive immunoglobulin. Family members should receive prophylaxis only during an outbreak and if their child is still in diapers.

Answer 591

E ## Footnote Late decelerations are thought to be associated with **uteroplacental insufficiency** and **fetal hypoxia** due to **decreased blood flow in the placenta**. This pattern is a warning sign and is **associated with increasing fetal compromise, worsening fetal acidosis, fetal CNS depression, and/or myocardial hypoxia**. Early decelerations are thought to result from vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity. Variable decelerations are thought to be due to acute, intermittent compression of the umbilical cord between fetal parts and the contracting uterus.

Answer 592

B ## Footnote An enlarged tongue (macroglossia) may be found in developmental conditions (Down syndrome), caused by a tumor (hemangioma or lymphangioma), metabolic diseases (primary amyloidosis), or endocrine disturbances (acromegaly or cretinism). A “bald” tongue may be associated with xerostomia, pernicious anemia, iron deficiency anemia, pellagra, or syphilis.

Answer 593

D Contraindications to treatment with electrosurgery include the use of a pacemaker and the treatment of melanoma. All the other lesions listed can be treated with electrosurgery.

Answer 594

A ## Footnote Patients who present with **acute cervical radiculopathy** and normal radiographs can be treated conservatively with NSAIDs. The vast majority of patients with cervical radiculopathy improve without surgery. Tricyclic antidepressants, as well as tramadol and venlafaxine, have been shown to help with chronic neuropathic pain. Cervical MRI is not indicated unless there are *progressive* neurologic defects or red flags such as fever or myelopathy. Likewise, referral to a subspecialist should be reserved for patients who have persistent pain after 6-8 weeks of conservative management and for those with signs of instability. Cervical corticosteroid injections have been found to be helpful in the management of cervical radiculopathy, but should _not_ be administered before MRI is performed

Answer 595

B Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia, Korea, China, and Vietnam. The belief is that one’s illness must be drawn out of the body, and the red marks produced by rubbing the skin with a coin are evidence of the body’s “release” of the illness. These marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the illness itself.

Answer 596

B This patient has a **Revised Cardiac Risk Index (Goldman Index) score of 1**, placing him in a low-risk group for perioperative cardiac complications. Low-risk patients who are able to walk for 2 blocks or climb a flight of stairs without stopping to rest (4 METS) * do not need noninvasive cardiac testing. * Patients in this risk group who are already on a β-blocker should continue it, but adding one preoperatively may increase risk. * Stopping aspirin therapy in patients with coronary stents places them at risk for perioperative cardiac events. Surgical bleeding is somewhat increased in patients on aspirin, but differences in the severity of bleeding events and mortality in surgical patients on low-dose aspirin versus controls are minimal. * Stopping clopidogrel in patients who have recently undergone coronary stent placement (6 weeks for bare-metal stents, 1 year for drug-eluting stents) markedly increases risk, but there is no need to start clopidogrel in other patients. Perioperative statin therapy should be continued for all patients undergoing surgery. For patients undergoing vascular therapy, statins have been associated with an improvement in postoperative cardiac outcomes.

Answer 597

D ## Footnote The synthesis of acute-phase proteins by hepatocytes is altered, leading to decreased serum levels of several of these proteins, including albumin and transferrin. Serum levels rise for other proteins, such as ceruloplasmin, complement proteins, haptoglobin, fibrinogen, and C-reactive protein. Serum levels of ferritin may be extremely high in certain conditions, but are also influenced by total-body iron stores.

Answer 598

C This patient has a H/P findings that are consistent with a rotator cuff tear. Most common mechanism of injury in an acute rotator cuff tear is forced abduction of the arm with significant resistance. Patients with a large tear cannot initiate shoulder abduction and will have a discrepancy between active and passive motion. Patients with significant tears will also have a positive drop arm test. This test is performed by passively abducting the arm to 90° and asking the patient to hold the arm in that position while the examiner applies pressure on the distal forearm or wrist. The test is positive if the pressure causes the arm to drop suddenly. * Acute tears are generally managed with a splint and orthopedic referral for surgical repair. Chronic tears may be managed with shoulder rehabilitation but may ultimately require surgical repair as well. * Bicipital tendinitis is caused irritation and microtrauma due to repetitive elevation or abduction of the shoulder, causing an inflammatory reaction in the synovial sheath. Patients generally present with a complaint of pain in the anterior shoulder that radiates into the upper arm. It is more painful with activity and is worse at night. Abduction and external rotation of the arm exacerbates the pain. On examination there should be point tenderness in the bicipital groove. Active ROM is limited by pain but passive ROM is intact. There should not be any weakness. * Acromioclavicular separation is usually caused by a fall or a direct blow to the point of the shoulder with the shoulder abducted. The pain associated with this injury is over the acromioclavicular joint margin and there may be swelling. Depending on the severity of the injury there may be full range of motion but it may be restricted due to pain. There should not be any weakness associated with this injury. * A fracture of the humeral head generally occurs with a fall on an outstretched arm or direct blow to the lateral side of the arm. Generally there is pain or bruising over the fracture site. Movement will be restricted by pain, but there should not be any weakness. * A tear of the labrum can occur with acute trauma or from repetitive shoulder motion. Acute trauma may occur from a dislocation of the shoulder, falling on an outstretched arm, or direct blows to the shoulder. Generally, people with a tear of the labrum will have increased pain with overhead activity, popping or grinding, loss of strength, and trouble locating a specific point of pain.

Answer 599

B ## Footnote This patient most likely has an anaerobic bacterial infection. Penicillin was used to treat these infections in the past, but because of the emergence of β-lactamase–producing organisms, clindamycin is now the drug of choice. **Clindamycin has broader coverage against both pulmonary anaerobes and facultative aerobes such as Staphylococcus aureus and Klebsiella, which are often seen with lung abscesses. Metronida**zole has anaerobic coverage, but not for the anaerobic species often involved in pulmonary infections, and is therefore associated with a high failure rate when used to treat lung abscesses. Doxycycline does not cover anaerobes. Trimethoprim/sulfamethoxazole is also not considered a good anaerobic antibiotic.

Answer 600

A ## Footnote Since this patient’s mean aortic-valve gradient is **\> 50 mm Hg** and the aortic-valve area is Medical management is not effective, and *balloon valvotomy only temporarily relieves the symptoms and does not prolong survival*. Patients who present with dyspnea have only a 50% chance of being alive in 2 years unless the valve is promptly replaced. Exercise testing is unwarranted and dangerous in patients with symptomatic aortic stenosis.

Answer 601

E Sporulating organisms such as Clostridium difficile are not killed by alcohol products. Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae are killed by alcohol products.

Answer 602

E Risk factors for thromboembolism: polycythemia vera, oral contraceptives, obesity, advanced age, and spinal cord injury. Spinal cord injury induces immobility, as do obesity and advanced age. Oral contraceptives make blood more coagulable, particularly in patients with clotting factor abnormalities such as factor V Leiden. Polycythemia vera increases sludging of blood cells and increases the risk of forming clots. Clot risk is not increased by oral hypoglycemic agents, low BMI, youth, or anemia.

Answer 603

E ## Footnote This patient is already receiving maximal medical therapy. Optimal candidates for CRT have a dilated cardiomyopathy on an ischemic or nonischemic basis, an LVEF ≤0.35, a QRS complex ≥120 msec, and sinus rhythm, and are NYHA class III or IV despite maximal medical therapy for heart failure. Using a pacemaker-like device, **CRT aims to get both ventricles contracting simultaneously**, **overcoming the delayed contraction of the left ventricle caused by the left bundle-branch block**. These guidelines were refined by an April 2005 AHA Science Advisory, which stated that

Answer 604

B ## Footnote Reducing consumption of red meat, seafood, and alcohol may help reduce the risk of a gout attack. Dairy products, in contrast to other foods high in protein, decrease the risk of another attack. Nuts and beans are high in purines and will worsen gout.

Answer 605

E ## Footnote GERD is one of the most common causes of chronic cough. Patients with “silent” gastroesophageal reflux may not have the classic symptoms of heartburn and regurgitation. The diagnosis is based on resolution of the cough with an empiric trial of a PPI, although a CXR should be obtained in all patients with a chronic cough to exclude bronchiectasis, tuberculosis, and sarcoidosis. Asthma is another frequent cause of chronic cough, but it can be ruled out with normal PFTs

Answer 606

D ## Footnote Subclinical hypothyroidism: _slightly elevated TSH_ and _normal levels of thyroid hormone_ in an asymptomatic patient. There is a low rate of progression to overt hypothyroidism manifested by symptoms, TSH levels \>10 mIU/L, or reduced levels of thyroid hormone. Recent studies have shown that there is an increased risk for cardiovascular morbidity and mortality in those with subclinical hypothyroidism. However, treatment with thyroid replacement hormone did not seem to affect this risk. The decision about whether to recommend thyroid replacement therapy to patients like the one described here should be individualized. An alternative to treating the patient with medication at this time would be to retest her TSH annually, or sooner if she becomes symptomatic.

Answer 607

C Asthma is classified into four categories: * Mild intermittent - daytime symptoms occurring no more than 2 days per week and nighttime symptoms no more than 2 nights per month. The peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV1) is 80% or more of predicted. * Mild persistent - daytime symptoms more than 2 days per week, but less than once a day, and nighttime symptoms more than 2 nights per month. PEF or FEV1 is 80% or more of predicted. * Moderate persistent - daytime symptoms daily and nighttime symptoms more than 1 night per week. PEF or FEV1 is 60%–80% of predicted. * Severe persistent - continuous daytime symptoms and frequent nighttime symptoms. PEF or FEV1 is 60% or less of predicted.

Answer 608

B ## Footnote **Panic attacks** generally begin between the ages of 17 and 30, and 80% of those affected are women. Panic attacks are manifested by the sudden onset of intense apprehension, fear, or terror, often associated with thoughts of impending doom and at least four of the following somatic symptoms: dyspnea (patients often hyperventilate); palpitations, chest pain, or discomfort; choking or smothering sensations; dizziness; a feeling of unreality; paresthesias; diaphoresis; faintness; trembling or shaking; hot and cold flashes; and fears of dying, going crazy, or losing control during an attack. Hypochondriasis is a condition where the patient is preoccupied with health and absorbed in his/her own physical ailments. Major depressive episodes/depression are characterized by marked, sustained changes of mood. In major depression the prevailing mood is low, being described as “blue,” “down in the dumps,” or apathetic. Part of the low mood consists of a decreased ability to enjoy activities that usually are a source of pleasure.

Answer 609

D Hospital management of acute exacerbations of asthma should include inhaled short-acting bronchodilators in all patients. Systemic corticosteroids are recommended for all patients admitted to the hospital. The efficacy of oral prednisone has been shown to be equivalent to that of IV methylprednisolone. Oxygen should also be considered in most patients.

Answer 610

D Clozapine + Quetiapine have weak D2 effects and have fewer EPS/Parkinsonian effects. Because of this, it is considered the antipsychotic of choice in patients with dementia associated with Parkinson’s disease, although its use has not been studied extensively in this clinical situation. The other atypical antipsychotics listed, olanzapine and risperidone, have some D2 receptor effect. Thioridazine and haloperidol are typical antipsychotics and have more side effects, including parkinsonian side effects; they are not recommended in this clinical situation.

Answer 611

D ## Footnote The lesions described are nonbullous **impetigo**, due to either Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as **mupirocin**, but not compounds containing neomycin, are the preferred first-line therapy for impetigo involving a limited area. Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs. Penicillin V and hexachlorophene have both been shown to be no more effective than placebo. Topical antibiotics have been shown to be as effective as erythromycin, which has a common adverse effect of nausea.

Answer 612

D ## Footnote Because the growth pattern of the fetus varies throughout pregnancy, the accuracy of measurements and their usefulness in determining gestational age and growth vary with each trimester. **Crown-rump length** (distance from the top of the head to the bottom of the fetal spine) is the most **accurate measure of gestational age at 7-14 weeks**. After that, other measurements are more reliable. In the second trimester, **biparietal diameter and femur length** are used. During the third trimester, **biparietal diameter, abdominal circumference, and femur length** are best for estimating gestational age.

Answer 613

E ## Footnote Osteoarthritis causes changes predominantly in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the hands known as Bouchard’s and Heberden’s nodes respectively, and the carpometacarpal joints of the thumbs. While rheumatoid arthritis commonly causes subluxations in the metacarpophalangeal joints, this patient’s hypertrophic changes are most likely due to osteoarthritis. The other choices are less likely to cause this presentation.

Answer 614

A ## Footnote Current methods for reducing the risk of renal failure induced by contrast material include **adequate hydration** and **N-acetylcysteine**. Neither mannitol nor furosemide has been shown to prevent contrast-induced renal failure. Corticosteroids and antihistamines are useful for the prevention of idiosyncratic reactions to contrast, but are not helpful in reducing the risk of renal failure.

Answer 615

D ## Footnote The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes **superior mesenteric artery embolization** likely. In this case, evidence of a brachial artery embolus and a cardiac rhythm indicating **atrial fibrillation** suggest the diagnosis. Microscopic **hematuria** and **blood in the stool** may both occur with embolization, and **severe leukocytosis** is present in more than two-thirds of patients with this problem. Diagnostic confirmation by **angiography** is recommended. Immediate **embolectomy** with removal of the propagated clot can then be accomplished and a decision made regarding whether or not the intestine should be resected. A second procedure may be scheduled to reevaluate intestinal viability.

Answer 616

A The findings in this patient are consistent with a stress fracture. Xrays should be the initial imaging modality because of availability and low cost. These are usually negative initially, but are more likely to be positive over time. If the initial films are negative and the diagnosis is not urgently needed, a second plain radiograph can be performed in 2–3 weeks.

Answer 617

D ## Footnote **Intertrigo** is inflammation of skinfolds caused by skin-on-skin friction. Secondary cutaneous bacterial and fungal infections are common complications. For example, **Corynebacterium minutissimum** infection (erythrasma) can result in small reddish-brown macules that may coalesce into larger patches with sharp borders. Treatment involves topical or oral **erythromycin**. Cutaneous erythrasma may complicate intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions.

Answer 618

A In early pregnancies of less than 5 weeks' gestation, serial hCG double every 1.4–2 days. Serial hCG levels + transvaginal US is the best combination for evaluation of first-trimester problems. * At 5 weeks GA, serum hCG is \>1000 mIU/mL and a gestational sac can be visualized in the uterus. * At 6 weeks GA, serum hCG is \>2500 mIU/mL and a yolk sac can be seen within the gestational sac. * An hCG level of 5000 mIU/mL is compatible with visualization of a fetal pole. * An hCG level of 17,000 mIU/mL, cardiac activity can be detected. Progesterone levels are also predictive of fetal outcome. * A single level of **≥25 ng/mL indicates a healthy pregnancy** and excludes ectopic pregnancy with a sensitivity of 98%. * If the level is **.** * Assessment of fetal well-being is difficult if levels are in the intermediate range of 5–25 ng/mL.

Answer 619

E ## Footnote Overflow incontinence is common in the institutionalized elderly, and is often due to constipating medications. Reduced storage capacity is usually seen with inflammatory bowel disease. Mild diabetes mellitus does not cause decreased rectal sensation, and puborectalis and internal sphincter weakness are uncommon in males, as they usually result from vaginal delivery.

Answer 620

A ## Footnote Once therapy is initiated, children with bacterial conjunctivitis should be allowed to remain in school. Careful hand hygiene is important, however, and behavior must be appropriate to maintain adequate hygiene. No specific length of treatment or evidence of clinical response is required before returning to school.

Answer 621

D The conditions that result in an absolute increase in lymphocytes (lymphocytosis) are divided into 1. **primary** causes * neoplastic hyperproliferation 2. **secondary / reactive** causes * Reactive lymphocytes have a distinctive appearance * viruses: EBV, CMV, HSV, HZV, HIV, hepatitis, adenovirus. * connective tissue disease (other sx are usually present) * bacteria - commonly result in increased PMNs; exception is Bordetella pertussis, which has been known to cause absolute lymphocyte counts of up to 70,000/μL. This infection is associated with classic symptoms that this patient does not have.

Answer 622

D ## Footnote This infant has a typical presentation of erythema toxicum neonatorum - the mother is healthy and the infant shows no evidence of being otherwise ill, thus systemic infections such as herpes are unlikely. Staphylococcal pyoderma is vesicular and the stain of the vesicle content shows polymorphonuclear leukocytes and clusters of gram-positive bacteria. Acne neonatorum consists of closed comedones on the forehead, nose, and cheeks. Rocky Mountain spotted fever is a tickborne disease that does not need to be considered in a child who is not at risk.

Answer 623

B (SIADH) is related to a variety of pulmonary and central nervous system disorders in which hyponatremia and hypo-osmolality are paradoxically associated with an inappropriately concentrated urine. Diagnostic criteria: * Patient must be euvolemic and not on diuretics (within 24-48 hours) * high urine osmolality in conjunction with low serum sodium + low osmolality * BUN is normal/ low * FENa is \>1% **Fluid restriction ( will correct the hyponatremia/hypo-osmolality, but definitive treatment requires eliminating the underlying cause, if possible.** In the case of severe, acute hyponatremia with symptoms (e.g., confusion, obtundation, seizures), **hypertonic (3%) saline** can be slowly infused intravenously but can have dangerous neurologic side effects. Elevated serum glucose levels give rise to a factitious hyponatremia, but not SIADH

Answer 624

C ## Footnote Melasma or chloasma is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. It is common in pregnancy; but often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist. The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient.

Answer 625

A ## Footnote Metformin is contraindicated in patients with chronic kidney disease. It should be stopped in females with a Cr ≥1.4 mg/dL and in males with a Cr ≥1.5 mg/dL. Pioglitazone should not be used in patients with hepatic disease. Acarbose should be avoided in patients with cirrhosis or a creatinine level \>2.0 mg/dL. Exenatide is not recommended in patients with a creatinine clearance Insulin glargine can be used in patients with renal disease at any stage, but the dosage may need to be decreased.

Answer 626

C ## Footnote In acute ankle sprains, functional treatment with a semi-rigid brace that allows flexion and axtension, or a soft lace-up brace is recommended over immobilization. Casting or posterior splinting is no longer recommended. Elastic bandaging does not offer the same lateral and medial support. External ankle support has been shown to improve proprioception.

Answer 627

D ## Footnote Biceps tendon rupture is one of the most common musculotendinous ruptures. Patients typically present with a visible lump in the upper arm following an audible, painful “pop.” The injury typically results from application of an eccentric load to a flexed elbow. Risk factors for biceps tendon rupture include age \>40, deconditioning, contralateral biceps tendon rupture, a history of rotator cuff tear, rheumatoid arthritis, and cigarette smoking. Weakness in forearm supination and elbow flexion may be present. The biceps squeeze test and the hook test are both sensitive and specific for diagnosing the condition. Acute anterior shoulder dislocation is typically very painful, with restricted shoulder movements. Lateral epicondylitis results in pain and tenderness over a localized area of the proximal lateral forearm. Biceps tendinitis results in a deep throbbing pain over the anterior shoulder, accompanied by bicipital groove tenderness.

Answer 628

D ## Footnote Factors associated with a higher risk of heat-related deaths include being **confined to bed, not leaving home daily,** and **being unable to care for oneself**. Living alone during a heat wave is associated with an increased risk of death, but this increase is not statistically significant. Among medical conditions, the highest risk is associated with preexisting **psychiatric illnesses**, followed by **cardiovascular disease**, use of **psychotropic medications,** and **pulmonary disease.** A lower risk of heat-related deaths has been noted in those who have working air conditioning, visit air-conditioned sites, or participate in social activities. Those who take extra showers or baths and who use fans have a lower risk, but this difference is not statistically significant.

Answer 629

B ## Footnote This patient suffers from **diarrhea-predominant IBS.** Her symptoms meet the Rome III criteria for diagnosis with no alarm features. Routine testing for celiac disease, however, should be considered in patients with diarrhea-predominant or mixed-presentation IBS. A systematic review that included more than 4000 patients found that 4% of those with diarrhea-predominant or mixed-presentation IBS had biopsy-proven celiac disease. *A CBC, serum chemistries, thyroid function studies, stool testing for ova and parasites, and abdominal imaging are all low-yield tests that are not recommended for routine diagnostic evaluation of IBS.* The association between IBS and bacterial overgrowth in the small intestine is not clear, so routine hydrogen breath testing is not recommended.

Answer 630

D ## Footnote To ensure that patients from other cultures understand instructions, it is helpful to ask 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.

Answer 631

B The **H/P** is critical for making a diagnosis in patients with scrotal pain. **Transillumination** may also be performed as part of the clinical assessment. If the diagnosis is uncertain, **US with Doppler imaging** has become the accepted standard for evaluation of the acutely swollen scrotum. US alone can confirm the diagnosis in a number of conditions, such as hydrocele, spermatocele, and varicocele. For other conditions such as orchitis, carcinoma, or torsion, color Doppler US is essential because it will show * increased flow in orchitis * normal or increased flow in carcinoma * decreased blood flow in testicular torsion. For testicular torsion, color Doppler ultrasonography has a sensitivity of 86%–88% and a specificity of 90%–100%. When testicular torsion is strongly suspected, emergent surgical consultation should be obtained before ultrasonography is performed, because surgical exploration as soon as possible is critical to salvaging the testis and should not be delayed for imaging unless the diagnosis is in doubt. While radionuclide imaging would be accurate for diagnosing testicular torsion, it is not used for this purpose because of time limits and lack of easy availability. CT or MRI may be appropriate if ultrasonography indicates a possibility of carcinoma. Plain films are not useful in assessing scrotal swelling or masses.

Answer 632

B Symptoms of **hyperactivity** + **impulsivity** ***_decreases_*** with age, but **inattention persists** Like some youth with ADHD, adults with ADHD tend to have additional cognitive deficits, specifically executive function deficits, which include problems encoding and manipulating information and difficulties with organization and time management.

Answer 633

B ## Footnote **_Bronchiectasis_** is an illness of the bronchi and bronchioles involving obstructive and infectious processes that injure airways and cause luminal dilation. In addition to **daily viscid, often purulent sputum** with **occasional hemoptysis**, **wheezing and dyspnea** occur in 75% of patients. _**Emphysema** and **chronic bronchitis**,_ forms of COPD, also cause a decreased FEV1/FVC ratio, but the sputum is generally **mucoid** and luminal dilation of bronchi is not characteristically present. **_Bronchiolitis_** is usually secondary to **respiratory syncytial virus** infection in **young children**. **_Asthma_** is not characterized by the sputum and CT findings seen in this patient.

Answer 634

E ## Footnote Progestins are the treatment of choice for menorrhagia due to endometrial hyperplasia _without_ atypia. Progestins convert the proliferative endometrium to a secretory one, causing withdrawal bleeding and the regression of hyperplasia. The most commonly used form is cyclic oral medroxyprogesterone, given 14 days per month, but implanted intrauterine levonorgestrel is the most effective and also provides contraception. High-dose estrogen supplementation would further stimulate the endometrium. Estrogen is useful in cases where minimal estrogen stimulation is associated with breakthrough bleeding. The anti-fibrinolytic agent tranexamic acid prevents the activation of plasminogen and is given at the beginning of the cycle to decrease bleeding. Side effects and cost limit this treatment option, however. It may be most useful in women with bleeding disorders or with contraindications to hormonal therapy. If medical management fails, hysteroscopic endometrial ablation is an option for reducing uterine bleeding but is considered permanent and obviously will impair fertility. Hysterectomy is reserved for severe and chronic bleeding that is not relieved by other measures.

Answer 635

E Intravenous magnesium sulfate reduces the risk of subsequent seizures in women with eclampsia compared with placebo, and with fewer adverse effects for the mother and baby compared with phenytoin or diazepam.

Answer 636

D ## Footnote This patient has a **malignant melanoma, often called lentigo maligna melanoma.** These lesions typically appear during the seventh or eighth decade of life, and are most often located on the face. This patient's age, health status, and wishes must be considered in any treatment plans. The other skin lesions listed can be seen in this age group, but they are easily distinguished from this malignant lesion.

Answer 637

E ## Footnote Uncomplicated HTN is often a chronic condition, but it also may result from an acutely painful situation. Hypertensive emergencies, defined as severe BP elevations to \>180/120 mm Hg complicated by evidence of impending or worsening target organ dysfunction, warrant emergent treatment. There is no evidence, however, to suggest that treatment of an isolated BP elevation is linked to a reduction in overall risk. In fact, the aggressive reduction of BP with either IV or oral agents is not without potential risk. The appropriate management for the patient in this scenario is simply to discharge her and ask her to follow up with you in the near future.

Answer 638

E ## Footnote Primary hyperparathyroidism and malignancy are the most common causes of hypercalcemia, accounting for about 90% of cases. An intact parathyroid hormone (PTH) level should be obtained initially, as the results will indicate what kind of additional evaluation is needed. Vitamin D and urine calcium studies are useful in evaluating hypercalcemia, but a PTH level should be obtained **first**. It would not be appropriate to wait for a repeat calcium level in 4–6 weeks, because this patient has nephrolithiasis and a calcium level 12 mg/dL, indicating a possible need for surgery or perhaps a malignancy. Calcitonin levels generally are not necessary in the evaluation of hypercalcemia.

Answer 639

D ## Footnote Preoperative evaluation prior to surgery involves an assessment of the perioperative cardiovascular risk of the procedure involved, the functional status of the patient, and clinical factors that can increase the risk, such as diabetes mellitus, stroke, renal insufficiency, compensated or prior heart failure, mild angina, or previous myocardial infarction. This patient cannot climb a flight of stairs or do heavy housework, her functional status is

Answer 640

A This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension, and to manage her weight. Current recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity physical activity on 5 or more days per week

Answer 641

D Gilbert’s syndrome is the most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is Gilbert’s syndrome. Fasting, heavy physical exertion, sickle cell anemia, and drug toxicity can also cause hyperbilirubinemia.

Answer 642

E ## Footnote Uterine fibroid tumors (leiomyomas) symptoms include menorrhagia, pelvic pain, obstructive symptoms, infertility, or pregnancy loss. However, many fibroids are asymptomatic and are discovered incidentally, with expectant management being the treatment of choice in this situation. The risk of malignant leiomyosarcoma is exceedingly small (0.23% in one study) and there is a risk of side effects or complications from other treatment modalities.

Answer 643

A ## Footnote Unless the history or physical examination point in a specific direction, standard tests should be performed first, including a CBC, chemistry panel, stool for occult blood, and TSH level. Although the etiology of unintentional weight loss in the elderly is malignancy in 16%-36% of such cases, specific tests are not indicated before CT. Medications, including SSRIs, NSAIDs, bupropion, digoxin, and metformin can cause weight loss; however, tricyclics often lead to weight gain. Mirtazapine has been shown to increase appetite and promote weight gain.

Answer 644

A ACEi do not need to be discontinued unless baseline creatinine **increases by \>30%.** (This patient’s creatinine increased by 20%.) The current dosage of lisinopril is appropriate, as the blood pressure meets the diabetic goal of

Answer 645

D ## Footnote Constipation is a very common side effect of opioids that does not resolve with time. Constipation is _easier to prevent than to treat_, so it is important to start an appropriate bowel regimen with the initiation of opioid therapy. Fiber supplements and detergents (such as docusate) are inadequate for the prevention of opioid-induced constipation. Metoclopramide is used for nausea and increases gastric motility, but is not indicated in the treatment of constipation. Polyethylene glycol, lactulose, magnesium hydroxide, and senna with docusate are all appropriate in this situation.

Answer 646

C “Nursemaid’s elbow” is one of the most common injuries in children under 5 years of age. It occurs when the child’s hand is suddenly jerked up, forcing the elbow into extension and causing the **radial head to slip out from the annular ligament.**

Answer 647

D ## Footnote ABI \>1.4 indicates noncompressible arteries (calcified vessels). Vascular imaging should be used to confirm peripheral vascular disease. MR or CT arteriography, duplex scanning, and hemodynamic localization are noninvasive methods for lesion localization and may be helpful when symptoms or findings do not correlate with the ABI. Contrast arteriography is used for definitive localization before intervention.

Answer 648

B ## Footnote HbA1c 6.0% correlates with a mean plasma glucose level of 120 mg/dL. Each percentage point is equivalent to a 30-mg/dL rise in average glucose. An HbA1c of 7.0% is therefore roughly equivalent to an average glucose level of 150 mg/dL, and an HbA1c of 8.0% translates to an average glucose level of 180 mg/dL.

Answer 649

C ## Footnote This patient demonstrates classic findings for ARDs. In many cases ARDS must be differentiated from heart failure. Heart failure is characterized by edema, JVD, a third heart sound, an elevated BNP level, and a salutary response to diuretics. A BNP level Hypersensitivity pneumonitis is usually preceded by exposure to an inciting organic antigen such as bird feathers, mold, or dust. Pulmonary embolus, while certainly in the differential, is unlikely to cause such dramatic radiographic findings. Pneumothorax would be seen on the chest radiograph.

Answer 650

C ## Footnote Wheezing associated with feeding is most commonly due to GERD. Tracheoesophageal fistula and laryngeal cleft also cause wheezing associated with feeding, but are rare. Foreign body aspiration is most common between 8 months and 4 years of age and the child is most likely to have a history of the sudden onset of wheezing associated with choking. The wheezing present with tracheomalacia is position related.

Answer 651

E ## Footnote **Pretibial myxedema** is a complication of Graves disease, whether it presents as hypo-or hyperthyroidism. It is a dermopathy that most often occurs in the lower legs and results from increased deposition of mucin due to the endocrine abnormality. Diabetes mellitus can cause necrobiosis lipoidica, a lesion on the lower extremities; hyperlipidemia can cause waxy papules; and collagen vascular and ischemic disease can cause urticaria and/or ulceration.

Answer 652

E ## Footnote Bladder cancer until proven otherwise, so get an US of the kidneys for upper tract and urine cytology + cystoscopy for lower tract

Answer 653

A ## Footnote The inhalation of asbestos fibers may lead to a number of respiratory diseases, including lung cancer, asbestosis, **pleural plaques**, benign pleural effusion, and **malignant mesothelioma**. igh-risk populations for asbestos exposure include individuals who worked in construction trades or as boilermakers, shipyard workers, or railroad workers, as well as U.S. Navy veterans. The occupational history helps to guide clinical suspicion in these high-risk populations. This patient is a retired U.S. Navy veteran who spent his entire career in ship maintenance and repair. Berylliosis is an occupational disease related to mining and manufacturing. Silicosis is seen in sandblasters, miners, persons who have worked with abrasives, and several other occupations. Uranium exposure occurs after nuclear reactor leaks or blasts. Uranium compounds are also used in photography and as dyes or fixatures. The chemical toxicity involves nonmalignant damage to alveolar cells. Iron oxide exposure is not known to be related to lung disease.

Answer 654

E ## Footnote 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.** **A single dose of 25–50 mg/kg of ceftriaxone administered IV or IM is the recommended treatment.** Silver was used for prophylaxis at one time, but is no longer available. Povidone-iodine has not been studied for prevention.

Answer 655

D ## Footnote This patient has multiple risk factors for depression: the hormonal changes of puberty, a family history of depression, and psychosocial stressors. Cognitive-behavioral therapy is effective in treating mild to moderate depression in children and adolescents. SSRIs are an adjunctive treatment reserved for treatment of severe depression, and have limited evidence for effectiveness in children and adolescents.

Answer 656

D ## Footnote A thrombosed external hemorrhoid is manifested by the sudden development of a painful, tender, perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.

Answer 657

C ## Footnote The majority of patients presenting with spontaneous PTX are **tall, thin** individuals **under 40** years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at onset and **may resolve within 24 hours** even if untreated. Patients with small PTX involving less than 15% of the hemithorax may have a normal physical examination, although **tachycardia** is occasionally noted. The diagnosis is confirmed by CXR. The treatment of an initial PTX of less than 20% may be monitored if a patient has few symptoms. Follow-up should include a CXR to assess stability at 24–48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous PTX, and perhaps almost all of them, will have subcutaneous bullae on a CT scan. Studies of recurrence have found that an average of 30% of patients will have a recurrence within 6 months to 2 years.

Answer 658

D Urinary retention is a common problem in hospitalized patients, especially following certain types of surgery. Starting an a-blocker at the time of insertion of the urethral catheter has been shown to increase the success of a voiding trial, as causes smooth muscle relaxation, thereby relaxing bladder neck muscles and muscle fibers in the prostate itself and make it easier to urinate.

Answer 659

C In patients with STEMI, the most important goal is to begin fibrinolysis oral clopidogrel, and should also chew **162–325 mg of aspirin.** Enteric aspirin has a delayed effect. Intravenous β-blockers such as metoprolol should not be routinely given, and warfarin is not indicated. Delaying treatment until cardiac enzyme results are available in a patient with a definite myocardial infarction is not appropriate.

Answer 660

D For combined hormonal contraceptives, migraine headaches with aura at any age are classified as category 4 because of the increased risk of ischemic stroke. ^{The U.S. Medical Eligibility Criteria for Contraceptive Use were created to guide health care providers in assessing the safety of contraceptive use for patients with specific conditions;} * ^{Category 1 includes conditions for which no restrictions exist for use of the contraceptive method.} * ^{Category 2 indicates that the method generally can be used, but careful follow-up may be required.} * ^{Category 3 is used to classify conditions for which the method usually is not recommended unless more-preferred methods are not available or acceptable.} * ^{Category 4 comprises conditions that represent an unacceptable health risk if the method is used.}

Answer 661

C ## Footnote Administration of general anesthesia may cause hypotension, which leads to renal hypoperfusion and peripheral tissue hypoxia, with subsequent lactate accumulation (metformin causes lactic acidosis). Therefore, if administration of radiocontrast material is required or urgent surgery is needed, metformin should be withheld and hydration maintained until preserved kidney function is documented at 24 and 48 hours after the intervention.

Answer 662

E ## Footnote Monotherapy for HTN in AAs is more likely to consist of **diuretics or calcium channel blockers** than β-blockers or ACE inhibitors; has been suggested that HTN in AAs is not as angiotensin II-dependent as it appears to be in Caucasians.

Answer 663

B Thrombolysis within 3 hours after the onset of the deficit is an approved treatment for acute stroke. Beyond that time span, the use of thrombolytic agents is contraindicated. Other contraindications include blood glucose levels 400 mg/dL, resolving TIAs, and hemorrhage visible on a CT scan.

Answer 664

D Excision of the lateral nail plate with lateral matricectomy yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy.

Answer 665

C This is a characteristic presentation of factitious disorder by proxy, or what is commonly known as Munchausen syndrome by proxy. Warning signs for this disorder include the episodes of illness beginning only when the child is, or has recently been, with the parent; the parent taking the child to numerous caregivers, resulting in multiple diagnostic evaluations but neither cure nor definitive diagnosis; the other parent (usually the father) being notably uninvolved despite the ostensible health crises; the parent not being assured by normal test results and continually advocating for painful or risky diagnostic tests for the child; the child persistently failing to tolerate or respond to usual medical therapies; and another child in the family having an unexplained illness or childhood death.

Answer 666

B ## Footnote The management of patients with **somatization disorder** can be difficult. One strategy that has been shown to be effective is to schedule regular office visits so that the patient does not need to develop new symptoms in order to receive medical attention. Regular visits have been shown to significantly reduce the cost and chaos of caring for patients with somatization disorder and to help progressively diminish emergency visits and telephone calls. In addition, it is important to describe the patient’s diagnosis with compassion and avoid suggesting that it’s “all in your head.”

Answer 667

B More than 50% of suicides are associated with a major depressive episode and 25% are associated with a substance abuse disorder. Suicide rates increase with age and are higher among men. Increased suicide rates also occur in patients with significant medical illnesses. Because discussing suicidal ideation may relieve the patient’s anxiety, the physician should directly ask depressed patients about any suicidal thoughts. The initial management of suicidal ideation should establish safety, often by hospitalization. The suicide prevention contract is of unproven clinical and legal usefulness. Antidepressant medication has not been shown to reduce suicide rates, especially on a short-term basis.

Answer 668

A The clinical triad of Horner’s syndrome-ipsilateral ptosis, miosis, and decreased facial sweating-suggests decreased sympathetic innervation due to involvement of the stellate ganglion, a complication of Pancoast’s superior sulcus tumors of the lung. Radiographs or MRI of the pulmonary apices and paracervical area is indicated. Horner’s syndrome may accompany intracranial pathology, such as the lateral medullary syndrome (Wallenbergs syndrome), but is associated with multiple other neurologic symptoms, so MRI of the brain is not indicated at this point. The acetylcholine receptor antibody level is a test for myasthenia gravis, which can also present with ptosis, but not with full-blown Horner’s syndrome. Diabetes mellitus and thyroid disease do not commonly present with Horner’s syndrome.

Answer 669

C ## Footnote The scenario described is suspicious for an occult fracture of the scaphoid bone of the wrist. The mechanism of injury, falling on an outstretched hand with the wrist extended, combined with tenderness in the anatomic snuff box (between the extensor pollicis longus and extensor pollicis brevis tendons) raises the possibility of a scaphoid fracture even if initial radiographs are negative. In order to reduce the potential for serious complications, including vascular necrosis and non-union, it is imperative that both the wrist and the thumb be immobilized. In the case described, a thumb spica splint is the best option initially. It should be worn continuously until a follow-up evaluation, including radiographs, in 1–2 weeks.

Answer 670

A ## Footnote Metformin increases insulin sensitivity much more than sulfonylureas or insulin. This means lower insulin levels achieve the same level of glycemic control, and may be one reason that weight changes are less likely to be seen in diabetic patients on metformin. Acarbose is an α-glucosidase inhibitor that delays glucose absorption.

Answer 671

A ## Footnote The criteria for chronic fatigue syndrome include **fatigue for 6 months** PLUS **_\>_ 4** of the following: impaired memory, postexertional malaise, muscle pain, polyarthralgia, tender lymph nodes, sore throat, new headaches, and unrefreshing sleep. **Cognitive-behavioral therapy** and **graded exercise therapy** have been shown to improve fatigue levels, anxiety, work/social adjustment, and postexertional malaise. Treatments that have not been shown to be effective include methylphenidate, melatonin, and galantamine. Citalopram has not been shown to be effective in the absence of a comorbid diagnosis of depression.

Answer 672

C ## Footnote Vaginal atrophy is a common symptom accompanying menopause. Local application of estrogen is the most effective treatment. Potential adverse effects of vaginal estrogen include candidal infections, bleeding, burning with application, and breast pain. It is not necessary to add an oral progestogen to the local estrogen treatment. Vaginal estrogen does not lead to endometrial proliferation, so endometrial protection in a patient who still has her uterus is not necessary.

Answer 673

E ## Footnote Undiagnosed vitamin D deficiency is not uncommon, and 25-hydroxyvitamin D is the barometer for vitamin D status. Although there is no consensus on optimal levels of 25-hydroxyvitamin D as measured in serum, vitamin D deficiency is defined by most experts as a 25-hydroxyvitamin D level of

Answer 674

E Second-generation “atypical” antipsychotics are associated with weight gain, elevated TGs, and type 2 DM. Olanzapine and clozapine are associated with the highest risk. Clonazepam, a benzodiazepine, does not share these risks. Thioridazine and chlorpromazine are first-generation antipsychotics, and carry less risk of these side effects. Aripiprazole, although it is a second-generation antipsychotic, has been found to cause weight gain and metabolic changes similar to those seen with placebo.

Answer 675

A Contraceptives containing **_drospirenone_** should be used with caution in patients taking spironolactone, however, because they can also lead to hyperkalemia. The other contraceptive options listed do not increase the risk for hyperkalemia.

Answer 676

C ## Footnote Treatment for a unilateral undescended testis should be started at 6–12 months of age to avoid testicular damage. It was once thought that delaying descent lowered the incidence of testicular cancer, but it is now believed that orchiopexy allows for early cancer detection. hCG treatment may promote descent into the distal canal, but the testicle often ascends again. US will not show an undescended testis in many cases and is therefore not recommended. Hormonal treatments have been used in Europe but randomized, controlled trials have not shown them to be effective.

Answer 677

A Drug-induced pleuritis is one cause of pleurisy. Several drugs are associated with drug-induced pleural disease or drug-induced lupus pleuritis. Drugs that may cause lupus pleuritis include **hydralazine, procainamide, and quinidine.** Other drugs known to cause pleural disease include **amiodarone, bleomycin, bromocriptine, cyclophosphamide, methotrexate, minoxidil, and mitomycin.**

Answer 678

A ## Footnote Randomized, controlled studies yield stronger evidence than other types of studies, especially case-control or cohort studies, because randomization provides the greatest safeguard against unanticipated study bias. Evidence obtained from randomized, controlled studies is considered level 1 (strongest) by the U.S. Preventive Services Task Force. Evidence obtained from nonrandomized, controlled studies is considered level 2a; well-designed case-control and cohort studies are considered level 2b; and reports of expert committees or respected authorities are considered level 3 (weakest).

Answer 679

D ## Footnote Recommendations for reducing ventilator-associated pneumonia (VAP) include elevation of the head to an angle of at least 30°, noninvasive mechanical ventilation rather than intubation when appropriate, oral intubation when an endotracheal tube is necessary, orogastric rather than NG tubes, minimization of sedation, administration of a PPI when prophylaxis is indicated, changing ventilator tubing every 7 days or when it becomes soiled, avoidance or elimination of endotracheal tube leaks, good technique in removal of condensate, and excellent hand hygiene. One study favored waiting more than 5 days before initiating tube feedings, as this reduced the incidence of VAP, although further data is needed to confirm this.

Answer 680

C The maneuver described is Hawkins’ impingement test. Pain with this maneuver may signify subacromial impingement, including a rotator cuff tendinopathy or tear.

Answer 681

B It is important to remember that because this patient was recently in the hospital, the usual coverage for community-acquired pneumonia is not adequate. Health care-associated pneumonia is more likely to involve severe pathogens such as **Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter species.** Methicillin-resistant Staphylococcus aureus also is a consideration, depending on local prevalence. Of the antibiotic regimens listed, **ceftazidime and gentamicin** is the only choice that covers these organisms.

Answer 682

A The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees. Tenderness of the anatomic snuffbox, Achilles tendons, or web spaces of the toes would most likely be related to another diagnosis.

Answer 683

C ## Footnote **Sinus bradycardia** is almost universally present in patients with anorexia nervosa. It is hypothesized that this is **due to vagal hyperactivity resulting from an attempt to decrease the amount of cardiac work by reducing CO**. It is also possible that the bradycardia can be accounted for by **low serum T3 levels,** a common finding in persons with chronic malnutrition. Sinus tachycardia may occur with refeeding in patients with anorexia. Other arrhythmias may also occur but are less frequent.

Answer 684

E ## Footnote Maintaining a regular sleep/wake schedule helps prevent insomnia. While a light snack before bed may be sleep inducing, heavy meals close to bedtime may be counterproductive. Alcohol should be avoided as a sedative, to prevent midsleep awakenings. Hours spent reading or watching television in bed can lead to long awakenings in the middle of the night.

Answer 685

C ## Footnote The diagnosis of schizophrenia requires **≥ 2** symptoms, each present for a significant portion of time during a **1-month** period): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e., affective flattening, alogia, or avolition). In addition, ≥ 1 major areas of functioning, such as work, interpersonal relationships, or self-care, should be markedly below the level seen prior to the onset of symptoms. Brief psychotic disorder is characterized by the presence of delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior lasting at least 1 day but less than 1 month.

Answer 686

B ## Footnote The patient has Dupuytren’s disease, which is most common in men over 40 years of age. It is a progressive condition that causes the fibrous fascia of the palmar surface to shorten and thicken. It initially can be managed with observation, but corticosteroid injection and surgery may be needed. The condition will regress in 10% of patients. There is a 3%-33% prevalence of Dupuytren’s contracture in patients with diabetes mellitus; however, these patients tend to have a mild form of the disease with slow progression.

Answer 687

E ## Footnote The only group in which screening for asymptomatic bacteriuria in adults is recommended is asymptomatic pregnant women at 12–16 weeks gestation, or at the first prenatal visit if it occurs later

Answer 688

B While rarely life threatening, acute dystonic reaction can be frightening and painful to the patient and confusing to the treating physician who may be unaware of what medications the patient is taking. **Dystonia can be caused by any agent that blocks dopamine, including prochlorperazine, metoclopramide, and typical neuroleptic agents such as haloperidol.** The acute treatment of choice is **diphenhydramine** or **benztropine.**

Answer 689

D ## Footnote **Head banging** has been estimated to be present in 3%–15% of normal children and usually **begins between the ages of 5 and 11 months**. The vast majority of these children will engage in this activity for only a few months, and most **will stop by age 3.** Rarely does the behavior cause lacerations or skull fractures, and the presence of either should prompt the physician to consider the possibility of another cause such as abuse. The incidence of head banging is higher in children with developmental disorders such as Lesch-Nyhan syndrome, Down syndrome, or autism. However, this child has no sign of any such disorder and has normal developmental milestones.

Answer 690

A **Azithromycin** has been shown to reduce the duration of lymphadenopathy in cat-scratch disease. Other antibiotics that have been used include rifampin, ciprofloxacin, trimethoprim/sulfamethoxazole, and gentamicin. Ceftriaxone, amoxicillin/clavulanate, doxycycline, and clindamycin are not effective in the treatment of Bartonella infection.

Answer 691

A SAD - unique to pediatric patients; characterized by excessive anxiety regarding separation from the home or from family members/caregivers. The anxiety is beyond what is developmentally appropriate for the child’s age. Other characteristics include persistent worry about harm occurring to major attachment figures, worry about an event that may separate the patient from caregivers, reluctance to attend school due to the separation it implies, fear of being alone, recurring nightmares with themes of separation, and physical complaints when faced with separation. Children diagnosed with separation anxiety disorder must be **under 18 years of age** and have had **symptoms for at least 4 weeks.** Social phobia - persistent fear of a specific object or situation. Exposure to the object provokes an immediate anxiety response such as a panic attack. Symptoms must be present for **at least 6 months.** Generalized anxiety disorder - excessive anxiety and worry regarding a number of events or activities. Physical symptoms include restlessness, irritability, or sleep disturbance. Symptoms must be present for **at least 6 months.** Acute stress disorder - occurs after a traumatic event that the individual considers life threatening. Patients experience dissociative symptoms, flashbacks, and increased arousal. Symptoms are present for at **least 2 days**, **with a maximum of 4 weeks**. * Beyond 4 weeks, a diagnosis of posttraumatic stress disorder is made. Panic disorder with agoraphobia - recurrent panic attacks with a fear of being in situations in which the patient cannot escape or may be embarrassed by doing so. Symptoms must be present for **1 month**

Answer 692

E Doxycycline is contraindicated in the second and third trimesters of pregnancy due to the risk of permanent discoloration of tooth enamel in the fetus.

Answer 693

C The diagnosis of PCOS based on the presence of **two** of the following: * oligomenorrhea or amenorrhea * clinical or biochemical hyperandrogenism * polycystic ovaries visible on US Lifestyle modifications are necessary, but medications are also needed. * hirsutism -\> spironolactone, metformin, and eflornithine * ovulation induction and treatment of infertility -\> metformin and clomiphene, alone or in combination with rosiglitazone * menstrual irregularities -\> metformin * promote weight reduction-\> metformin * improves insulin resistance -\> metformin, rosiglitazone, pioglitazone * Pioglitazone would not be appropriate for this patient because it causes weight gain. OCs would improve the patient’s menstrual irregularities and hirsutism, but she wishes to become pregnant. Testosterone would worsen the hyperandrogenism and would not treat the PCOS.

Answer 694

C The others are all category C drugs.

Answer 695

A The patient has a score of 5 under the Modified Centor scoring system for management of sore throat. Patients with a score ≥4 are at highest risk (at least 50%) of having group A β-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with antibiotics is warranted.

Answer 696

B In adults and children over 5 years of age, 5% permethrin cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and minimally toxic.

Answer 697

A ## Footnote HMG-CoA reductase inhibitors/Statins play an important role in the management of patients with CVD and have an excellent safety and tolerability record. The incidence of significant liver injury from statin drugs is about 1%, and nonalcoholic fatty liver disease or stable hepatitis B or C infection is not a contraindication to treatment with statins. Although many patients taking statins experience elevation of hepatic transaminases, these elevations are generally mild and asymptomatic, and ***often resolve spontaneously even with no changes in treatment***. Transaminase elevations up to three times the upper limit of normal are not a contraindication to continued use of the drug at the same dosage.

Answer 698

A Patients with hemoglobinopathies (sickle cell, hereditary spherocytosis, thalassemia) are at a significantly increased risk for developing pigmented stones.

Answer 699

A A comprehensive, systematic literature review found an association of sexual abuse with a lifelong history of functional gastrointestinal disorders, irrespective of the age of the victim at the time of abuse. There was no statistically significant association with obesity, headache, or syncope.

Answer 700

D ## Footnote **Constitutional growth delay** - delayed but eventually normal growth in an adolescent, is usually genetic. If evaluation of the short adolescent male reveals no evidence of chronic disease, if his sexual maturity rating is 2 or 3, and if his height is appropriate for skeletal age he can be told without endocrinologic testing that he will begin to grow taller within a year or so. Adult height may be below average, but cannot be predicted reliably. Average sexual maturity ratings for a male of 14.3 years are 4 for genitalia and 3 to 4 for pubic hair. The history and physical examination would have given clues to any illnesses or nutritional problems.

Answer 701

C Patients who fail initial treatment with metronidazole should be retreated with 500 mg PO BID x 7 days. If treatment fails again, the patient should be treated with 2 g daily for 3–5 days.

Answer 702

C ## Footnote The pes anserine bursa is associated with the tendinous insertion of the sartorius, gracilis, and semitendinosus muscles into the medial aspect of the proximal tibia. Commonly **associated with early osteoarthritis in the medial knee compartment, pes anserine bursitis can also result from overuse of the involved muscles or from direct trauma to the area.** A patient with pes anserine bursitis will generally complain of **pain in the area of insertion when flexing and extending the knee**. **Slight swelling** may be present but no effusion is generally evident. Treatments may include **oral anti-inflammatory agents, physical therapy, and corticosteroid injection.**

Answer 703

B ## Footnote In patients who are depressed after CABG, impaired memory and cognition are seen more frequently than other depressive symptoms. Patients with *_rapid*_ progression of cardiac symptoms _*before_* surgery are at particular risk of depressive symptoms after surgery. The Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) showed that antidepressant use was associated with a slight reduction (but not significant) in the rates of cardiovascular events. The Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial showed that although it did not reduce the risk of cardiac events, participation in a cardiac rehabilitation program reduced depressive symptoms and increased social ties.

Answer 704

E ## Footnote Risk factors for proximal neoplasia include high-grade dysplasia, three or more adenomas, adenomas with villous features, and an adenoma ≥1 cm in size. For patients with one or more of these findings, follow-up colonoscopy in 3 years is recommended. The clinical benefit of follow-up surveillance colonoscopy in patients with one or two small adenomas has never been demonstrated. Distal hyperplastic polyps are not markers for proximal or advanced neoplasia. Patients with this finding on colonoscopy should be considered to have a normal colonoscopy and the interval until the next colonoscopy should be 10 years.

Answer 705

B ## Footnote **Anticonvulsants (ie phenytoin)** increase the hepatic metabolism of vitamin D, thereby reducing intestinal calcium absorption. Other medications that adversely affect bone mineral density include **glucocorticoids**, **cyclosporine, phenobarbital, and heparin.** Thiazide diuretics reduce urinary calcium loss and are believed to preserve bone density with long-term use. Benzodiazepines and SSRIs have not been associated with increases in bone loss or in hip fractures. Raloxifene, a selective estrogen receptor modulator, is indicated for the prevention and treatment of osteoporosis in postmenopausal women.

Answer 706

A The statistics that are clinically useful for evaluating diagnostic tests include the positive predictive value, negative predictive value, and likelihood ratios. * **Likelihood ratios -** indicate how a positive or negative test correlates with the likelihood of disease. Ratios **greater than 5–10 greatly increase the likelihood of disease**, and ratios **less than 0.1–0.2 greatly decrease it**. * In the example given, if the patient’s endometrial stripe is \>25 mm, the likelihood ratio is 15.2 and her post-test probability of endometrial cancer is 63%. However, if it is ≤ 4 mm, the likelihood ratio is 0.02 and her post-test probability of endometrial cancer is 0.2%. * The number needed to treat is useful for evaluating data regarding treatments, not diagnosis. * Prevalence is the existence of a disease in the current population * Incidence describes the occurrence of new cases of disease in a population over a defined time period * Relative risk is the risk of an event in the experimental group versus the control group in a clinical trial

Answer 707

D ## Footnote All women ≥65 and all men ≥70 should be screened for osteoporosis.

Answer 708

C ## Footnote The patient's history most consistent with a recent, resolved TIA, most likely due to an embolus related to her a-fib. Her risk for recurrence is high, thus long-term anticoagulation with warfarin reduces this risk. The use of antiplatelet agents such as clopidogrel to reduce TIAs has not been studied. Lowering blood pressure and lipid levels can reduce risks over the long term, but do not require immediate intervention. Cardioversion for patients with atrial fibrillation of uncertain or long duration may be appropriate but should _not be attempted_ before several weeks of anticoagulation in the stable patient.

Answer 709

A Since its FDA approval, imiquimod has been used off-label to treat all of the conditions listed, but is approved only for treatment of external genital and perianal warts in patients 12 years of age and over

Answer 710

A ## Footnote This patient has **moderate persistent asthma**. Although many parents are concerned about corticosteroid use in children with open growth plates, inhaled corticosteroids have not been proven to prematurely close growth plates, and are the most effective treatment with the least side effects. Scheduled use of a shortacting bronchodilator has been shown to cause tachyphylaxis, and is not recommended. The same is true for long-acting bronchodilators. Leukotriene use may be beneficial, but compared to those using inhaled corticosteroids, patients using leukotrienes are 65% more likely to have an exacerbation requiring systemic corticosteroids.

Answer 711

E The patient’s hx is typical of **primary dysmenorrhea**, defined as severe cramping pain in the lower abdomen that occurs during menses; it may also occur prior to the onset of menses in the absence of associated pelvic pathology. Although many women complain of pain beginning with the first cycle, symptoms usually begin at the onset of ovulation around 6-12 months after menarche. Symptoms typically last 48 hours or less, but sometimes may last up to 72 hours. It is common to find daughters with dysmenorrhea whose mothers had the same symptoms. Additionally, the symptoms of primary dysmenorrhea often resolve after the first pregnancy. Multiple placebo-controlled studies have shown that NSAIDs such as naproxen, at the onset of symptoms, provide significant relief of primary dysmenorrhea compared to placebo. In this patient, who has no history suggesting an emotional disorder, there is no need for psychological counseling at this time. Further evaluation could include US to rule out causes of dysmenorrhea such as uterine leiomyomata, adnexal masses, and endometrial polyps. However, a trial of symptomatic therapy is most reasonable before other invasive studies, such as a laparoscopic examination or a hysterosalpingogram, are ordered. It is not reasonable to begin danazol without a diagnosis of endometriosis, which is by definition secondary dysmenorrhea. Since neither inhibits prostaglandin synthetase, acetaminophen (which she had already tried without complete relief) combined with a narcotic is not an appropriate management strategy.

Answer 712

A ## Footnote In cases of hyperglycemia, the main cause of the hyponatremia is the **glucose-related increase in osmolality of extracellular fluid --\>** movement of **water from intracellular to extracellular fluid compartments** --\> **subsequent loss of excessive extracellular fluid and electrolytes**. The serum sodium concentration is also diminished in patients with _hyperlipidemia_ or _hyperproteinuria_ because of the volume occupied by the lipids or proteins. If the lipids or proteins are removed, the sodium concentration in the remaining plasma is found to be normal. No treatment is needed for these conditions.

Answer 713

D ## Footnote This ingrown nail meets the criteria for **_moderate_** severity: *increased swelling, seropurulent drainage, infection, and ulceration of the nail fold.* **_mild-moderate_**_:_ **conservative** - elevate nail edge with a wisp of cotton or a gutter splint. **_moderate_:** partial nail avulsion followed by **phenolization**, _or_ direct surgical excision of the nail matrix Several studies demonstrate that once the ingrown portion of the nail is removed and matricectomy is performed, the localized infection will resolve without the need for antibiotic therapy. **_severe/recurrent:_** Bilateral partial matricectomy (maintains the functional role of the nail plate

Answer 714

A ## Footnote It is best to discuss prognosis after accurate cancer staging, when specific details about survival rates will give a much clearer and more accurate picture. After assessing the patient’s readiness to receive prognostic information, the physician should focus on communicating an accurate prognosis without giving a false sense of hope. Using simultaneous-care models, physicians can provide palliative and curative care at the same time. Physicians should initiate a discussion about the availability of coordinated, symptom directed services such as palliative care early in the disease process; as the disease progresses, patients should transition from curative to palliative therapy. How much information to share with the patient depends on the physician’s assessment of the patient’s level of understanding about the disease and how much patients themselves want to know.

Answer 715

B ## Footnote **Propranolol** is a first-line therapy for migraine prophylaxis in adults. Other first-line agents include timolol, amitriptyline, divalproex sodium, sodium valproate, and topiramate. Gabapentin, fluoxetine, vitamin B , and naproxen are considered second-line therapies for migraine prophylaxis in adults, and should be used when no first-line agent or combination is effective or tolerable.

Answer 716

A ## Footnote This patient is experiencing sepsis syndrome due to urinary infection. The renal failure that has resulted is almost certainly due to **low perfusion of the kidneys (prerenal azotemia).** This condition requires **aggressive IV fluids** to halt and reverse the reduction in nephrologic function. At times, this **underperfusion can result in acute tubular necrosis** (an intrinsic renal dysfunction) that may prevent excretion of any excess fluid, so the patient’s fluid status should be monitored carefully. **Metabolic acidosis will likely reverse with appropriate hydration**, and sodium bicarbonate should be reserved for severe acidosis ( Low-dose dopamine has been proven to be ineffective in acute renal failure, and this patient does not have an indication for dialysis. IV furosemide is contraindicated.

Answer 717

B ## Footnote One of the most common types of incontinence results from uninhibited contractions of the detrusor muscle. This detrusor instability causes an intense urge to void, which overcomes the patient’s voluntary attempt to hold the sphincter closed; hence, the common term urge incontinence.

Answer 718

B ## Footnote 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 at all. **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.

Answer 719

C ## Footnote Any patient with a new scrotal mass should be evaluated immediately because of the risk of potential emergencies, such as testicular torsion, or of life-threatening diseases such as testicular carcinoma. **Color Doppler US** is the test of choice for immediate evaluation of scrotal masses because it can be done quickly and has a high sensitivity and specificity or detecting testicular torsion, which is a surgical emergency.

Answer 720

E ## Footnote **Short-acting bronchodilators such as albuterol and ipratropium** are recommended on an as-needed basis for treatment of breathlessness in stage I (mild) COPD and as-needed in stage II (moderate), stage III (severe), and stage IV (very severe) COPD. **Long-acting bronchodilators such as salmeterol or tiotropium** are recommended for stages II, III, and IV. Inhaled corticosteroids are recommended for stages III and IV. **Mucolytics** can be considered for stages III and IV

Answer 721

A ## Footnote The most common cause of nasal obstruction in all age groups is the common cold, which is classified as mucosal disease. Anatomic abnormalities, however, are the most frequent cause of constant unilateral obstruction, with nasal septal deviation being most common. Foreign-body impaction is an important, but infrequent, cause of unilateral obstruction and purulent rhinorrhea. Mucosal disease is usually bilateral and intermittent. Adenoidal hypertrophy is the most common tumor or growth to cause nasal obstruction, followed by nasal polyps, but both are less frequent than true anatomic causes of constant obstruction.

Answer 722

A ## Footnote **Threatened abortion** - bleeding, _closed_ os, no passage of POCs. **Inevitable** abortion - bleeding, _open_ os, no passage of POCs **Complete** abortion - bleeding, closed os, complete passage of POCs. **Incomplete** abortion - bleeding, open os, but POCs are visualized in the os or vaginal vault. **Missed** abortion - no symptoms with missed abortion, but there is no embryo or fetus on US

Answer 723

D ## Footnote Considering RRR without also considering the absolute rate can distort the importance of a therapy. A useful way to assess the importance of a therapy is to determine the number needed to treat to benefit one patient. To calculate this number, the % of absolute risk reduction of a particular therapy is divided into 100. In the case in question, the absolute risk reduction is 0.5% (0.5×.01). Thus, the number-needed-to-treat for the example cited is 200 (=100/0.5).

Answer 724

D ## Footnote **Pseudoaddictionis -** describes patient behaviors that may occur when *pain is undertreated.* Patients may become focused on obtaining specific medications, seem to watch the clock, or engage in other behaviors that appear to be due to inappropriate drug seeking. Pseudoaddiction can be distinguished from true addiction because the *behaviors will resolve when the pain is effectively treated.* The concurrent use of alcohol and/or illicit drugs complicates the management of chronic pain in patients. If these are known problems, patients should be referred for psychiatric or pain specialty evaluation before the decision is made to use opioids.

Answer 725

B ## Footnote **Procainamide** and **Hydralazine** can induce a syndrome resembling systemic lupus erythematosus. There is a genetic predisposition for this drug-induced lupus, determined by drug acetylation rates. Polyarthritis and pleuropericarditis occur in half of patients, but CNS or renal involvement is rare. While all patients with this condition have **_positive_ antinuclear antibody titers** and **ant-histone antibodies** , **antibodies to dsDNA and decreased complement levels are _rare_**, which distinguishes drug-induced lupus from idiopathic lupus. The best initial management for drug-induced lupus is to **withdraw the drug**, and most patients will improve in a few weeks. For those with severe symptoms, a short course of corticosteroids is indicated. Once the offending drug is discontinued, symptoms seldom last beyond 6 months.

Answer 726

D Women with premenstrual dysphoric disorder (PMDD) experience a cluster of mood, cognitive, and physical symptoms that **recur in the luteal phase** and **remit in the follicular phase** of the menstraul cycle. **SSRIs, especially if administered during the luteal phase of the menstrual cycle have been shown to help**. Because many patients with PMDD do not have depressive symptoms, this disorder should not be considered as simply a depressive variant. Some studies have shown that symptoms actually worsen with the administration of oral contraceptive pills. **Benzodiazepines** are second-line drug therapy if an optimal response is not achieved with an SSRI.

Answer 727

A ## Footnote In general, recommended preop testing is based on the patient’s medical history and risk factors, the risk associated with the planned surgery, and the patient’s functional capacity. In the case of cataract surgery, however, randomized, controlled trials have established a lack of benefit from preoperative testing for patients in their normal state of health.

Answer 728

B ## Footnote This patient has classic signs of hypothyroidism. Of the drugs listed, only lithium is associated with the development of hypothyroidism. In patients taking lithium, it is recommended that in addition to regular serum lithium levels, thyroid function tests including total free T4, and TSH be obtained yearly.

Answer 729

C ## Footnote The most common form of advance directive is a patient’s conversations with **relatives _and_ friends**, and these **carry the same ethical and legal weight as written directives**. Neither the hospital attorney nor the patient’s personal attorney, in the absence of a previous discussion with the patient, has the ethical or legal authority to make the decision. Since the patient has previously expressed his wishes, it is unnecessary to have the court appoint a surrogate decision maker. Care should be transferred to another physician only if the original physician has a philosophical or religious objection to carrying out the patient’s wishes.

Answer 730

A An oral loading dose of clopidogrel should be administered as soon as possible in patients with unstable angina/NSTEMI who are to be treated conservatively. The **standard clopidogrel dosage should then be prescribed, to be taken daily for at least 1 month along with aspirin.** * Immediate-release Ca channel antagonists such as nifedipine are not indicated. * If β-blockers are contraindicated, verapamil or diltiazem would be the preferred agents. * IV ACE inhibitors may induce shock and should be avoided in the first 24 hours. * Abciximab is used for patients who will undergo rapid catheterization with a significant chance of acute coronary intervention. * NSAIDs are contraindicated because they may weaken areas of damaged myocardium and increase the risk of rupture, and may also increase the risk of infarction or extension. They have been used in the past for treatment of associated pericarditis, which most frequently develops a few days after presentation, but are now avoided.

Answer 731

B ## Footnote After several unsuccessful attempts to remove an object deep in the ear canal of an uncooperative child, it is best to refer the patient to an otolaryngologist for removal under anesthesia. Additional attempts are very unlikely to succeed, especially with the techniques listed. A loop curette cannot be safely placed behind a foreign body that is close to the tympanic membrane. A round, hard object cannot be grasped with forceps. Acetone can be used to dissolve Styrofoam foreign bodies, but it would not dissolve a plastic bead.

Answer 732

A The patient has the typical symptoms and signs of BV. There is no need for confirmatory testing. The treatment of choice is **PO metronidazole**, which may cause a disulfiram-like interaction with alcohol.

Answer 733

E Regular BSE do not reduce breast cancer–specific mortality or all-cause mortality and USPSTF recommends _against_ teaching BSE. The rationale for this recommendation is that there is moderate certainty that the harms outweigh the benefits.

Answer 734

A ## Footnote Easy bruising, moon facies, buffalo hump, abdominal striae, hypertension, and proximal myopathy suggest Cushing’s syndrome. Because this syndrome is very rare compared to polycystic ovarian syndrome, routine screening is not indicated in women with hypoandrogenic anovulation. Acne, hirsutism, androgenic alopecia, and acanthosis nigricans are all consistent with polycystic ovarian syndrome

Answer 735

C ## Footnote Red cell distribution width (RDW) is a measure of the variability of size of the red cells. It is particularly useful in distinguishing anemic disorders, especially iron deficiency anemia (high RDW, normal to low mean corpuscular volume) and uncomplicated heterozygous thalassemia (normal RDW, low mean corpuscular volume)

Answer 736

A Erythema infectiosum is caused by parvovirus B19. It presents with the typical viral prodrome, along with mild upper respiratory symptoms. The hallmark rash has three stages: * Stage 1: facial flushing/“slapped cheek” * Stage 2: exanthem spreads concurrently to the trunk and proximal extremities as a diffuse macular erythematous rash * Stage 3: central clearing of this rash creates a lacy, reticulated appearance, as seen in the figure. This rash tends to be on the extensor surfaces and ***_spares_*** the palms and soles. It resolves in 1–3 weeks but can recur with heat, stress, and exposure to sunlight.

Answer 737

B ## Footnote ß-blockers and ACEi have been found to decrease mortality late after MI. Aspirin has been shown to decrease nonfatal MI, nonfatal stroke, and vascular events. Nitrates, digoxin, thiazide diuretics, and calcium channel antagonists have not been found to reduce mortality after MI.

Answer 738

D ## Footnote **Gastroparesis -** autonomic neuropathy commonly seen in type 1 DM and in women. The initial evaluation should include a H&P, CBC, CMP, endoscopy, and a biliary tract evaluation, but the diagnosis is best **confirmed by scintigraphy**. Pelvic US and colonoscopy are not indicated because the patient’s symptoms are upper intestinal. Cardiac evaluation and psychiatric consultation are not warranted with these symptoms.

Answer 739

D ## Footnote In addition to an appropriate diet and exercise regimen, pharmacologic therapy should be initiated in pregnant women with gestational diabetes mellitus whose fasting plasma glucose levels remain above 100 mg/dL despite diet and exercise. While oral therapy with metformin or glyburide is considered safe and possibly effective, **insulin therapy is the best option for the pharmacologic treatment of gestational diabetes.** Most patients are successfully treated with a twice-daily combination of an intermediate-acting insulin and a short-acting insulin while continuing a diet and exercise program. **T**he use of long-acting basal insulin analogues, such as glargine and detemir, has not been sufficiently evaluated in pregnancy. Sliding-scale coverage with ultra-short-acting insulin or insulin analogues, such as lispro and aspart, is generally not required in most women with gestational diabetes. While it may be effective, it involves four daily glucose checks and injections.

Answer 740

A In elderly patients, detrusor instability is the most common cause of urinary incontinence in both men and women. Incontinence may actually become worse after surgical relief of obstructive prostatic hypertrophy.

Answer 741

B Pseudomonas organisms have been associated with outbreaks of otitis externa, dermatitis, and folliculitis in persons using swimming pools and hot tubs.

Answer 742

A ## Footnote This patient has a high clinical probability for pulmonary embolism (PE). **compression US** - only ~40% of patients with PE will have positive findings for DVT in the lower extremities A **normal ventilation-perfusion** lung scan rules out PE, but inconclusive findings are frequent and are not reassuring (ie "low probability of PE") A **normal D-dimer** level reliably rules out the diagnosis of venous thromboembolism in patients at low or moderate risk of PE, but the negative predictive value of this test is low for high-probability patients. A **positive D-dimer** test does not confirm the diagnosis; it indicates the need for further testing, and is thus not necessary for this patient. **A multidetector CT angiogram or ventilation-perfusion lung scan should be the next test, as these are reliable to confirm or rule out PE.**

Answer 743

E According to JNC 7, the risk of both ischemic heart disease and stroke increases progressively when systolic blood pressure exceeds 115 mm Hg and diastolic blood pressure exceeds 75 mm Hg...wha?

Answer 744

c The appropriate management of a thrombosed hemorrhoid presenting **within 48 hours of onset** of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of _internal_ hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate.

Answer 745

B ## Footnote This patient is experiencing delirium, which is common in the last weeks of life. Antipsychotic agents such as haloperidol are effective for the management of delirium, and they are widely used. While benzodiazepines are used extensively in persons with delirium who are terminally ill, there is no evidence from well-conducted trials that they are beneficial. Trazodone is an antidepressant that is sometimes used for insomnia. Scopolamine is an anticholinergic that is used to reduce respiratory secretions in hospice patients, but its anticholinergic side effects would increase delirium severity. Amitriptyline also has significant anticholinergic properties.

Answer 746

B ## Footnote **Radial fractures** are the **most common fracture** in this age group, but **can be missed on xray**. The **bend in the cortex** of the distal radius indicates the fracture. It will heal with almost any choice of treatment. Most clinicians opt for casting to reduce the chance of reinjury during the first few weeks of healing, but the parents’ preferences in this regard are important. Some pediatric long-bone fractures involve growth plates, and the results can be indeterminate, requiring either more advanced imaging or comparison views of the opposite limb.

Answer 747

C Polymyalgia rheumatica is an inflammatory disorder that occurs in persons over the age of 50. White women of European ancestry are most commonly affected. The clinical hallmarks of polymyalgia rheumatica are * pain and stiffness in the shoulder and pelvic girdle * normal or elevated ESR. * systemic symptoms: fever as high as 39°C (102°F) along with night sweats, depression, fatigue, malaise, anorexia, and weight loss **Corticosteroids** are the mainstay of therapy for polymyalgia rheumatica. Typically, a dramatic **response is seen within 48–72 hours.**

Answer 748

A Suppressive therapy with **acyclovir, valacyclovir, or famciclovir** reduces, but does not eliminate, the risk of transmission of HSV to sexual partners. HSV type 1 /2 infections in the genital area are clinically identical. Psychological issues, including anger, guilt, low self-esteem, anxiety, and depression are common after first receiving a diagnosis of genital HSV infection. Initial clinical outbreaks of genital HSV infections are often recurrences of previous infection. Either of the partners may have had an asymptomatic infection acquired in a previous relationship. An experimental HSV type 2 vaccine has been developed, but it is ineffective in men.

Answer 749

D ## Footnote Recent clinical experience has shown that MRSA is the most common identifiable cause of skin and soft-tissue infections among patients presenting to ED in 11 U.S. cities. The other responses should be considered in evaluating these infections, but they are not as common as MRSA infections.

Answer 750

A ## Footnote Tumor necrosis factor (TNF) inhibitors 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. A PPD skin test should be performed prior to initiating TFN-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 is necessary prior to TFN-inhibitor use, even for patients previously vaccinated with bacille Calmette-Guérin (BCG)

Answer 751

E ## Footnote This patient had a classic **simple febrile seizure** and no additional diagnostic studies are recommended. A lumbar puncture following a seizure is not routinely recommended in a child over 18 months of age, since by that age a patient with meningitis would be expected to demonstrate meningeal signs and symptoms or clinical findings suggesting an intracranial infection. There is no evidence to suggest that routine blood tests or neuroimaging studies are useful in a patient following a first simple febrile seizure, and it has not been shown that EEG performed either at the time of presentation or within the following month will predict the likelihood of recurrence.

Answer 752

B The best site for the tracheotomy incision is directly above the cricoid cartilage, through the cricothyroid membrane. Strictly speaking, this is not a tracheotomy, because it is actually *above* the trachea. However, it is *below* the vocal cords and bypasses any laryngeal obstruction

Answer 753

B While the majority of masses are benign, as many as 11% are hypersecreting tumors and approximately 7% are malignant tumors; the size of the mass and its appearance on imaging are major predictors of malignancy. Once an adrenal mass is identified, adrenal function must be assessed with an * **overnight dexamethasone suppression test. A morning cortisol level \>5 μg/dL after a 1-mg dose indicates** adrenal hyperfunction. * **24-hour fractionated metanephrines and catecholamines** to rule out pheochromocytoma. * **morning plasma aldosterone activity and plasma renin activity** should be assessed to rule out a primary aldosterone-secreting adenoma if the patient has hypertension

Answer 754

D ## Footnote If the patient is immunodeficient or pregnant, rather than a household contact, then MMR is contraindicated. Breastfeeding is not a contraindication.

Answer 755

A ## Footnote The drug most often recommended as first-line therapy for hypertension in pregnancy is **labetalol**. Reports of an association of metoprolol with fetal growth restriction have given rise to the recommendation to avoid its use in pregnancy. Both ACEi/ARBs are contraindicated in pregnancy because of the risk of birth defects and fetal or neonatal renal failure. Immediate-release nifedipine is not recommended due to the risk of hypotension.

Answer 756

C ## Footnote Hantavirus is usually spread by inhalation of dried aerosolized deer mouse urine or droppings. Infected deer mice usually have few outward signs. Other hosts include the white-footed mouse, the rice rat, and the cotton rat. Other rodents have not been shown to carry the virus.

Answer 757

E The results of this urine test were that * 10 people had the disease and tested positive (true positives) * 8 people had the disease but tested negative (false negatives) * 17 people did not have the disease (27 – 10) but tested positive (false positive) * 69 people did not have the disease (77 – 8) and tested negative (true negative) The negative predictive value is determined by dividing the true negatives (69) by the total number who tested negative (true plus false negatives = 77). The result is 89.6%, which rounded to a whole number is 90%.

Answer 758

A ## Footnote The chest pain associated with pericarditis is typically pleuritic, and is worse with inspiration or in positions that put traction on the pleuropericardial tissues, such as lying supine. Patients with acute pericarditis typically get relief or improvement when there is less tension on the pericardium, such as when sitting and leaning forward. This position brings the heart closer to the anterior chest wall, which incidentally is the best position for hearing the pericardial friction rub associated with acute pericarditis. Radiation of chest pain to both arms should raise concerns about myocardial ischemia or infarction. Radiation to the right scapula is sometimes seen with cholelithiasis. Worsening pain with the Valsalva maneuver is nonspecific and is of no particular diagnostic value.

Answer 759

A ## Footnote The ophthalmopathy of Grave’s disease may initially flare and worsen when treated with radioactive iodine. Antithyroid drugs, including propylthiouracil, and methimazole, are not associated with this problem. The addition of thyroid hormone to these drugs at suppressive doses has not shown any clear benefit over titration of the antithyroid drug, and relapse rates are similar. Thyroid surgery in the controlled patient has not been significantly associated with this problem.

Answer 760

A The live, attenuated influenza vaccine is an option for vaccinating healthy, nonpregnant individuals age 5-49 years. The vaccine is administered intranasally. It is not indicated in patients with underlying medical conditions, such as chronic pulmonary or cardiovascular disease, or in patients with a history of Guillain-Barré syndrome, pregnant patients, or children and adolescents who receive long-term aspirin or salicylate therapy. Patients with a history of hypersensitivity to eggs should not receive this vaccine.

Answer 761

B ## Footnote Omeprazole is associated with an increased risk of CAP and C. diff colitis. Omeprazole has also been shown to acutely decrease the absorption of Calcium (---\>\> increased risk of hip fracture) and vitamin B 12 (via blocking activity of intrinsic factor)

Answer 762

D ## Footnote Bullous impetigo is caused by Staphylococcus aureus exfolatin. Complications are rare, but cellulitis occurs in Systemic therapy should be used in patients with widespread lesions. With the emergence of MRSA, trimethoprim/sulfamethoxazole and clindamycin are options for outpatient therapy. Intravenous vancomycin can be used to treat hospitalized patients with more severe infections.

Answer 763

E ## Footnote levels of BNP lack the specificity necessary to function as absolute indicators of acute heart failure syndrome even when they exceed established thresholds for the diagnosis. BNP levels vary with age, sex, body habitus, renal function, and abruptness of symptom onset. Elevated BNP levels also have been associated with renal failure (because of reduced clearance), pulmonary embolism, pulmonary hypertension, and chronic hypoxia.

Answer 764

B ## Footnote As long as the attending physician is not employed by hospice, Medicare Part B can be billed. Medicare Part A (**hospital** insurance) covers inpatient care in hospitals and skilled nursing facilities, hospice, and home health services, but not custodial or long-term care. Medicare Part B (**medical** insurance) covers outpatient physician services, including office visits and home health services. Medicare Part C **(hospital + mediacal**) combines Part A and Part B coverage and is offered by private companies. These plans always cover emergency and urgent care, and may offer extra coverage such as vision, hearing, dental, and/or health and wellness programs. Most plans also include Medicare Part D, which provides prescription drug coverage. Medicare Part D plans vary with regard to cost and drugs covered.

Answer 765

B HFMD is caused by coxsackievirus A16. In addition to the oral lesions, _vesicular_ lesions may occur on the feet and nonvesicular lesions may occur on the buttocks. A low-grade fever may also develop. Herpangina is also caused by coxsackieviruses, but it is a more severe illness characterized by severe sore throat and _vesiculo-ulcerative_ lesions limited to the tonsillar pillars, soft palate, and uvula, and occasionally the posterior oropharynx. Temperatures can range to as high as 41°C (106°F). The etiology of aphthous stomatitis is multifactorial, and it may be due to a number of conditions. Systemic signs, such as fever, are generally absent. Lesions are randomly distributed. Herpetic gingivostomatitis also causes randomly distributed oral ulcers, but it is a more severe illness, regularly accompanied by a higher fever, and is extremely painful. Streptococcal pharyngitis is rarely accompanied by _ulceration_ except in agranulocytic patients.

Answer 766

B ## Footnote **Stress fractures of the femoral neck** are most commonly seen in military recruits and runners. They present with persistent groin pain, and limited hip flexion and internal rotation. Radiographs may be normal early. Iliotibial band syndrome also occurs in runners and presents with stinging pain over the lateral femoral epicondyle. Osteitis pubis occurs in distance runners and presents with pain in the anterior pelvic area and tenderness over the symphysis pubis. Pelvic inflammatory disease is associated with abdominal pain and fever.

Answer 767

D ## Footnote ADA recommends insulin infusion with a target glucose level of 140–180 mg/dL in critically ill patients, as studies have shown that there was no reduction in mortality from intensive treatment targeting near-euglycemic glucose levels compared to conventional management with a target glucose level of

Answer 768

A This patient has _smoldering (asymptomatic) multiple myeloma_. He does not have any organ or tissue damage related to this disease and has no symptoms. **Early treatment of these patients does not improve mortality and may increase the likelihood of developing acute leukemia**. The standard treatment for _symptomatic patients_ * _under 65_ is **autologous stem cell transplantation**. * _over 65_ **autologous stem cell transplantation** if they are healthy enough to undergo transplantation _OR_ **melphalan and prednisolone with or without thalidomide** if they are not candidates for transplantation. **Radiotherapy** can be used to relieve metastatic bone pain or spinal cord compression.

Answer 769

A ## Footnote Pertussis - prodromal phase that lasts 1–2 weeks and is indistinguishable from a viral URI. It progresses to a more severe cough after the second week. The cough is paroxysmal and may be severe enough to cause vomiting or fracture ribs. Patients are rarely febrile, but may have increased lacrimation and conjunctival injection. The incubation period is long compared to a viral infection, usually 7–10 days. Nonasthmatic eosinophilic bronchitis, cough-variant asthma, and gastroesophageal reflux disease cause a severe cough not associated with a catarrhal phase. A rhinovirus infection would probably be resolving within 2–3 weeks.

Answer 770

B ## Footnote The treatment for acute symptoms of asthma is an inhaled β2-adrenergic agonist such as albuterol, terbutaline, or pirbuterol. **If symptoms do not respond to β-agonists, they should be treated with a course of systemic ORAL corticosteroids**. Theophylline has limited usefulness for treatment of acute symptoms in patients with intermittent asthma; it is a less potent bronchodilator than subcutaneous or inhaled adrenergic drugs, and therapeutic serum concentrations can cause transient adverse effects such as nausea and central nervous system stimulation in patients who have not been taking the drug continuously. Cromolyn can decrease airway hyperreactivity, but has no bronchodilating activity and is useful only for prophylaxis. Inhaled corticosteroids should be used to suppress the symptoms of chronic persistent 2 asthma. Oral β2-selective agonists are less effective and have a slower onset of action than the same drugs given by inhalation.

Answer 771

C **Cefazolin** is the recommended prophylactic antibiotic for most patients undergoing orthopedic procedures such as total joint replacement, unless the patient has a β-lactam allergy

Answer 772

B The most likely diagnosis is septic arthritis of the hip. **US is highly sensitive** for the effusion seen in septic arthritis, which can be aspirated to confirm the diagnosis. Clinical features of septic arthritis include an * oral temperature \>38.5°C (101.3°F) * refusal to bear weight on the affected leg * an erythrocyte sedimentation rate \>40 mm/hr * WBC count \>12,000/mm3 * C-reactive protein level \>20 mg/L If US is negative, a bone scan should be done. CT of the hip is indicated to visualize cortical bone. MRI is especially valuable for osteomyelitis.

Answer 773

B ## Footnote The decision to utilize the Medicare hospice benefit is reversible, and patients may elect to return to Medicare Part A. Individuals who reside in nursing homes and assisted-living facilities are eligible for the Medicare hospice benefit. Patients with end-stage Alzheimer’s disease are eligible for the Medicare hospice benefit if they meet criteria for hospice. If the patient lacks decision-making capacity, a family member or guardian may elect the Medicare hospice benefit for the patient. The patient must be certified by the hospice medical director and primary physician to have a life expectancy of less than 6 months to qualify for hospice services. This requirement is the same whether or not the patient resides in a nursing home.

Answer 774

C A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. Aspirin is ineffective for prophylaxis of venous thromboembolism. Warfarin is effective at an INR of 2.0–3.0. Full anticoagulation with heparin is unnecessary for prophylaxis and can result in a higher rate of postoperative hemorrhage.

Answer 775

D ## Footnote Ethylene glycol poisoning should be suspected in a patient who appears intoxicated but does not have an odor of alcohol, and has anion gap acidosis (arterial pH Treatment with **fomepizole** (Antizol) should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary.

Answer 776

B ## Footnote Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with premenstrual syndrome, and must be ruled out before initiating therapy. The most accurate way to make the diagnosis is to have the patient keep a menstrual calendar for at least two cycles, carefully recording daily symptoms. Dysthymia consists of a pattern of ongoing, mild depressive symptoms that have been present for 2 years or more and are less severe than those of major depression. This diagnosis is consistent with the findings in the patient described here. Symptoms are cyclic in true PMS.

Answer 777

B ## Footnote Temporal arteritis: age over 50, new-onset headache, abnormalities of the temporal artery, and an elevated erythrocyte sedimentation rate. A temporal artery biopsy is needed to confirm the diagnosis, but when the findings are this compelling, corticosteroids should be started even before a biopsy, to prevent further vision loss.

Answer 778

C ## Footnote **Gilbert syndrome** - autosomal dominant, characterized by **indirect hyperbilirubinemia** caused by **impaired glucuronyl transferase activity**. The workup includes studies to exclude *hemolysis* (CBC, reticulocyte count, and haptoglobin) and *liver disease* (AST, ALT, alkaline phosphatase, and prothrombin time). Alcoholic liver disease is associated with a greater elevation of AST than of ALT. Dubin-Johhnson syndrome is a benign liver disease distinguished by direct or conjugated hyperbilirubinemia. Imaging studies are not required to confirm Gilbert syndrome; such studies are more useful for conditions involving conjugated hyperbilirubinemia. Other causes of indirect hyperbilirubinemia include hematoma, infection, cardiac disease, rhabdomyolysis, living at high altitude, thyrotoxicosis, and some medications.

Answer 779

E In a patient complaining of **flashes of light** and a **visual field defect**, **_retinal detachment_** is the most likely diagnosis. Many cases of _vitreous detachment_ are *asymptomatic*, and it does not cause sudden visual field defects in the absence of a retinal detachment. A _vitreous hemorrhage_ would cause more *blurring of vision* in the entire field of vision. _Ocular migraine_ causes binocular symptoms.

Answer 780

B Asthma controller medications are recommended for all patients with persistent asthma, and the preferred long-term controller treatment in mild persistent asthma is a low-dose inhaled corticosteroid. Cromolyn, leukotriene modifiers, nedocromil, and sustained-release theophylline are alternatives, but are not preferred initial agents. Quick-acting, quick-relief agents such as short-acting beta-agonists are appropriate for prompt reversal of acute airflow obstruction.

Answer 781

C ## Footnote This patient is engaged in cognitive therapy, which is a treatment process that helps patients correct false self-beliefs that can lead to negative moods and behaviors. Cognitive therapy has been shown to effectively treat patients with unipolar major depression, and is particularly useful in patients who do not respond to medication or who prefer nonpharmacologic therapy. Psychoanalysis is a process of free association where repressed memories are recovered. Biofeedback involves instrumentation that gives feedback about a patient’s *physiologic* response to various situations in order to bring the autonomic nervous system under voluntary control. Group psychotherapy is a form of treatment in which people who are emotionally ill meet in a group guided by a trained therapist and help one another effect personality change. Hypnosis involves helping a patient enter a state of heightened focal concentration and receptivity that is typified by a feeling of involuntariness or an altered state of consciousness.

Answer 782

D Atrial flutter is not ordinarily a serious arrhythmia, but this patient has heart failure manifested by rales, jugular venous distention, hepatojugular reflux, hypotension, and angina. Electrical cardioversion should be performed immediately. **Digoxin and verapamil** are appropriate in hemodynamically stable patients.

Answer 783

E ## Footnote Substantial toxicity can occur with one or two tablets, and all children suspected of ingesting a calcium channel blocker should be admitted to a pediatric intensive-care unit for monitoring and management. The use of gastric emptying, cathartics, or adsorptive agents is unlikely to be helpful and should be considered only in patients presenting within 1 hour of ingestion, if then. The American Academy of Pediatrics has advised that syrup of ipecac not be kept in the home because of toxicity and dubious benefit.

Answer 784

E ## Footnote The purpose of tocolysis of preterm labor before 34 weeks gestation is to allow time to administer corticosteroids to stimulate lung maturation. Treatment does not substantially delay delivery beyond 1 week. Repeated administration of corticosteroids does not confer more benefit than a single course. Antibiotics are administered for prophylaxis of group B Streptococcus and are useful for delaying delivery if membranes are ruptured. Prolonged and repeated tocolysis is believed to be harmful. Tocolysis would not be indicated in this patient because she has had no cervical change and is therefore having preterm contractions, not preterm labor. Careful monitoring for fetal compromise, consultation with obstetric colleagues, and neonatal ICU involvement should be part of expectant management of preterm labor cases.

Answer 785

B ## Footnote The Medicare Hospice Benefit reimburses hospice providers for the care of terminally ill patients. In order to be eligible for this benefit, patients must be entitled to **Medicare Part A** and be **certified by both the personal physician and the hospice medical director as having a life expectancy of 6 months or less**. Services covered include physician services; nursing services; social services; counseling services; physical, occupational, and speech therapy; diagnostic testing; home health aides; homemaker services; and medical supplies. These services may be provided in the patient’s home or in the hospital setting. Malignancy, ambulatory status, caregiver availability, and do-not-resuscitate orders are not specifically related to eligibility requirements for this benefit.

Answer 786

A ## Footnote When the flexion abduction external rotation (FABER) test elicits pain posteriorly, it indicates sacroiliac involvement. Anterior pain indicates hip involvement.

Answer 787

E ## Footnote Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants

Answer 788

C ## Footnote **Cutaneous larva migrans** occur when third-stage hookworm larvae penetrate the skin and migrate through the dermis, creating the serpiginous, erythematous tracks. Most encountered in tropical and semitropical regions such as the Caribbean, Africa, Asia, and South America. Travelers to beach environments where pet feces have been previously deposited are most at risk because of the direct contact of bare skin with the sand. As in this case, a stinging or itching sensation may be noted upon penetration; this is followed by the development of the creeping eruption, which usually appears 1–5 days later, although the onset may be delayed for up to a month. The larvae will not develop in the human host, so the infection is self-limited, usually resolving within weeks to months. Treatment with antihelminthic drugs can greatly reduce the clinical course. Preventive measures include treatment of infected dogs and cats and limiting exposure to contaminated soil by wearing shoes and protective clothing.

Answer 789

B ## Footnote Blood flow to the kidney is autoregulated so as to sustain pressure within the glomerulus. This is influenced by angiotensin II-mediated vasoconstriction. ACEi impair the kidney’s autoregulatory function, resulting in a decreased GFR and possibly AKI. This is usually reversible if it is recognized and the offending agent stopped. NSAIDs can exert a similar effect, but they can also cause glomerulonephritis and interstitial nephritis. Statins, haloperidol, and drugs of abuse (cocaine, heroin) can cause rhabdomyolysis with the release of myoglobin, which causes AKI. Thrombotic microangiopathy is a rare mechanism of injury to the kidney, and may be caused by clopidogrel, quinine, or certain chemotherapeutic agents.

Answer 790

D ## Footnote **Frontotemporal dementia** is the second most common cause of early-onset dementia. It often presents with behavioral and personality changes, such as disinhibition, impairment of personal conduct, loss of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimer’s disease presents with memory loss and visuospatial problems. Vascular dementia is associated with risk factors for stroke, or occurs in relation to a stroke, with a stepwise progression. Alzheimer’s disease and vascular dementia can occur together, with features of both. Progressive supranuclear palsy is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance.

Answer 791

D ## Footnote This patient has typical symptoms and laboratory findings of multiple myeloma, which accounts for 1% of all malignant diseases and has a mean age at diagnosis of 61 years. The diagnosis is confirmed by a bone marrow examination showing \>10% plasma cells in the marrow. The serum level of monoclonal immunoglobulin is typically \>3 g/dL. A bone scan is inferior to conventional radiography and should not be used. Tamoxifen is indicated for the treatment of breast cancer, which is unlikely given the physicaland laboratory findings in this case.

Answer 792

E ## Footnote Approximately 85% of cases of acute interstitial nephritis result from a drug-related hypersensitivity reaction. Medications that commonly cause acute interstitial nephritis through hypersensitivity reactions include **penicillins, sulfa drugs, and NSAIDs.** Urinalysis typically reveals moderate to minimal **proteinuria**, except in NSAID-induced acute interstitial nephritis, in which proteinuria may reach the nephrotic range. Other typical findings include **sterile pyuria**, the **absence of red blood cell casts**, and frequently **eosinophiluria**, but none of these findings is pathognomonic. Withdrawal of the causative agent leads to **resolution within 7–10 days** in the majority of cases, and most patients have a good recovery.

Answer 793

E ## Footnote Carisoprodol is metabolized to meprobamate, which is a class III controlled substance. It has been shown to produce both physical and psychologic dependence.

Answer 794

A ## Footnote Secondary hyperaldosteronism is characterized by sodium retention, and thus decreased urinary sodium excretion, while potassium secretion is normal to increased ``` Primary aldosteronism (hyporeninemic hyperaldosteronism) was previously thought to be most commonly caused by an adrenal adenoma, termed Conn's syndrome. Results in HTN, Hypokalemia, Alkalosis. Labs show high serum aldosterone, low serum renin ``` Secondary hyperaldosteronism (also hyperreninism, or hyperreninemic hyperaldosteronism) is due to overactivity of RAAS, commonly caused by RAS

Answer 795

C ## Footnote For men older than 65 years of age with small-volume, low-grade disease and a 10- to 15-year life expectancy, the risk of complications from treatment outweighs any decreased risk of dying from prostate cancer. Radiation, androgen deprivation therapy, and surgical approaches have not been shown to improve disease-free survival (SOR A).

Answer 796

D Secondary causes of N/V in pregnancy are more likely to be present if the onset of symptoms occurs after 9 weeks' gestation. Metoclopramide is more effective than placebo and has not been associated with an increased risk of adverse effects on the fetus.

Answer 797

E ## Footnote This child has typical findings of bronchiolitis caused by respiratory syncytial virus (RSV). Bronchodilator treatment may be tried once and discontinued if there is no improvement. Treatment usually consists of **supportive care only**, including oxygen and intravenous fluids if indicated. Corticosteroids, antibiotics, and decongestants are of no benefit. RSV infection may recur, since an infection does not provide immunity. Up to 10% of infected children will have wheezing past age 5, and bronchiolitis may predispose them to asthma.

Answer 798

D ## Footnote Based on this patient’s history and physical examination, COPD is the most likely cause of his dyspnea. Initial testing should include **spirometry to diagnose airflow obstruction.** CT, a BNP level, a D-dimer level, and arterial blood gas measurements would not be the best initial tests in the evaluation of this patient’s dyspnea.

Answer 799

D ## Footnote Placental abruption - separation of the placenta from the uterine wall before delivery Uterine rupture - usually occurs during active labor in women with a history of a previous C-section or with other predisposing factors, such as trauma or obstructed labor. Fetal distress or demise is the most reliable presenting clinical symptom Vasa previa - velamentous insertion of the umbilical cord into the membranes in the lower uterine segment; typically manifested by the onset of hemorrhage at the time of amniotomy or by SROM; hemorrhage is actually fetal blood, and exsanguination can occur rapidly. No prior maternal symptoms of distress. Placenta previa - placental implantation that overlies or is within 2 cm of the internal cervical os; clinically manifested as painless vaginal bleeding in the late second or third trimester, often after sexual intercourse.

Answer 800

D ## Footnote Excisional biopsy is the procedure of choice when melanoma is suspected. A shave biopsy should never be done for suspected melanoma, as this is likely to transect the lesion and destroy evidence concerning its depth, thus making it difficult to assess the prognosis. A punch biopsy should be used only with discretion when the lesion is too large for complete excision, or if substantial disfigurement would occur. Since this may not actually retrieve cancerous tissue from an unsampled area of a large lesion that might be malignant, it would be safest to refer such patients. Neither cryotherapy nor electrocautery should be used for a suspected melanoma.

Answer 801

B A small spontaneous pneumothorax involving less than 15%-20% of lung volume can be managed by administering oxygen and observing the patient. The pneumothorax will usually resorb in about 10 days if no ongoing air leak is present. Oxygen lowers the pressure gradient for nitrogen and favors transfer of gas from the pleural space to the capillaries. Chest tube placement is used if observation is not successful or for larger pneumothoraces Decompression with anterior placement of an intravenous catheter is usually reserved for tension pneumothorax.

Answer 802

E ## Footnote Somatization disorder - psychological disorder characterized by the chronic presence of several unexplained symptoms beginning before the age of 30 years. By definition, the symptom complex must include a **minimum of two symptoms** relating to the GI system, one neurologic complaint, one sexual complaint, and four pain complaints. The condition is more common in women than in men, and the incidence is increased as much as tenfold in female first degree relatives of affected patients.

Answer 803

C ## Footnote Muscle strength is scored on a scale of 0 to 5. The inability to contract a muscle is scored as 0. Contraction without movement constitutes grade 1 strength. Movement with the effect of gravity neutralized is grade 2 strength, Movement against gravity only is grade 3 strength. Movement against gravity plus some additional resistance indicates grade 4 strength. Normal, or grade 5, strength is demonstrated by movement against substantial resistance.

Answer 804

B hydration with sodium bicarbonate-containing fluids reduces the risk of contrast-induced nephropathy in those undergoing cardiac catheterization

Answer 805

A Clinical practice guidelines recommend that all patients with atypical glandular cells of undetermined significance (AGUS) be evaluated by colposcopy and endocervical curettage; endometrial sampling is recommended in women \> 35 yo and in those with AGUS favoring neoplasia or suggesting an endometrial source. CIN is the most common histologic diagnosis found in patients evaluated for AGUS.

Answer 806

D ## Footnote This patient has **tendinopathy of the posterior tibial tendon**. The tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture. Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem. While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. ***Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended.*** The best initial treatment is immobilization in a cast boot or short leg cast for 2–3 weeks.

Answer 807

D Plantar fasciitis is characterized by pain that is worse with the first few steps in the morning or after a prolonged rest. NSAIDs may help with the discomfort, but prompt relief of the pain by any modality is not common. The pain is typically in the medial heel. While 50% of people with plantar fasciitis have heel spurs on radiographs, this finding is not causative or diagnostic. The diagnosis is made clinically.

Answer 808

C ## Footnote This patient has epididymitis. In males 14–35 years of age, the most common causes are Neisseria gonorrhoeae and Chlamydia trachomatis. The recommended treatment in this age group is **ceftriaxone**, 250 mg intramuscularly, and **doxycycline**, 100 mg twice daily for 10 days. A single 1-g dose of **azithromycin** may be substituted for doxycycline. In those under age 14 or over age 35, the infection is usually caused by one of the common urinary tract pathogens, and **levofloxacin**, 500 mg once daily for 10 days, would be the appropriate treatment. If there is concern about testicular torsion, urgent surgical evaluation and US are appropriate. Testicular torsion is most common between 12 and 18 years of age but can occur at any age. It usually presents with an acute onset of severe pain and typically does not have associated urinary symptoms. On examination there may be a high-riding transversely oriented testis with an abnormal cremasteric reflex and pain with testicular evaluation. Color Doppler ultrasonography will show a normal-appearing testis with decreased blood flow

Answer 809

E ## Footnote The focus of screening for HIV has been shifted from testing only high-risk individuals to routine testing of all individuals in health-care settings. There are an estimated 1.1 million people in the US with HIV, and 25% are undiagnosed. Only 36.6% of adults have had an HIV test. Screening for hepatitis B and for TB is recommended only for certain at-risk populations. There is no generally used test for human papillomavirus. The CDC has not made any recommendations regarding screening for high cholesterol.

Answer 810

B This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks. Complete bed rest is unnecessary and could lead to complications. Physical therapy is not indicated, and NSAIDs should be used with caution.

Answer 811

D Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties such as mahi-mahi, amberjack, sardines, and herring can also cause this problem. **The poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine.** Symptoms occur within minutes to hours, and include flushing of the skin, oral paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia, tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually lead to resolution of symptoms within several hours. Only symptomatic treatment is indicated for ciguatera poisoning, as there is no specific treatment. The same is true for shellfish poisoning, although potential respiratory distress or failure must be kept in mind.

Answer 812

B Resistant or refractory hypertension is defined as a blood pressure ≥140/90 mm Hg, or ≥130/80 mm Hg in patients with diabetes mellitus or renal disease (i.e., with a creatinine level \>1.5 mg/dL or urinary protein excretion \>300 mg over 24 hours), despite adherence to treatment with full doses of at least three antihypertensive medications, including a diuretic. JNC 7 guidelines suggest adding a **loop diuretic** if serum creatinine is \>1.5 mg/dL in patients with resistant hypertension.

Answer 813

A ## Footnote The USPSTF and the AHA/ASA recommend **not** performing carotid artery screening with US or other screening tests in patients **without neurologic symptoms** because the **harms outweigh the benefits**. In the general population, screening tests for carotid artery stenosis would result in more false-positive results than true-positive results. This would lead to surgical procedures that are not indicated or to confirmatory angiography. As a result of these procedures, some patients would suffer serious harms such as death, stroke, or myocardial infarction, which outweigh the potential benefit surgical treatment may have in preventing stroke.

Answer 814

A ## Footnote **Apraxia** - **transmission disturbance on the output side, which interferes with skilled movements**. Even though the patient understands the request, he is unable to perform the task when asked, but may then perform it after a time delay. **Agnosia - inability to recognize previously familiar sensory input**, and is a modality-bound deficit. For example, it results in a loss of ability to recognize objects. Aphasia - language disorder, and expressive aphasia is a loss of the ability to express language. astereognosis - ability to recognize objects by palpation in one hand but not the other

Answer 815

B ## Footnote Diastolic dysfunction is due to LV hypertrophy as a response to chronic systolic hypertension. The ventricle becomes stiff and unable to relax or fill adequately, thus limiting its forward output. The typical patient is an elderly person who has systolic hypertension, LV hypertrophy, and a normal ejection fraction (50%–55%).

Answer 816

D The black box warning for thiazolidinediones specifically addresses **heart failure**. These agents are also contraindicated in patients with type 1 DM or hepatic disease, and in premenopausal anovulatory women.

Answer 817

E The current Dietary Reference Intake (DRI) recommendation for vitamin D is * 200 IU/day for all women between the ages of 9 and 50 years; pregnancy or lactation does not affect the recommendation. * 400 IU daily for women age 51-70 * 600 IU daily for women \>70. The maximum daily oral intake of vitamin D thought to be safe is 2000 IU/day for all females over the age of 12 months.

Answer 818

E Because there is no therapeutic ceiling for morphine, extremely large dosages can be used safely and effectively if the drug is titrated properly.

Answer 819

C Kawasaki disease is a common vasculitis often seen in children under 5 years of age. It is typically self-limited, with fever and acute inflammation lasting 12 days on average without therapy. However, if untreated, this illness can result in heart failure, coronary artery aneurysm, MI, arrhythmias, or occlusion of peripheral arteries. This diagnosis requires that **fever be present for \> 5 days** with no other explanation, and at least four of the following symptoms must be present: * (1) **nonexudative conjunctivitis that spares the limbus** * (2) **changes in the oral membranes such as diffuse erythema, injected or fissured lips, or “strawberry tongue”** * (3) **erythema of the palms and soles**, and/or edema of the hands or feet followed by **periungual desquamation** * (4) **cervical adenopathy** in the anterior cervical triangle with at least one node larger than 1.5 cm in diameter * (5) **an erythematous polymorphous rash**, which may be targetoid or purpuric in 20% of cases. The disease must be distinguished from toxic shock syndrome, streptococcal scarlet fever, Stevens-Johnson syndrome, juvenile RA, measles, adenovirus infection, echovirus infection, and drug reactions. Current recommendations are to hospitalize the patient for treatment with **IVIg and aspirin** for anti-inflammatory and antithrombotic effects. While prednisone is used to treat other forms of vasculitis, it is considered _unsafe_ in Kawasaki disease, as a study has shown an extraordinarily high rate of coronary artery aneurysm with its use.

Answer 820

B The ability to touch the tip of the thumb to the tip of the little finger indicates normal motor function of the median nerve. The median nerve ALSO partially controls flexion of the wrist, but the site of innervation is proximal to the wound site at the base of the thumb.

Answer 821

D ## Footnote For many women, labor will be preceded by several hours, or even days, by “bloody show.” So-called “false labor,” or Braxton Hicks contractions, consists of weak, irregular, regional contractions that usually occur for weeks before the onset of actual labor and abate with time, analgesia, and sedation. Spontaneous membrane rupture precedes the onset of labor in about 10% of pregnancies, and amniotic fluid leaks through the cervix and out the vagina. The second stage of labor is defined as the period from complete cervical dilation to complete delivery of the baby. When the cervix is completely dilated, the patient usually experiences the urge to push with contractions. The third stage of labor begins with the delivery of the baby and ends with the delivery of the placenta.

Answer 822

A ## Footnote The American Psychiatric Association recommend a trial of **lithium** or **_low_-dose T 3** for patients who have an incomplete response to antidepressant therapy. While thyroid supplementation as adjunctive therapy is effective, the recommended dosage is no higher than 50 μg/day. Atypical antipsychotics can be used as add-on therapy, but are not as effective as lithium or T3 Anticonvulsant medications such as gabapentin have been shown to be effective in the management of bipolar affective disorder, but not as adjunctive therapy in the treatment of unipolar depression resistant to single-agent antidepressants.

Answer 823

D ## Footnote Hamartomatous (or juvenile) polyps and hyperplastic polyps are benign lesions and are not considered to be premalignant. Adenomas, on the other hand, have the potential to become malignant. Sessile adenomas and lesions \>1.0 cm have a higher risk for becoming malignant. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are the most likely to develop into an adenocarcinoma.

Answer 824

D ## Footnote Spirometry is the best test for the diagnosis of COPD. The pressure of outflow obstruction that is not fully reversible is demonstrated by postbronchodilator spirometry showing an FEV /FVC ratio of 70% or less.

Answer 825

B ## Footnote This tracing shows **fetal tachycardia,** defined as a baseline fetal heart rate **\>160 beats/min for at least 15 minutes.** Causes include maternal fever, fetal hypoxia, hyperthyroidism, maternal or fetal anemia, medication effects of parasympatholytic or sympathomimetic drugs, chorioamnionitis, fetal tachyarrhythmia, and prematurity. Fetal tachycardia is not a sign of normal progression of labor. Epidural anesthesia, post-dates pregnancy, and umbilical cord prolapse would all be causes of fetal bradycardia.

Answer 826

D ## Footnote The knee-chest position has been found to allow for visualization of the vagina and cervix of a prepubertal child after 2 years of age without instrumentation. An assistant holds the child’s buttocks apart and the child is asked to relax her abdominal muscles and take a few deep breaths. With these preliminary steps, the vaginal orifice opens and the short vaginal canal fills with air. A bright light will help to illuminate the prepubertal child’s vagina and cervix. In the young child (usually For the older prepubertal child, examination is best done with the child lying supine with the knees spread apart on the examination table. The other positions listed are not helpful or recommended when examining the genital area of a prepubertal child.

Answer 827

A Tardive dyskinesia is much less common with second-generation antipsychotics. However, several of the second-generation drugs require monitoring for major side effects. For example, clozapine, shown by studies to be the most efficacious of the new class, causes granulocytopenia or agranulocytosis, requiring weekly and later biweekly CBCs. Both classes have depot formulations for IM administration every 2–4 weeks. Oral dosing of drugs from both classes varies from 1 to 3 times daily. First-generation antipsychotics cost less than second-generation drugs

Answer 828

A ## Footnote The score is known to be affected by the patient’s educational attainment. Given the same level of cognitive impairment, those with higher education levels score somewhat better than those with less education. Race, sex, and socioeconomic status per se do not affect patients’ scores.

Answer 829

A Polymyalgia rheumatica = discomfort is common in the neck, shoulders, and hip girdle areas; findings tend to be symmetric and ø objective joint swelling. ESR and CRP are significantly elevated but, these tests are nonspecific. Occasionally there are mild elevations of liver enzymes, but muscle enzymes, including CK, are not elevated in this disorder. Elevation of muscle enzymes strongly suggests another diagnosis. * Polymyositis and dermatomyositis are associated with variable levels of muscle enzyme elevations during the active phases of the disease. * Drug-induced myopathies such as those seen with the cholesterol-lowering statin medications tend to produce some elevation of muscle enzymes during the course of the disorder. * Hypothyroidism is associated with creatine kinase elevation. It should be strongly considered in the patient with unexplained, otherwise asymptomatic CK elevation found on a routine chemistry profile. * Hyperthyroidism may cause muscle disease and loss of muscle, but it is not associated with CK elevation.

Answer 830

A ## Footnote **Slow ascent** is the most effective way to prevent acute mountain sickness. **Acetazolamide or dexamethasone** can be used for both prevention and treatment. Acute mountain sickness is common in people traveling to altitudes higher than 8200 ft. Symptoms include HA and at least one of the following: N, V, anorexia, dizziness or lightheadedness, fatigue or weakness, and difficulty sleeping. Ataxia and AMS are signs of cerebral edema and occur with end-stage acute mountain sickness. This can progress to coma and death and requires prompt treatment and descent. High-altitude pulmonary edema can occur without acute mountain sickness. Alcohol consumption on the first day at altitude can exacerbate acute mountain sickness.

Answer 831

C ## Footnote This child has had a simple febrile seizure, the most common seizure disorder of childhood. Treatment includes finding a source for the fever; this should include a lumbar puncture if meningitis is suspected. The most common infections associated with febrile seizures include viral upper respiratory infections, otitis media, and roseola. Antipyretics are the first-line treatment. Antibiotics are indicated only for appropriate treatment of underlying infections. Phenytoin and carbamazepine are ineffective for febrile seizures. Phenobarbital is sometimes used for prevention of recurrent febrile seizures, but is not indicated as an initial therapy. Only 30%–50% of children with an initial febrile seizure will have recurrent seizures.

Answer 832

D ## Footnote Atypical squamous cells of undetermined significance (ASC-US) is one that is poorly reproducible, having been shown to be frequently downgraded to negative or upgraded to a low- or high-grade squamous intraepithelial lesion on review. Recommended management strategies for women with ASC-US include repeat cytology at 4–6 months, immediate colposcopy, and reflex DNA testing for oncogenic HPV types. Should two repeat cytologic examinations at 4- to 6-month intervals prove negative, the patient can safely return to routine cytologic screenings. Should any repeat examination detect ASC-US or more significant cytology, colposcopy is indicated.

Answer 833

A Patients with **persistent hyperestrogenic states are at heightened risk for the development of endometrial cancer.** The **chronic anovulation and consequent hyperstimulation of the endometrium seen with PCOS predispose women to endometrial hyperplasia and carcinoma**. Conversely, multiparity and late menarche are protective of the endometrium. Combination OCs use seems to decrease the risk for endometrial cancer. There is no evidence that IUD use leads to endometrial cancer, and it is thought that copper-containing IUDs may in fact provide some protection against endometrial cancer

Answer 834

B Macrolides are considered first-line therapy for Bordetella pertussis infection. Trimethoprim/sulfamethoxazole is considered second-line therapy

Answer 835

D All staff, visitors, and nursing-home residents should observe strict handwashing practices in this situation. Barrier precautions for wounds and medical devices should also be initiated. Surveillance cultures are not warranted. Aggressive housekeeping practices play little, if any, role in preventing the spread of MRSA. Isolating the patient is not practical or cost-effective.

Answer 836

B ## Footnote The primary treatment for symptomatic mitral valve prolapse is β-blockers. Asymptomatic patients require only routine monitoring, while those with significant mitral regurgitation may require surgery. Some patients with palpitations can be managed with lifestyle changes such as elimination of caffeine and alcohol. Orthostatic hypotension can often be managed with volume expansion, such as by increasing salt intake.

Answer 837

C ## Footnote The most common infection transmitted person-to-person in wrestlers is herpes gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm, which is manifested by round to oval raised areas with central clearing. Mat burn is an abrasion.

Answer 838

B The best initial imaging study for acute pelvic pain in women is transvaginal US because it provides the greatest level of detail regarding the uterus and adnexae,

Answer 839

A The first study ordered in any patient with suspected subarachnoid hemorrhage should be a **head CT _without_ contrast.** As blood is cleared from the affected area, CT sensitivity drops to 93% within 24 hours, and to 50% at 7 days. * Positive CT for SAH -\> angiography and treatment * Negative or equivocal results on head CT -\> lumbar puncture MRI and CT with contrast are not used for the diagnosis of acute subarachnoid hemorrhage.

Answer 840

D ## Footnote First-line therapies for urge urinary incontinence include **behavioral therapy, such as pelvic muscle contractions, and anticholinergic therapy.** Oral estrogen is not indicated. Noninvasive treatments should be tried initially. Urodynamic testing is indicated preoperatively. Stopping the hydrochlorothiazide would not be helpful, as it would not address the issue of detrusor instability.

Answer 841

D ## Footnote Nonbenzodiazepine muscle relaxants such as cyclobenzaprine are beneficial for the relief of acute low back pain for the first 7–14 days after the onset of symptoms. It is a muscle relaxer medication used to relieve skeletal musclespasms and associated pain in acute musculoskeletal conditions. Patient education, physical therapy, and the application of ice or heat may also help. Unsupported treatment options for acute low back pain include oral corticosteroids, acupuncture, lumbar support, massage, chiropractic spinal manipulation, and traction. Bed rest for acute low back pain is inadvisable.

Answer 842

B ## Footnote **Lichen sclerosus** is a chronic, progressive, inflammatory skin condition found in the anogenital region. It is characterized by intense vulvar itching. The treatment of choice is **high-potency topical corticosteroids.** Testosterone has been found to be no more effective than petrolatum. Fluorouracil is an antineoplastic agent most frequently used to treat actinic skin changes or superficial basal cell carcinomas.

Answer 843

B ## Footnote **Somatization disorder** - unconscious process or conflict that manifests as somatic/physical complaints without evidence of a medical disorder and does not involve lying or deliberate self-harm. **Conversion disorder** - involves a *single* symptom which is neurologic or pain-related. **Schizophrenia with multiple somatic delusions** - symptoms are bizarre and more vivid, persist over time, are unaltered by reasoned argument, and are not congruent with the patient’s social or cultural background. The delusional nature of psychotic somatic symptoms usually unfolds as the patient talks. **Histrionic personality disorder** is a pervasive pattern of excessive emotionality and attention seeking; constantly seeking to be the center of attention. Emotions are often expressed with inappropriate exaggeration. People with this disorder tend to be very self-centered and have little tolerance for delayed gratification. These people are typically attractive and seductive, often to the point of looking flamboyant and acting inappropriately. **Primary hypochondriasis -** fixed conviction that he or she is ill, the interpretation of all somatic changes as confirmation of this, and a relentless pursuit of medical assistance despite persistent dissatisfaction with the results; symptoms remain consistent for years. Physicians frequently feel overwhelmed when initially presented with a patient with somatization disorder. This disorder begins before age 30 and is rarely seen in males. The patient complains of multiple symptoms which involve many organ systems and do not readily conform to patterns seen in organic diseases. The patient skips back and forth from symptom to symptom during the interview. Anxiety and depressed mood are frequent in this disorder, and suicide attempts are common.

Answer 844

A ## Footnote Cognitive-behavioral therapy is the recommended treatment for OCD. Psychoanalytic therapy has not been shown to help treat OCD. Family therapy can help reduce family tensions that result from the disease. Psychodynamic psychotherapy and motivational interviewing may help patients overcome their resistance to treatment.

Answer 845

A Infants born to hepatitis B–positive mothers should receive both immune globulin and hepatitis B vaccine. They should receive the entire series of the vaccine, with testing for seroconversion only after completion of the vaccination series; the recommended age for testing is 9–12 months of age.

Answer 846

D ## Footnote This patient has nonspecific chronic back pain, most likely a **lumbar strain or sprain**. In addition to analgesics (acetaminophen or NSAIDs) and spinal manipulation, a **multidisciplinary rehabilitation program is the best choice for management.** This program includes a physician and at least one additional intervention (psychological, social, or vocational). Such programs alleviate subjective disability, reduce pain, return the person to work earlier, and reduce the amount of sick time taken in the first year by 7 days. Benefits persist for up to 5 years. TENS, and SSRIs have been found to have negative or conflicting evidence of effectiveness. There is no evidence to support the use of epidural corticosteroid injections in patients without radicular signs or symptoms.

Answer 847

E ## Footnote Pancreatitis is most closely associated with gallstones, extreme hypertrigliceridemia, and excessive alcohol use. Gastroesophageal reflux disease, pyelonephritis, drug abuse (other than alcohol), and angiotensin receptor blocker use are not risk factors for the development of pancreatitis.

Answer 848

E ## Footnote **ATR**ial fibrillation - **RAT**e control is the best initial management, with the most efficacious drugs for rate control are Ca channel blockers and ß-blockers. Digoxin is less effective for rate control and its role should be limited to a possible additional drug for those not controlled with a ß-blocker or calcium channel blocker, or for patients with significant LV systolic dysfunction. In patients \> 65 years or older or with one or more risk factors for stroke, the best choice for anticoagulation to prevent thromboembolic disease is warfarin. If rhythm control is successful and sinus rhythm is maintained, the thromboembolic rate is equivalent to that seen with a rate control strategy. Thus, the data suggests that patients managed with a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm.

Answer 849

A ## Footnote Intrahepatic cholestasis of pregnancy - Approximately 80% of patients present with pruritus alone, and another 20% with jaundice and pruritus. Laboratory results usually reveal normal or minimal elevation in transaminase levels, elevated bilirubin (usually Acute viral hepatitis is a common cause of jaundice in pregnancy; however, it usually does not present with severe pruritus, and transaminase levels are markedly elevated. Acute fatty liver of pregnancy is another rare condition occurring in the third trimester and is usually associated with preeclampsia. It presents with N/V, anorexia, jaundice, abdominal pain, headache, and neurologic abnormalities. Transaminase levels are moderately elevated, PT/PTT are prolonged, and profound hypoglycemia and renal failure are usually present. Pruritic urticarial papules and plaques of pregnancy (PUPPP) is more common in women that present with severe pruritus. However, jaundice and liver function abnormalities are absent. HELLP syndrome is an uncommon but serious condition which presents in the third trimester with hemolysis, elevated transaminases, and low platelet count.

Answer 850

C ## Footnote In normal term infants, there is little evidence that solid foods contribute to well-being before the age of 4–6 months. In addition, the **extrusion reflex** (pushing foreign material out of the mouth with the tongue) makes feeding of solids difficult and often forced. This reflex disappears around the age of 4 months, making feeding easier. The introduction of solids at this age helps supply calories, iron, and vitamins, and may prepare the infant for later dietary diversity and healthy dietary habits.

Answer 851

C ## Footnote Patients diagnosed with pharyngeal gonorrhea may be asymptomatic, or they may have oropharyngeal erythema and an exudate, along with cervical lymphadenopathy. Gonorrheal pharyngitis can coexist with cervical gonorrhea. First-line treatment for gonorrheal pharyngitis is **ceftriaxone**, 250 mg IM once. Although chlamydial pharyngitis is uncommon, patients with pharyngitis due to gonorrhea are often coinfected with genital Chlamydia and therefore should **also be treated empirically for chlamydial infection.** There is no need to perform a pelvic examination or order additional testing. All patients who are diagnosed with gonorrhea should be retested at 3–6 months due to a high rate of reinfection. Partner treatment is highly recommended.

Answer 852

B ## Footnote This patient is suffering from **patellofemoral pain syndrome**, which causes *anterior knee pain that is worse with running downhill*. The examination is often normal, although there may be *apprehension when the knee is extended with pressure over the patella and the patella will sometimes track laterally*. Patellofemoral pain syndrome can be **treated with exercises to strengthen the quadriceps and hips, and by using a knee sleeve with a doughnut-type cushion that the patella fits into.** Static stretching would not address the problem. MRI would be indicated if there were joint-line pain or an unstable knee. Pes anserine bursitis usually causes pain and tenderness medially, _below_ the joint line.

Answer 853

B Effective treatments for chronic orthostatic hypotension include **fludrocortisone, midodrine, and physostigmine.** Clonidine, pseudoephedrine, terbutaline, and theophylline are not appropriate therapies.

Answer 854

A ## Footnote The combination of arthritis with a typical palpable purpuric rash is consistent with a diagnosis of Henoch-Schönlein purpura. This most often occurs in children from 2 to 8 years old. Arthritis is present in about two-thirds of those affected. Gastrointestinal and renal involvement are also common. Rocky Mountain spotted fever presents with a rash, but arthralgias are not typical. These patients are usually sick with a fever and headache. Juvenile rheumatoid arthritis is associated with a salmon-pink maculopapular rash, but not purpura. The rash associated with Lyme disease is erythema migrans, which is a bull’s-eye lesion at the site of a tick bite. The rash associated with rheumatic fever is erythema marginatum, which is a pink, raised, macular rash with sharply demarcated borders.

Answer 855

C ## Footnote Anxiety, shortness of breath, paresthesia, and carpopedal spasm are characteristic of psychogenic hyperventilation. Respiratory alkalosis secondary to hyperventilation is diagnosed when arterial pH is 2 elevated and pCO is depressed. Low pH is characteristic of acidosis, either respiratory or metabolic, and 2 elevated pH with elevated pCO is characteristic of metabolic alkalosis with respiratory compensation

Answer 856

C Valproic acid is FDA-approved for the treatment of manic episodes associated with bipolar disorder. It has been shown in controlled studies to be significantly more effective than placebo. The initial dosage is 750 mg daily given in divided doses, and most individuals require between 1000 and 2500 mg daily. Carbamazepine has also been used to treat mania and is an alternative for individuals who cannot tolerate lithium or valproic acid. Clonazepam is used in the treatment of panic attacks, and gabapentin is used to treat anxiety. Both phenytoin and gabapentin are also used to treat peripheral neuropathy. The primary use of phenobarbital is as an anticonvulsant.

Answer 857

E ## Footnote Studies most strongly support the use of **thiazides** and **long-acting calcium channel blockers** as first-line therapy. Alpha-blockers are not recommended. ACEi, ß-blockers, and ARBs are indications for patients with DM or MI

Answer 858

C The seat belt should be positioned _under_ the pregnant woman’s abdomen (over both the ASIS and the pubic symphysis). The shoulder harness should be positioned between the breasts.

Answer 859

E Characteristic vital signs in patients with severe anorexia nervosa include: **hypotension, bradycardia,** and **hypothermia**. Criteria for hospital admission include a HR

Answer 860

E ## Footnote The effects of short-acting inhaled β-agonists begin within 5 minutes and last 4–6 hours. In the past, giving inhaled β-agonists just before inhaled corticosteroids was felt to improve the delivery and effectiveness of the corticosteroids. However, this has been proven to be ineffective and is no longer recommended. **β-Blockers do diminish the effectiveness of inhaled β-agonists,** but this effect is not severe enough to contraindicate using these drugs together. **Oral β-agonists are less potent than inhaled forms**. **Anticholinergic drugs** cause less bronchodilation than inhaled β-agonists and are not recommended as first-line therapy.

Answer 861

D ## Footnote A **perilymphatic fistula** between the middle and inner ear may be caused by barotrauma from scuba diving, as well as by direct blows, heavy weight bearing, and excessive straining (e.g., with sneezing or bowel movements.)This patients recent trip involved two of these potential factors. **Vestibular neuronitis** is a more sudden, unremitting syndrome. **Menieres disease** is manifested by episodes of vertigo, associated with hearing loss and often with nausea and vomiting. **Benign paroxysmal positional vertigo** is more likely in older individuals, and is associated with postural change. **Multiple sclerosis** requires symptoms in multiple areas and is not thought to be provoked by climate change.

Answer 862

C ## Footnote Patients with Parkinson's disease should respond to an adequate therapeutic challenge of levodopa or a dopamine agonist. The diagnosis of idiopathic Parkinson's disease is clinical, not radiographic. Cardinal signs of Parkinson's disease include an asymmetric tremor onset and a distal resting tremor of 3–6 Hz.

Answer 863

D ## Footnote The only approved treatments for male osteoporosis are **alendronate** and **recombinant parathyroid hormone.** Several drugs have been tested in clinical trials, and more pharmacologic treatments should become available in the future as male osteoporosis is increasingly recognized. Testosterone should not be used in this patient because of his history of prostate cancer.

Answer 864

E ## Footnote For those at **highest** risk and/or immunocompromised, including HIV-positive patients, transplant patients, and household contacts of a tuberculosis patient, an induration **≥5** mm is considered positive. For those at **low** risk of exposure, a screening test is not recommended, but if one is performed, induration **≥15 mm** is considered positive. For those who have an increased probability of exposure or risk, an induration ≥10 mm should be read as positive. This group includes children; employees or residents of nursing homes, correctional facilities, or homeless shelters; recent immigrants; intravenous drug users; hospital workers; and those with chronic illnesses. For individuals who are subject to repeated testing, such as health-care workers, an induration ≥10 mm within a 2-year period would be considered positive and an indication of a recent infection with M. tuberculosis. A nurse with a 9-mm induration would be considered to have a negative PPD.

Answer 865

D Of the drugs listed, the only maternal medication that affects the infant is lithium. Breastfed infants of women taking lithium can have blood lithium concentrations that are 30%–50% of therapeutic levels.

Answer 866

A Serum 25-hydroxyvitamin D should be obtained in any patient with suspected vitamin D deficiency because it is the major circulating form of vitamin D 1,25-Dihydroxyvitamin D is the most active metabolite, but levels can be increased by secondary hyperparathyroidism. In persons with vitamin D deficiency, ergocalciferol (vitamin D ) or cholecalciferol (vitamin D ) can be used to replenish stores

Answer 867

B ## Footnote Ziprasidone is a second-generation antipsychotic used in the treatment of schizophrenia. These drugs cause QT-interval prolongation, which can in turn lead to torsades de pointes and sudden cardiac death. This risk is further increased when these drugs are combined with certain antibiotics (**clarithromycin**), **antiarrhythmics (class I and III)**, and **tricyclic antidepressants.**

Answer 868

C All of the items listed are inhibitors of the cytochrome P450 enzyme except phenytoin, which is a potent inducer.

Answer 869

B ## Footnote Blood flow to the kidney is autoregulated so as to sustain pressure within the glomerulus. This is influenced by angiotensin II–related vasoconstriction. ACE inhibitors can impair the kidney’s autoregulatory function, resulting in a decreased GFR and possibly AKI. This is usually reversible if it is recognized and the offending agent stopped. NSAIDs can exert a similar effect, but they can also cause glomerulonephritis and interstitial nephritis. Statins, haloperidol, and drugs of abuse (cocaine, heroin) can cause rhabdomyolysis with the release of myoglobin, which causes AKI. Thrombotic microangiopathy is a rare mechanism of injury to the kidney, and may be caused by clopidogrel, quinine, or certain chemotherapeutic agents.

Answer 870

E ## Footnote **Acoustic neuroma** - due to cranial nerve involvement and progression of tumor size. **Hearing loss** and **tinnitus** is very common, with the loss is usually chronic (over 3 years) and as many as one-third of patients are unaware it has occurred. Diagnosis based on **asymmetric sensorineural hearing loss** or another cranial nerve deficit, with confirmation based on **MRI with gadolinium contrast** or **CT scan**. The _best initial screening test is **audiometry**_. Sensorineural loss is usually in the higher frequencies. Brainstem-evoked response audiometry may be used as a further screening measure when there are unexplained symmetrics and standard audiometric testing. Vestibular nerve involvement most often causes mild unsteadiness and rarely has accompanying true vertigo. Trigeminal involvement can cause pain, paresthesias, or numbness of the face. Facial paresis occurs 6% of the time.

Answer 871

B ## Footnote The elevated pH, normal oxygen saturation, and low pCO2 are characteristic of acute respiratory alkalosis, as seen with acute hyperventilation states. In patients with a PE, pO2 and pCO2 are decreased, while the pH is elevated. Vital signs would be normal with CO poisoning. Patients with an asthma exacerbation have a prominent cough and wheezing, and possibly other abnormalities. Tension pneumothorax causes severe cardiac and respiratory distress, with significant physical findings including tachycardia, hypotension, and decreased mental activity.

Answer 872

C ## Footnote **Teriparatide (recombinant PTH)** is indicated for **severe osteoporosis**, for patients with **multiple osteoporosis risk factors**, or for patients who have **failed bisphosphonate therapy**. It stimulates osteoblasts and new bone growth, increase turnover, improves micro-architecture; resulting in a net effect: increase BMD and decreased fractures. Therapy is limited to 2 years due to increased risk of osteosarcoma and contraindicated in persons with a history of bone malignancy, Paget disease, hypercalcemia, or previous treatment with skeletal radiation. Zoledronic acid is a parenterally administered bisphosphonate and would not be appropriate in a patient who has already failed bisphosphonate therapy. Raloxifene and calcitonin are not indicated in patients with severe osteoporosis who have failed bisphosphonate therapy.

Answer 873

D ## Footnote The USPSTF recommends vitamin D supplementation to prevent falls in community-dwelling adults 65 and older who are at increased risk for falls. Some studies suggest that low vitamin D levels are associated with an increased risk of cardiovascular disease, multiple sclerosis, colon cancer, dementia, and even diabetes.

Answer 874

B In general, when young children are found to be behind schedule in receiving recommended immunizations, catch-up immunization is important. However, the **rotavirus series should not be started past 15 weeks of age, or continued past 8 months of age due to increased risk of intussusception**. This child should have received Hep B vaccine at 6 mo, and should be given a catch-up dose. The MMR and varicella vaccines are recommended at the 12-month visit.

Answer 875

B ## Footnote The use of a ***non-exercised injection site*** for insulin administration, such as the abdomen, may ***reduce the risk of exercise-induced hypoglycemia.*** If the leg is used as an injection site, exercise may accelerate insulin absorption, resulting in increased levels of plasma insulin. However, leg exercise has no effect on insulin disappearance from the arm and may actually reduce the rate of insulin disappearance from abdominal injection sites. Compared with leg injection, arm or abdominal injection reduces the hypoglycemic effect of exercise by approximately 60% and 90%, respectively.

Answer 876

D ## Footnote Spiral CT has high sensitivity and specificity for diagnosing appendicitis. Ultrasonography is used in women who are pregnant and women in whom there is a high degree of suspicion of gynecologic disease. Abdominal xray has low specificity and sensitivity for the diagnosis of acute appendicitis. Air contrast barium enema also has low accuracy. Limitations of MRI include increased cost, decreased availability, and increased examination time compared to CT.

Answer 877

A ## Footnote Both **ectopic** pregnancy and **abortion** (spontaneous or therapeutic) pose a significant risk for fetomaternal hemorrhage. Thus, RHO immune globulin (RhoGAM) is recommended for **any Rh-negative patient who is unsensitized** (D antibody screen–negative). If the estimated gestational age is 12 weeks or less, 50 mcg of RhoGAM is recommended. If the estimated gestational age is greater than 12 weeks, 300 µg of RhoGAM is recommended

Answer 878

A ## Footnote Osgood-Schlatter disease is an inflammatory condition that is a common cause of knee pain in children and adolescents. The diagnosis is usually based on clinical findings, although radiographs may be necessary to rule out fractures or other problems if findings are not typical. MRI, ultrasonography, and orthopedic referral are not usually needed. The problem is typically self-limited and responds to activity modification, over-the-counter analgesics, stretching, and physical therapy.

Answer 879

E ## Footnote **Diabetes insipidus -** caused by ∆ arginine vasopressin aka ADH, which acts to concentrate urine in the distal tubules. Both low secretion of AVP from the pituitary and reduced antidiuretic action on the kidney can be primary or secondary, and the causes are numerous. Patients with diabetes insipidus present with **profound urinary volume, frequency of urination, and thirst.** Urine is very dilute, with **osmolality . Further workup will help determine the specific type of diabetes insipidus and its cause, which is necessary in order to implement appropriate treatment. Low levels of aldosterone, plasma renin activity, or angiotensin would cause abnormal blood pressure, electrolyte levels, and/or renal function. Insulin deficiency results in diabetes mellitus.**

Answer 880

B ## Footnote Chest pain is common in patients with pulmonary embolism (PE). When evaluating a patient for possible PE, the presence of orthopnea suggests heart failure, fever suggests an infectious process, wheezing suggests asthma or COPD, and rhonchi suggest heart failure, interstitial lung disease, or infection.

Answer 881

E ## Footnote Difficult-to-control hypertension has many possible causes, including nonadherence or the use of alcohol, NSAIDs, certain antidepressants, or sympathomimetics. Secondary hypertension can be caused by relatively common problems such as chronic kidney disease, obstructive sleep apnea, or primary hyperaldosteronism, as in this case. As many as 20% of patients referred to specialists for poorly controlled HTN have primary hyperaldosteronism. It is more common in women and often is asymptomatic. A significant number of these individuals will not be **hypokalemic**. Screening can be done with a morning **plasma aldosterone/renin ratio.** If the ratio is **\> 20** and the aldosterone level is \>15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered.

Answer 882

A ## Footnote This child has an RSV nfection and supportive care is the mainstay of therapy. If the child can take in fluids by mouth and tolerate room air, outpatient management is reasonable, especially in the absence of significant underlying risk factors. Routine use of corticosteroids is _not_ recommended. Although up to 60% of infants hospitalized for bronchiolitis receive corticosteroid therapy, studies have not provided sufficient evidence to support their use. Inhaled corticosteroids have not been shown to be beneficial, and the safety of high doses in infants is unclear. Supplemental O2 should be administered if functional oxygen saturation (SpO2) persistently falls below 90% and can be discontinued when an adequate level returns. Antiviral therapy for RSV bronchiolitis is controversial because of its marginal benefit, cumbersome delivery, potential risk to caregivers, and high costbb. Studies of ribavirin in patients with bronchiolitis have produced inconsistent findings. Palivizumab is a preventive measure, and is not used for treatment of the active disease. It may be considered in select infants and children with prematurity, chronic lung disease of prematurity, or congenital heart disease (SOR A). If used, it should be administered intramuscularly in five monthly doses of 15 mg/kg, usually beginning in November or December.

Answer 883

B ## Footnote Amoxicillin remains the recommended first-line treatment for uncomplicated acute otitis media. Various other antimicrobial agents have not proved to be more efficacious, and are associated with more frequent side effects.

Answer 884

E ## Footnote Any patient with a life expectancy of less than 6 months who chooses a palliative care approach is an appropriate candidate for hospice. **There is no penalty if patients do not die within 6 months, as long as the disease is allowed to run its natural course.** Medicare does not require a DNR order to enroll in hospice, but it does require that patients seek only palliative, not curative, treatment. **Patients may receive chemotherapy, blood transfusions, or radiation if the goal of the treatment is to provide _symptom relief_**. Patients can be referred to hospice by anyone, including nurses, social workers, family members, or friends.

Answer 885

C Age-related macular degeneration is the most common cause of blindness in the older population. It occurs more frequently in light-skinned individuals than in dark-skinned individuals. **Risk factors include smoking and hypertension**

Answer 886

E In controlled studies, it has been shown that a single 200-mg dose of doxycycline given within 72 hours after an Ixodes scapularis tick bite can prevent the development of Lyme disease.

Answer 887

C In women of average or low weight, lack of weight gain throughout pregnancy is often associated with fetal growth retardation The greatest demand for iron is during the latter half of pregnancy. Only vegetarians and those with actual serum vitamin B12 deficiency require vitamin B12 supplementation. Unless there are complications, e.g., hypertension or cardiovascular disease, there is no reason the pregnant patient cannot salt her food to taste. Obstetric risk factors for teenagers include poor nutrition, smoking, alcohol and drug abuse, and genital infections.

Answer 888

A ## Footnote There is not a linear correlation between bone mineral density and fracture risk. Bone architecture may be changed by bisphosphonate therapy, which may result in a decreased fracture risk. This patient has not had a fracture and is on adequate medical therapy that should be continued.

Answer 889

C ## Footnote VSD causes overload of both ventricles, since the blood is shunted L -\> R. The murmur is harsh and holosystolic, generally heard best at the LLSB. As the volume of the shunting increases, cardiac enlargement and increased pulmonary vascular markings can be seen on a chest x-ray.

Answer 890

A ## Footnote Many elderly patients with heart failure are hospitalized repeatedly at short intervals. There is now good evidence that case management interventions led by a heart failure specialist nurse reduce heart failure readmissions, all-cause readmissions, and all-cause mortality. Case management interventions include home care, telephone calls, patient education, self-management, and face-to-face visits. It is not possible to say which specific interventions were optimal, but telephone follow-up was a common component in most of these trials. Multidisciplinary interventions may also be effective. For patients treated with lisinopril, 40 mg/day is the maximum amount recommended for heart failure. While ß blockers and aldosterone antagonists are used in the treatment of heart failure, prophylactic amiodarone would not be expected to help and may be harmful. Admission to a nursing home may reduce hospitalization, but it would also increase overall costs of care.

Answer 891

C ## Footnote Lower-extremity edema is common in the last trimester of normal pregnancies and can be treated symptomatically with compression stockings. Edema has been associated with preeclampsia, but the majority of women who have lower-extremity edema without BP elevation will not develop preeclampsia or eclampsia. For this reason, edema has recently been removed from the diagnostic criteria for preeclampsia. Disproportionate swelling in one leg versus another, especially associated with leg pain, should prompt a workup for deep venous thrombosis but is unlikely given this patient’s presentation, as are cardiac or renal conditions.

Answer 892

B ## Footnote A **serum total** **testosterone** level is recommended as the initial screening test for late-onset male hypogonadism. Due to its high cost, a **free testosterone level is recommended only if the total testosterone level is borderline and abnormalities in SHBG are suspected.** Follow-up LH and FSH levels help to distinguish primary from secondary hypogonadism.

Answer 893

C ## Footnote The etiology of **prepubertal labial adhesions** is idiopathic. The adhesions may be partial or complete; in some cases only a small pinhole orifice may be seen that allows urine to exit from the fused labia. This problem may be asymptomatic, but the patient may also have a pulling sensation, difficulty with voiding, recurrent UTIs, or vaginitis. If there is enough labial fusion to interfere with urination, treatment should be undertaken. The use of topical estrogen cream twice daily at the point of the midline fusion will usually result in resolution of the problem.

Answer 894

E ## Footnote Approximately 4% of US studies at 20–24 weeks gestation show a placenta previa, but it occurs in only 0.4% of pregnancies at term, because of migration of the placenta away from the lower uterine segment. Therefore, in the absence of bleeding, the most appropriate management is to repeat the US in the third trimester. Because many placenta previas resolve close to term, a decision regarding mode of delivery should not be made until after US is performed at 36 weeks gestation

Answer 895

E ## Footnote The initial treatment of mild - moderate allergic rhinitis should be an IN corticosteroid alone, with the use of second-line therapies for moderate to severe disease. The adverse effects and higher cost of IN antihistamines, as well as their decreased effectiveness compared with IN corticosteroids, limit their use as first-or second-line therapy for allergic rhinitis. Moderate to severe disease not responsive to IN corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.

Answer 896

A ## Footnote Treatment with corticosteroids is now routinely recommended for acute laryngotracheitis (croup). **A single dose of dexamethasone, either orally or intramuscularly, is appropriate.** Prolonged courses of corticosteroids provide no additional benefit and may lead to secondary bacterial or fungal infections. **Secondary infections rarely occur with single-dose treatment.** Corticosteroid therapy shortens emergency department stays and decreases the need for return visits and hospitalizations. It is indicated for patients with croup of any severity.

Answer 897

D ## Footnote A 95% CI is an estimate of certainty. It means there is 95% certainty that the true value lies within the given interval range. When a confidence interval crosses 1.00, the validity of the resulting statistical estimate is questionable. Sensitivity is the percentage of patients with a disease who have a positive test for the disease. Specificity is the percentage of patients without a disease who have a negative test for the disease. Relative risk reduction is the percentage difference in risk between the treatment and control groups. The number needed to treat is the number of patients who need to receive an intervention instead of the alternative in order for one additional patient to benefit.

Answer 898

C ## Footnote Metformin has been found to reduce cardiovascular risk in patients with type 2 diabetes mellitus. It also decreases the risk of weight gain, and unlike some oral agents it does not significantly increase the risk of hypoglycemia. It should be continued when insulin is initiated in patients with no renal impairment.

Answer 899

E * **Pioglitazone** is a thiazolidinedione, which reduces insulin resistance via activation of PPAR-Y, a receptor that affects several insulin-responsive genes. * **Repaglinide and nateglinide** are nonsulfonylureas that act on a portion of the sulfonylurea receptor to stimulate insulin secretion. * **Acarbose** is a competitive inhibitor of α-glucosidases, enzymes that break down complex carbohydrates into monosaccharides. * **Sitagliptin** is a DPP-IV inhibitor, and this class of drugs inhibits the enzyme responsible for the breakdown of the incretins GLP-1 and GIP. * **Exenatide** is an incretin mimetic that stimulates insulin secretion in a glucose-dependent fashion, slows gastric emptying, and may promote satiety.

Answer 900

A Sexual dysfunction, including decreased libido, ejaculatory disturbance, and anorgasmia, is common with the SSRIs (e.g., sertraline and fluoxetine). Tricyclic antidepressants such as imipramine also cause sexual dysfunction. Trazodone can cause priapism. Only bupropion is relatively free of sexual side effects.

Answer 901

D ## Footnote There are no proven therapies to reduce the severity of borderline personality disorder. The most promising psychological therapy is dialectic behavioral therapy (DBT). Another promising therapy is psychoanalytic-oriented day hospital therapy. Omega-3 fatty acids, second-generation antipsychotics, and mood stabilizers have been shown to be helpful for some symptoms of borderline personality disorder but not for overall severity. Their benefits are based on single-study results and side effects were not addressed in the studies. SSRIs are not recommended for borderline personality disorder unless there is a concomitant mood disorder.

Answer 902

C ## Footnote The recommended treatment regimen for gonorrhea is **ceftriaxone, 250 mg intramuscularly.** In addition, the patient should be give**n azithromycin, 1 g orally**, because of the high incidence of coinfection with Chlamydia*, even if testing is negative*, and to decrease the risk for cephalosporin resistance.

Answer 903

C ## Footnote Recent data suggest that insulin resistance and hyperinsulinemia are important in the pathogenesis of polycystic ovary syndrome (POS). Treatment with drugs that reduce insulin levels, such as metformin, has been shown to correct many of the metabolic abnormalities associated with POS. Such correction results in resumption of ovulation, decreased insulin resistance, and improved beta-cell function; it also produces improvement in cardiovascular risk factors such as dyslipidemia and impaired fibrinolysis.

Answer 904

E ## Footnote For unknown reasons, Streptococcus bovis bacteremia or endocarditis is associated with a high incidence of occult colorectal malignancies. It may also occur with upper gastrointestinal cancers. Radiography or endoscopy is indicated.

Answer 905

A ## Footnote The “Get Up and Go Test” is the most frequently recommended screening test for mobility. Any unsafe or ineffective movement with this test suggests balance or gait impairment and an increased risk of falling. If the test is abnormal, referral to PT for complete evaluation and assessment should be considered. Other interventions should also be considered, such as a medication review for factors related to the risk of falling.

Answer 906

A Withdrawal can be divided into four levels of severity: minor, major, seizures, and delirium tremens. * Minor - (6-24 hours after the last drink) tremor, anxiety, nausea, vomiting, and/or insomnia * Major - (10-72 hours after the last drink) minor withdrawal + **visual and auditory hallucinations**, **diaphoresis, tachycardia,** **HTN**. * Delirium tremens (3-10 days after the last drink) - minor/major withdrawal + **delirium** + **fever** Alcoholic seizure generally occurs within 2 days of the last drink and may be the only sign of withdrawal, although approximately one-third of these patients will progress to delirium tremens.

Answer 907

A ## Footnote Community-acquired MRSA should be considered the cause of this type of infection until definitive cultures are obtained. CA-MRSA can cause aggressive infections in children, especially in the skin and soft tissue. Incision and drainage of the abscess is necessary for treatment. In a severe infection, vancomycin should be started initially until culture and sensitivities are available

Answer 908

C ## Footnote The American Academy of Otolaryngology recommends **initiating antibiotic treatment in patients with symptoms persisting for 7–10 days that are not improving or worsening**. **_Amoxicillin_** should be the _first-line_ agent, with azithromycin or TMP/SMX for penicillinallergic patients. Broader-spectrum antibiotics such as fluoroquinolones should be reserved for treatment failures. Imaging is indicated only if other etiologies are being considered or if the problem is recurrent.

Answer 909

E ## Footnote BNP is secreted in the ventricles and is sensitive to changes in left ventricular function; concentrations correlate with EDP, which in turn correlates with dyspnea and congestive heart failure. BNP BNP \> 400 pg/mL, the likelihood of CHF is 95%. BNP 100–400 pg/mL need further investigation, as there are some pulmonary problems that may elevate BNP, such as lung cancer, cor pulmonale, and pulmonary embolus. However, these patients do not have the same extent of elevation that those with acute LV dysfunction will have. If these problems can be ruled out, then individuals with levels between 100–400 pg/mL most likely have CHF. **Initial therapy for CHF should be a loop diuretic**. It should be noted that BNP is partially excreted by the kidneys, so levels are inversely proportional to creatinine clearance.

Answer 910

E There are no absolute contraindications to ECT, but more complications are seen in patients with a history of recent cerebral hemorrhage, stroke, or increased ICP.

Answer 911

E ## Footnote Gallstones are frequently discovered on a diagnostic workup for an unrelated problem. Only 1%–2% of persons with asymptomatic gallstones will require cholecystectomy in a given year, and two-thirds of patients with asymptomatic gallstones will remain symptom free over a 20-year period. The longer the patient remains asymptomatic, the more likely that no symptoms will develop in the future. This patient may have had gallstones for several years, and the best management would be to do nothing unless symptoms develop.

Answer 912

C ## Footnote surgical treatment of severe obesity be considered for any patient with a BMI \>40 or those with a BMI \>35 who have serious coexisting medical problems. Examples of such coexisting medical problems include severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy, and severe diabetes mellitus.

Answer 913

C This patient **subacute thyroiditis**, including a painful thyroid gland, hyperthyroidism, and an elevated ESR. It is unclear whether there is a viral etiology to this self-limited disorder. Thyroid function returns to normal in most patients after several weeks, and may be followed by a temporary hypothyroid state. Treatment is symptomatic, but NSAIDs can be helpful for mild pain, high-dose glucocorticoids provide quicker relief for the more severe symptoms.

Answer 914

E The American Heart Association recommends a goal blood pressure of 130/80 mm Hg or less for the treatment of hypertension in patients with DM, CKD, or CAD

Answer 915

C Actinic keratoses are scaly lesions that develop on sun-exposed skin, and are believed to be carcinoma in situ. While most actinic keratoses spontaneously regress, others progress to squamous cell cancers.

Answer 916

B ## Footnote This patient with moderate COPD and moderate nonpulmonary arterial hypertension pulmonary hypertension is hypoxic and meets the criteria for use of supplemental oxygen. Sildenafil and nifedipine are utilized in pulmonary arterial hypertension, but evidence is lacking for their use in pulmonary hypertension associated with chronic lung disease and/or hypoxemia. Low-dose prednisone may be a future option.

Answer 917

A ## Footnote Metformin = first-line drug for type 2 DM. It is relatively effective, safe, and inexpensive, and has been used widely for many years. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione, or insulin can be added, with the choice based on the severity of the hyperglycemia. Unlike other oral hypoglycemics and insulin, metformin does not cause weight gain.

Answer 918

E ## Footnote Patients with CKD and those at risk for CKD because of conditions such as hypertension and diabetes have an increased risk of deterioration in renal function from NSAIDs because they induce renal injury by acutely reducing renal blood flow and, in some patients, by causing interstitial nephritis. ACE inhibitors and angiotensin II receptor blockers are renoprotective and their use is recommended in all diabetics. The use of low-dose aspirin and folic acid is recommended in all patients with diabetes, due to the vasculoprotective properties of these drugs. High-dose aspirin should be avoided because it acts as an NSAID.

Answer 919

A ## Footnote Up to 20% of patients diagnosed with epilepsy actually have **pseudoseizures**. A history of fibromyalgia or chronic pain syndrome is predictive of pseudoseizures. If obtained within 20 minutes of the event, a serum prolactin level may be useful in differentiating a true seizure from a pseudoseizure. An elevated level has a sensitivity of 60% for generalized tonic-clonic seizures and 46% for complex partial seizures. Other features suggestive of seizure activity include tongue biting, the presence of an aura, postictal confusion, and focal neurologic signs. Eye closure throughout the event is uncommon in true seizures.

Answer 920

A DSM IV criteria for delirium include the following: * A. ∆ in consciousness (i.e., reduced clarity of awareness about the environment) with reduced ability to focus, sustain, or shift awareness. * B. ∆ in cognition (e.g., memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. * C. **develops over hours to days,** with a tendency to **fluctuate** during the course of a day * D. evidence from the H&P or labs that indicates the disturbance is caused by direct physiologic consequences of a general medical condition. In the case described, the patient’s history does not indicate preexisting problems and she had a relatively abrupt onset of disturbance of consciousness and change in cognition, related to the hospitalization for hip fracture.

Answer 921

C ## Footnote Age-related macular degeneration (AMD) is the leading cause of blindness in the U.S. in individuals over age 65. AMD currently affects more than 1.75 million individuals in the U.S. Due to the rapid aging of the population, this number will increase to almost 3 million by 2020.

Answer 922

E ## Footnote Trimethoprim/sulfamethoxazole is the treatment of choice for acute Pneumocystis pneumonia. Adjunctive corticosteroids should also be started in any patient whose initial pO2 on room air is All of the other medications listed are effective therapy for Pneumocystis pneumonia, but they do not need to be given with trimethoprim/sulfamethoxazole.

Answer 923

A ## Footnote A Cochrane meta-analysis of nicotine replacement therapy (NRT) found that it almost doubles a smokers chances of quitting. There was no benefit to tapering NRT as compared to abrupt discontinuation. Treatment for 8 weeks was as effective as a longer course. No one type of NRT is significantly more effective, but combining several types may aid a relapsed smoker in his or her next quit attempt.

Answer 924

E If supraventricular tachycardia is refractory to adenosine or rapidly recurs, the tachycardia can usually be terminated by the administration of **IV verapamil or a β-blocker**. If that fails, IV **propafenone or flecainide** may be necessary. It is also important to look for and treat possible contributing causes such as hypovolemia, hypoxia, or electrolyte disturbances. Electrical cardioversion may be necessary if these measures fail to terminate the tachyarrhythmia.

Answer 925

A ## Footnote BNP is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload; its release is directly proportional to ventricular dysfunction. It is a simple and rapid test that reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram

Answer 926

D Breast cancer screening has resulted in an increase in the diagnosis of localized disease without a commensurate decrease in the incidence of more widespread disease. Unfortunately, it cannot predict which of the discovered cancers are more aggressive, and cannot accurately detect premalignant lesions. The decrease in the mortality rate of breast cancer is due both to earlier detection and better follow-up medical care.

Answer 927

E ## Footnote Hypertrophic cardiomyopathy is an **autosomal dominant** condition and close relatives of affected individuals should be screened. The hypertrophy usually stays the same or worsens with age. This patient should not participate in strenuous sports, even those considered noncontact. Beta-blockers have not been shown to alter the progress of the disease. The mortality rate is believed to be about 1%, with some series estimating 5%. Thus, in most cases lifespan is normal.

Answer 928

B ## Footnote According to several RCTs, mortality rates are improved in patients with heart failure who receive ß-blockers in addition to diuretics, ACEi, and occasionally, digoxin. **Contraindications to ß-blocker use include hemodynamic instability, heart block, bradycardia, and severe asthma.** ß-blockers may be tried in patients with mild asthma or COPD as long as they are monitored for potential exacerbations. Beta-blocker use has been shown to be effective in patients with NYHA Class II or III heart failure. There is no absolute threshold ejection fraction. Beta-blockers have also been shown to decrease mortality in patients with a previous history of myocardial infarction, regardless of their NYHA classification.

Answer 929

B Women who take combination OCs have a _reduced risk of both ovarian + endometrial cancer_. This benefit is detectable within a year of use and appears to persist for years after discontinuation. Other benefits include a _reduction in dysfunctional uterine bleeding and dysmenorrhea_; a _lower incidence of ovarian cysts, ectopic pregnancy and benign breast disease_; and an _increase in hemoglobin concentration_. Many women also benefit from the convenience of menstrual regularity. All combination oral contraceptives raise sex hormone–binding globulin and decrease free testosterone concentrations, which can lead to _improvement in acne_.

Answer 930

A Clozapine was the first atypical antipsychotic drug, so designated because it has antipsychotic effects without the adverse effects on movement seen with first-generation agents, in addition to having enhanced therapeutic efficacy compared with first-generation drugs. Because of these advantages, it was introduced into clinical practice in the United States despite a serious known adverse effect: an increased incidence of agranulocytosis. Although only clozapine causes agranulocytosis in a substantial proportion of patients, many second-generation drugs produce clinically significant weight gain.

Answer 931

D ## Footnote In IDA, serum iron and ferritin is low but iron-binding capacity is high. Bone marrow iron stores are depleted. Oral Fe replacement will raise the hemoglobin level by 0.2 g/dL/day. A reticulocyte response should be seen in a week to 10 days unless factors such as a concomitant folic acid deficiency prevent a full response to therapy.

Answer 932

E ## Footnote Both typical and atypical antipsychotics can cause prolongation of the QTc interval, resulting in torsades de pointes, ventricular tachycardia, and sudden death. The best way of monitoring the QTc interval is electrocardiography.

Answer 933

E ## Footnote Entrapment of the **posterior tibial nerve** or its branches as the nerve courses behind the medial malleolus results in a neuritis known as t**arsal tunnel syndrome**. Causes of compression within the tarsal tunnel include varices of the posterior tibial vein, tenosynovitis of the flexor tendon, structural alteration of the tunnel secondary to trauma, and direct compression of the nerve. **Pronation of the foot causes pain and paresthesias in the medial aspect of the ankle and heel, and sometimes the plantar surface of the foot.** The usual site for a stress fracture is the shaft of the second, third, or fourth metatarsals. A herniated nucleus pulposus would produce reflex and sensory changes. Plantar fasciitis is the most common cause of heel pain in runners and often presents with pain at the beginning of the workout. The pain decreases during running only to recur afterward. Diabetic neuropathy is usually bilateral and often produces paresthesias and burning at night, with absent or decreased deep tendon reflexes.

Answer 934

A ## Footnote A **hydrocele of the tunica vaginalis testis** occurs frequently at birth but usually **resolves in a few weeks or months.** No treatment is indicated during the first year of life unless there is a clinically evident hernia. A simple scrotal hydrocele without communication with the peritoneal cavity and no associated hernia should be excised if it has not spontaneously resolved by the age of 12 months. Aspirating the mass for diagnostic or therapeutic reasons is not recommended, since a loop of bowel may be injured. Removing the fluid is ineffectiveas it will quickly reaccumulate.

Answer 935

C This patient has metrorrhagia, or “bleeding intermenstrual,” characterized by bleeding heavy enough to require the use of multiple pads; the heavy bleeding occurs between normal menstrual bleeding. It is important to evaluate metrorrhagia because potential causes include cervical disease, problems with IUDs, endometritis, polyps, submucous myomas, endometrial hyperplasia, and cancer. Mid-cycle spotting, as the term implies, refers to light spotting and is often caused by a decline in estrogen levels. Polymenorrhea is bleeding occurring at intervals of less than 21 days. Menometrorrhagia is heavy and/or prolonged bleeding occurring at irregular, noncyclic intervals. Acute emergent abnormal uterine bleeding is characterized by significant blood loss resulting in hypovolemia.

Answer 936

C Several prospective trials have shown significant benefits from the use of sports-specific training of the hips and legs in preventing ACL injuries, such as * plyometrics (repetitive actions that rapidly load and contract a targeted muscle group), * strength training, * balance exercises * consistent feedback about proper landing technique ACL risk in female athletes is up to 10 times that of males, there is no data to show that restricting their participation in male-dominated sports is a successful strategy to prevent injuries.

Answer 937

B ## Footnote Fat-pad atrophy is a common cause of heel pain in the geriatric patient, and in contrast to plantar fasciitis, causes pain as the day progresses. Plantar fasciitis classically presents as morning pain. Tarsal tunnel syndrome causes neuropathic pain in the distribution of the posterior tibial nerve, radiating into the plantar aspect of the foot toward the toes. Lumbar radiculopathy involves pain radiating down the leg into the heel, and is usually associated with weakness of dorsiflexion of the big toe and a decreased ankle reflex. Multiple myeloma would be an extremely unusual cause of heel pain; heel pain associated with cancer more commonly presents nocturnally.

Answer 938

B ## Footnote While hepatotoxicity with NSAIDs is rare, they can increase the risk of bleeding in cirrhotic patients as they **further impair platelet** function (cirrhotics already produce less platelets). In addition, NSAIDs decrease blood flow to the kidneys and can **increase the risk of renal failure** in patients with cirrhosis. NSAIDs differ from aspirin in terms of their cardiovascular effects. They have the potential to **increase cardiovascular morbidity**, worsen heart failure, increase BP, and increase events such as ischemia and acute MI.

Answer 939

E ## Footnote Cytomegalovirus (CMV) is the leading cause of congenital hearing loss. The virus is transmitted by contact with infected blood, urine, or saliva, or by sexual contact. Risk factors for CMV include low socioeconomic status, birth outside North America, first pregnancy prior to age 15, a history of cervical dysplasia, and a history of sexually transmitted diseases. Infection can be primary or a reactivation of a previous infection. While the greatest risk of infection is during the third trimester, those occurring in the first trimester are the most dangerous to the fetus.

Answer 940

D ## Footnote Hantavirus pulmonary syndrome results from exposure to rodent droppings, mainly the deer mouse in the southwestern U.S. In other parts of the country the virus is carried by the white-footed mouse. Hantavirus can cause in influenza-like illness followed by sudden respiratory failure, frequently culminating in death. It is also associated with hemorrhagic fever with renal failure in parts of Asia/Europe.

Answer 941

D ## Footnote The retinal findings shown are consistent with central retinal artery occlusion. The painless, unilateral, sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis. Acute narrow-angle glaucoma is an abrupt, painful, monocular loss of vision often associated with a red eye, which will lead to blindness if not treated. In persons with optic neuritis, funduscopy reveals a blurred disc and no cherry-red spot. Occlusion of the central retinal vein causes unilateral, painless loss of vision, but the retina will show engorged vessels and hemorrhages

Answer 942

E RIPE therapy is indicated when TB is suspected. Delays in diagnosis and treatment not only increase the possibility of disease transmission, but also lead to higher morbidity and mortality. Standard regimens including INH, ethambutol, rifampin, and pyrazinamide are recommended.

Answer 943

D ## Footnote Fetal macrosomia = birth weight \> 4000–4500 g, with increased risks of difficult vaginal delivery and shoulder dystocia above tihs weight. This has led to attempts to prevent shoulder dystocia and possible birth injury by either performing an elective C section or inducing labor when the fetus is estimated to be macrosomic. However, no studies have shown a benefit to either intervention in otherwise uncomplicated pregnancies. Suspected macrosomia on its own is no longer considered an indication for induction or C section. However, should this patient not spontaneously go into labor she will soon need to be managed as a post-dates pregnancy and thus a return visit should be scheduled in a week.

Answer 944

C A large review of multiple studies identified abdominal pain as the most consistent feature found in IBS, and its absence makes the diagnosis less likely. Of the symptoms listed, passage of blood is least likely with IBS, and passage of mucus, constipation, and diarrhea are less consistent than abdominal pain

Answer 945

E Ginkgo biloba has been associated with serious intracerebral bleeding - in most of these patients, concurrent anticoagulant drugs were being used. Ginkgo has been shown in vitro to inhibit platelet aggregation. Caution is recommended when using this supplement with aspirin or other anticoagulants. Kava is associated with gastrointestinal side effects and skin rashes. Yohimbine is associated with hypertension. Saw palmetto and echinacea are not associated with bleeding.

Answer 946

B any person with elevated LDL cholesterol or any other form of hyperlipidemia should undergo testing to rule out secondary dyslipidemia before initiation of lipid-lowering therapy. Causes of secondary dyslipidemia include * diabetes mellitus * hyp**O**thyroidism * obstructive liver disease * chronic renal failure * some medications

Answer 947

B ## Footnote Studies have shown that epidural analgesia increases the length of both the first _and_ second stage of labor. Although there is an increase in the rate of instrument-assisted delivery and fourth degree laceration, an increase in the rate of cesarean sections has not been shown. An increase in the rate of urinary incontinence also has not been shown.

Answer 948

B ## Footnote EF is an important measure of left ventricular function, especially with regard to previous cardiac events, medications, exercise tolerance, and preoperative risk. The normal predicted value is **55%–75%** when measured by ECHO in a healthy asymptomatic patient. There is no gender difference, but there is a decline with age. It may be as low as 15% in patients with left ventricular dysfunction. Ischemic and valvular heart disease may significantly reduce the ejection fraction.

Answer 949

A ## Footnote Approximately 30%–50% of infants born to Chlamydia-positive mothers will develop **conjunctivitis**, and at least 50% of these children will also have **nasopharyngeal** **infection**. Infants born to women with chlamydial infection may also develop associated **pneumonia**, but this affects only 10%–20% of this population.

Answer 950

A ## Footnote NSAIDs, oral contraceptive pills, and danazol have not been shown to have sufficient evidence of effect on DUB. Progestin is effective when used on a 21-day cycle, but not if used only during the luteal phase. Hysterectomy and ablation are very effective, but both destroy fertility. In a young woman unsure about having children, the **levonorgestrel IUD** is most effective and preserves fertility.

Answer 951

D The MMSE is considered valuable because it assesses a broad range of cognitive abilities (i.e., memory, language, spatial ability, set shifting) in a simple and straightforward manner and can facilitate the identification of patients with cognitive dysfunction.

Answer 952

B ## Footnote The currently recommended test for eradication of H. pylori in this clinical setting is either the **urea breath test** or **H. pylori stool antigen.**

Answer 953

B ## Footnote Vocal cord dysfunction is an idiopathic disorder in which the vocal cords partially collapse or close on inspiration. It mimics, and is commonly mistaken for, asthma. Symptoms include episodic tightness of the throat, a choking sensation, SOB, and coughing. A careful H/P reveal that the symptoms are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma. PFTs are normal, with the exception of ***flattening of the inspiratory loop, which is diagnostic of extra-thoracic airway compression.*** Fiberoptic laryngoscopy shows paradoxical inspiratory and/or expiratory partial closure of the vocal cords. Vocal cord dysfunction is treated with speech therapy, breathing techniques, reassurance, and breathing a helium-oxygen mixture (heliox).

Answer 954

A ## Footnote The primary indication for joint replacement surgery in patients with osteoarthritis is intractable pain, which is almost always relieved by the surgery. Joint replacement may also be appropriate for patients with significant limitations of joint function or with altered limb alignment. Range of motion, joint laxity, and recurrent subluxation relate to musculotendinous function, and are not reliably improved by joint replacement.

Answer 955

E Several RCTs have shown that Fluoxetine (Prozac, Serafem) for the last 2 weeks of the menstrual cycle is superior to placebo for PMDD Studies using alprazolam have shown it to be effective for premenstrual anxiety only.

Answer 956

A ## Footnote This patient likely has gout. Aspiration should be attempted to get a specific diagnosis. The initial treatment for gout is NSAIDs, colchicine, or cortisone injections. Allopurinol should be avoided until the episode of gout is controlled, because it may cause temporary worsening. In addition to medication, recommended management includes addressing risk factors such as obesity, diuretic use, high-purine diet, and alcohol intake

Answer 957

B The most likely diagnosis is cutaneous leishmaniasis, caused by an intracellular parasite transmitted by the bite of small sandflies. Lesions develop gradually, and are often misdiagnosed as folliculitis or as infected epidermal inclusion cysts, but they fail to respond to usual skin antibiotics. Treatment is not always required, as most lesions will resolve over several months; however, scarring is frequent.

Answer 958

A Biofeedback, a modality that seeks to control physiologic response to skin temperature and skin conductance has been shown to have a therapeutic effect on migraines. Oxygen is used to treat cluster headaches. The Epley maneuver is used for managing benign positional vertigo, and phototherapy is useful in seasonal affective disorder. Ma huang, a Chinese herb, has ephedrine properties but is not useful in treating migraine headaches.

Answer 959

B Patients receiving dual antiplatelet therapy who require bypass surgery should _continue taking aspirin_. **Clopidogrel or prasugrel should be stopped 5 days before the surgery** due to the increased risk of major bleeding during surgery.

Answer 960

D ## Footnote The patient described has a classic presentation of an osteoporotic vertebral compression fracture. The diagnosis should be confirmed with a plain radiograph. Treatment is basically symptomatic, with a period of bed rest as short as possible (to avoid complications of immobility), pain medication, and bracing. **Salmon calcitonin (injectable or intranasal) is often helpful in providing pain relief.** Long-term management of underlying osteoporosis may help prevent future fractures.

Answer 961

E ## Footnote The major concern with regard to pneumonia in the nursing-home setting is the increased frequency of oropharyngeal colonization by **gram-negative organisms**. In the absence of collectible or diagnostic sputum Gram’s stains or cultures, empiric therapy **must cover Streptococcus pneumoniae, Staphylococcus aureus,Haemophilus influenzae, _and_ gram-negative bacteria**. **Levofloxacin** is the best single agent for providing coverage against this spectrum of organisms.

Answer 962

D ## Footnote This child meets the DSM-IV criteria for **oppositional defiant disorder**, defined as a pattern of **negativistic, hostile, and defiant behavior lasting at least 6 months.** The child will often lose his or her temper, argue with adults, actively defy or refuse to comply with adults’ requests or rules, deliberately annoy people, blame others for his or her mistakes or misbehavior, be easily annoyed by others, appear angry and resentful, or be spiteful or vindictive. At least four of these behaviors must be present to meet the criteria for diagnosis. The disturbance in behavior must also cause clinically significant impairment in social, academic, or occupational functioning, and the behaviors must not occur exclusively during the course of a psychotic or mood disorder. Meeting the criteria for conduct disorder excludes the diagnosis of oppositional defiant disorder. If the individual is 18 years of age or older and meets the criteria for antisocial personality disorder, then oppositional defiant disorder is excluded.

Answer 963

B ## Footnote axillosubclavian vein thrombosis (ASVT) is becoming more frequent with the increased use of indwelling subclavian vein catheters. Spontaneous ASVT (not catheter related) is seen most commonly in young, healthy individuals. The most common associated etiologic factor is the presence of a compressive anomaly in the thoracic outlet. These anomalies are often bilateral, and the other upper extremity at similar risk for thrombosis.

Answer 964

A ## Footnote Pharyngeal and laryngeal side effects of inhaled corticosteroids include sore throat, coughing on inhalation of the medication, a weak or hoarse voice, and oral candidiasis. Rinsing the mouth after each administration of the medication and using a valved holding chamber when it is delivered with a metered-dose inhaler can minimize the risk of oral candidiasis.

Answer 965

D **Glycopyrrolate** does not cross the BBB, and is therefore least likely to cause CNS effects such as sedation. The other medications listed do cross the blood-brain barrier.

Answer 966

C ## Footnote According to USPSTF, there is good evidence that screening for Chlamydia infection in women who are at increased risk can reduce the incidence of PID, while the harms are minimal. Evidence regarding screening for cervical cancer with Pap test or HPV testing, however, shows that the harms outweigh any possible benefits. Harms include overdiagnosis and overtreatment, including invasive cervical procedures that can affect future pregnancy outcomes. In addition, there is adequate evidence that screening women younger than 21 years of age (regardless of sexual history) does not reduce the incidence of cervical cancer or mortality compared with beginning screening at age 21. The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders or intimate partner violence in women this age.

Answer 967

E The GI tract is the most likely reservoir of GBS with secondary spread to the genital tract. Cultures from the **vaginal introitus + rectum** are the _most sensitive_ for detecting colonization. No speculum examination is necessary. The **closest time to delivery that cultures can be performed and allow time for results to be available is 35-37 weeks' GA**. Culture (+) women are then treated during labor.

Answer 968

B Autonomic hyperreflexia is characterized by the sudden onset of HA and HTN in a pts with **spinal cord transections** **_above_ the T6 level**. There may be associated bradycardia, sweating, dilated pupils, blurred vision, nasal stuffiness, flushing, or piloerection. It usually occurs several months after the injury and has an incidence as high as 85% in quadriplegic patients. Frequently, it subsides within 3 years of injury, but it can recur at any time. **Bowel and bladder distention are common causes.** HTN is a major concern because of associated seizures and cerebral hemorrhage. Cluster headaches have a constant unilateral orbital localization. The pain is steady (non-throbbing) and lacrimation and rhinorrhea may be part of the syndrome. Sepsis is usually manifested by chills, fever, nausea, and vomiting. Common signs include tachycardia and hypotension rather than bradycardia and hypertension. Signs and symptoms of intracranial hemorrhage vary depending upon the site of the hemorrhage, but the unchanged neurologic status and the lack of a history of hypertension decrease the likelihood of this diagnosis. There are no neurologic findings or history which suggest progression of the patient’s lesion at C6.

Answer 969

D Circumflex occlusion causes changes in I, AVL, and possibly V5 and V6 as well. Left anterior descending coronary artery occlusion causes changes in V1 to V6. Right coronary occlusion causes changes in II, III, and AVF.

Answer 970

A Treating basal cell carcinoma with Mohs micrographic surgery leads to the lowest recurrence rate. Because of its cost and limited availability, however, this procedure is limited to tumors with a higher risk for recurrence. Risk factors include **larger size**, **more invasive histologic subtypes** (micronodular, infiltrative, and morpheaform), and **sites associated with a higher risk of recurrence.** * High-risk locations: “mask” areas of the face (central face: eyelids, eyebrows, periorbital area, *nose*, lips, chin, mandible), preauricular and postauricular skin/sulci, temple, and ear, genitalia, hands, and feet. * Moderate-risk locations: cheeks, forehead, scalp, and neck * Low-risk locations: trunk and extremities Even with a low-risk location, a lesion that is ≥20 mm in size has a high risk of recurrence. With a moderate-risk location a lesion ≥10 mm in size carries a higher risk of recurrence, and a lesion ≥6 mm in size is considered high risk in a high-risk location.

Answer 971

B Indications for parathyroid surgery include kidney stones, age less than 50, a serum calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density. Hyperthyroidism is not a factor in deciding to perform parathyroid surgery.

Answer 972

B Intranasal decongestants such as phenylephrine should not be used for more than 3 days, as they cause rebound congestion on drug withdrawal. When used for several months or more, these agents can cause a form of rhinitis, rhinitis medicamentosa, that can be extremely difficult to treat.

Answer 973

A **Secondary prevention of cardiac events** consists of long-term treatment to prevent recurrent cardiac morbidity and mortality in patients who have either already had an acute MI or are at high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures. Effective treatments include: * **aspirin + β-blockers** after MI * **ACE inhibitors** in patients at high risk after MI * **ARBs** in those with coronary artery disease * **amiodarone** in patients who have had a MI and have a high risk of death from cardiac arrhythmias Oral glycoprotein IIb/IIIa receptor inhibitors appear to _increase_ _the risk of mortality_ when compared with aspirin. Calcium channel blockers, class I anti-arrhythmic agents, and sotalol all appear to _increase_ _mortality_ compared with placebo in patients who have had a MI. Multiple randomized, controlled trials show _no cardiac benefit_ from hormone therapy in postmenopausal women.

Answer 974

B ## Footnote Children from the ages of 2 to 6 often believe they are somehow responsible for the death of a loved one. The emotional pain may be so intense that the child may react by denying the death, or may somehow feel that the death is reversible. If children wish to attend a funeral, or if their parents want them to, they should be accompanied by an adult who can provide comfort and support. Telling a child the loved one is asleep or that he or she “went away” usually creates false hopes for return, or it may foster a sleep phobia.

Answer 975

E Clinical predictors of increased perioperative cardiovascular risk for elderly patients include major risk factors such as * unstable coronary syndrome (acute or recent MI, unstable angina) * decompensated CHF * significant arrhythmia (high-grade AV block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate) * severe valvular disease. Intermediate predictors are * mild angina * previous MI * compensated CHF * DM * renal insufficiency Minor predictors are * advanced age * abnormal EKG * LV hypertrophy * LBBB * ST and T-wave abnormalities * rhythm other than sinus * low functional capacity * history of stroke * uncontrolled HTN

Answer 976

D The evidence supports a 10-year interval for colonoscopy in patients less than 80 years old. For patients with a family history of colon cancer a 5-year interval is recommended, or 3 years if benign polyps are found. Screening in patients over 80 years old is controversial.

Answer 977

C ## Footnote In a young adult with community-acquired pneumonia who is not sick enough to be hospitalized, the current recommendation is to empirically treat with a macrolide antibiotic such as azithromycin. This covers the atypical organism **Mycoplasma pneumoniae**, which is one of the most common causes of community-acquired pneumonia. Certain fluoroquinolones such as levofloxacin also cover atypical causes, but ciprofloxacin does not. The other antibiotics listed are also ineffective against Mycoplasma.

Answer 978

A A single morning serum cortisol level \>13µg/dL reliably excludes adrenal insufficiency. If the morning cortisol level is lower than this, further evaluation with a 1µg ACTH stimulation test is necessary.

Answer 979

C ## Footnote A pulmonary capillary wedge pressure of 8 mm Hg suggests hypovolemia. Normal saline should be given because 5% dextrose is not a reliable volume expander.

Answer 980

E ## Footnote Fingernails and toenails document a history of the body during the past several months. The symmetric depression across the nail plate growing toward the distal edge of the nail shown here represents significant trauma to the body some weeks ago. These classic lines are called **Beau’s lines**. No treatment is required.

Answer 981

C ## Footnote Diabetes mellitus can be diagnosed if the patient’s fasting blood glucose level is **≥126** mg/dL on two separate occasions. It can also be diagnosed if a random blood glucose level is **≥200 mg/dL** if classic symptoms of diabetes are present. A fasting blood glucose level of **100–125 mg/dL**, a glucose level of 140–199 mg/dL 2 hours following a 75-g glucose load, or a **hemoglobin A 1c of 5.7%–6.9%** signifies impaired glucose tolerance. Patients meeting these criteria have a significantly higher risk of progression to diabetes and should be counseled about lifestyle modifications such as weight loss and exercise.

Answer 982

C The recommended time to screen for gestational diabetes is **24–28** weeks gestation. The patient may be given a 50-g oral glucose load followed by a glucose determination 1 hour later.

Answer 983

D ## Footnote Celiac sprue - autoimmune d/o, inflammation of the small bowel wall resulting in a blunting of the villi, and resultant malabsorption. Symptoms commonly include diarrhea, fatigue, weight loss, abdominal pain, and borborygmus (gurgling noise produced by movement of the GI contents through the small intestines). Extraintestinal manifestations are less common but may include **elevated transaminases, osteopenia,** and **IDA**. **Serum IgA tissue transglutaminase (TTG) antibodies** are highly sensitive and specific for celiac sprue, and a small bowel biopsy showing villous atrophy is the gold standard for diagnosis. This patient’s rash is consistent with **dermatitis herpetiformis**, which is pathognomonic for celiac sprue and responds well to a strict gluten-free diet. Lactose intolerance, irritable bowel syndrome, collagenous colitis, and Crohn’s disease are in the differential diagnosis for celiac sprue. However, significant weight loss is not characteristic of irritable bowel syndrome or lactose intolerance. The diarrhea associated with Crohn’s disease is typically bloody. Collagenous colitis does cause symptoms similar to those experienced by this patient, but it is not associated with dermatitis herpetiformis.

Answer 984

A ## Footnote This infant has the typical “flea-bitten” rash of erythema toxicum neonatorum (ETN). Transient neonatal pustular melanosis is most common in African-American newborns, and the lesions lack the surrounding erythema typical of ETN. Acne neonatorum is associated with closed comedones, mostly on the face. As the infant described is not ill, infectious etiologies are unlikely.

Answer 985

C **Immediate biopsy if:** * the patient does _not_ have inflammatory symptoms and the lymph node is \>3 cm * the node is in the supraclavicular area * patient has coexistent constitutional symptoms such as night sweats or weight loss * patient has risk factors for malignancy. * Treatment with antibiotics is warranted in patients who have inflammatory symptoms such as pain, erythema, fever, or a recent infection. In a patient with no risk factors for malignancy and no concerning symptoms, **monitoring the node for 4–6 weeks is recommended**. If the node continues to enlarge or persists after this time, then further evaluation is indicated. This may include a biopsy or imaging with CT or ultrasonography. The utility of serial ultrasound examinations to monitor lymph nodes has not been demonstrated.

Answer 986

B ## Footnote Randomized, controlled trials found that **luteal-phase spironolactone** improved psychological and physical symptoms of premenstrual syndrome over 2–6 months compared with placebo. Based on existing evidence, the effectiveness is unknown for cognitive-behavioral therapy, bright light therapy, evening primrose oil, and black cohosh.

Answer 987

E ## Footnote In patients with head and neck lymphadenopathy, supraclavicular nodes are the most likely to be malignant. Lymphadenopathy of these nodes should always be investigated, even in children. Overall, the prevalence of malignancy with this presentation is unknown, but rates of 54%–85% have been seen in biopsy series reports.

Answer 988

E ## Footnote **Alcohol withdrawal syndrome** is mediated by the abrupt removal of alcohol-enhanced GABA inhibition of excitatory glutamate receptors in the CNS. It generally is divided into three stages, based on severity and timeline; seizures may occur during any of these stages and may be the first sign of withdrawal. The ideal pharmacologic agent should provide not only safe sedation but also protection from seizures. Long-acting benzodiazepines such as **chlordiazepoxide** have been shown to be superior to the other choices in numerous studies. **Clonidine and atenolol** have been found to be useful in symptom reduction but not in seizure prevention. **Phenytoin** would seem to offer protection from seizures, but studies have not consistently shown this to be the case. **Phenobarbital**, while effective, has a very narrow therapeutic window, making its use problematic.

Answer 989

B ## Footnote Delirium risk factors include vision impairment, hearing impairment, dehydration, immobility, cognitive impairment, and sleep deprivation. Repeated reorientation of patients with cognitive impairment, early mobilization, and minimizing unnecessary noise or stimulation are all effective interventions for reducing the risk of delirium in hospitalized patients. Not having family members available at the time of admission has no effect on the incidence of delirium.

Answer 990

D In young children with bilious emesis, anorexia, and lack of fever, the most likely diagnosis is intestinal malrotation with volvulus. Abdominal ultrasonography is less sensitive and specific for malrotation than an upper gastrointestinal series, so an upper GI series should be ordered initially if volvulus is suspected.

Answer 991

E ## Footnote This patient has **conversion aphonia -** patient loses his or her spoken voice, but the whispered voice is maintained. Vocal cords appear normal, but there is a *loss of vocal cord adduction during phonation*, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce) **Muscle tension aphonia** - strained, effortful phonation, vocal fatigue, and normal vocal cords; caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress. **Laryngopharyngeal reflux** - raspy or harsh voice; hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing. **Spasmodic dysphonia** (also known as laryngeal dystonia) - halting, strangled vocal quality; due to neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm. **Vocal abuse -** hoarseness that is usually worse later in the day after effortful singing or talking. Nodules or cysts may be seen on the vocal cords with this condition.

Answer 992

E ## Footnote Risk factors for osteoarthritis of the hip include obesity, high bone mass, old age, participation in weight-bearing sports, and hypothyroidism.

Answer 993

D ## Footnote Meckels diverticulum is the most common congenital abnormality of the small intestine. It is prone to bleeding because it may contain heterotopic gastric mucosa. Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis.

Answer 994

D ## Footnote Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications. The hallmark biochemical feature of refeeding syndrome is **hypophosphatemia**. However, the syndrome is complex and may also include abnormal sodium and fluid balance; changes in glucose, protein, and fat metabolism; thiamine deficiency; **hypokalemia; and hypomagnesemia.**

Answer 995

D ## Footnote Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard

Answer 996

C Dental infections complicated by the development of cellulitis should be treated with oral antibiotic therapy. The antibiotic of choice is penicillin. Clindamycin should be used if a patient is allergic to penicillin.

Answer 997

C Even mild chronic excess thyroid hormone replacement over many years can cause bone mineral resorption, increase serum calcium levels, and lead to osteoporosis. The elevated calcium decreases parathyroid hormone.

Answer 998

C ## Footnote This patient most likely has pseudogynecomastia due to increases in subareolar fat secondary to his obesity. This is based upon clinical findings of symmetric adipose tissue in the breast region bilaterally and a _lack of firm, palpable glandular tissue in the nipple and areolar region_. In gynecomastia, there is _palpable, firm glandular tissue in a concentric mass around the nipple-areola complex._ Hard, immobile masses, masses associated with skin changes, nipple retraction, nipple discharge, or enlarged lymph nodes would suggest possible malignancy. Fat necrosis would involve a history of breast region trauma and would generally be asymmetric. Mastitis would cause clinical signs of infection.

Answer 999

D Some of the atypical antipsychotics, notably **olanzapine and clozapine**, have been associated with hyperglycemia and the development of type 2 diabetes mellitus.

Answer 1000

C ## Footnote In cases of drug overdose, several critical physical findings must be evaluated. Tolerance rarely reduces the miotic effects of narcotic medications. A patient who is comatose, with decreased breathing, a slow pulse, and small pupils should be strongly suspected of having overdosed on a narcotic. **Naloxone** should be administered to reverse these effects Cerebral infarction in the pontine angle, organophosphate poisoning, phenothiazine overdose, and treatment for glaucoma can also cause constricted pupils, but these associations are seen much less frequently than narcotics overdose.

Answer 1001

D ## Footnote Genetic disorders (e.g., Waardenburg syndrome, Usher’s syndrome, Alport syndrome, and Turner’s syndrome) are responsible for more than 50% of hearing impairments in children. Intraventricular hemorrhage is a central cause of hearing loss, and is rare. Conductive abnormalities such as external canal anomalies and congenital cholesteatoma, and sensorineural causes other than genetic disorders (e.g., infectious diseases) are important but less frequent

Answer 1002

A ## Footnote Effective oral antiviral drugs are now available for chronic hepatitis B (at a cost of about $20 per day) and can be added to highly active antiretrovirals. The recent trend in the treatment of newly diagnosed patients with AIDS and hepatitis B is to treat both problems initially, selecting AIDS drugs that are also active against hepatitis B.

Answer 1003

E ## Footnote Any child 12 years or younger who presents with nasal polyps should be suspected of having cystic fibrosis until proven otherwise. A sweat chloride test, along with a history and clinical examination, is necessary to evaluate this possibility.

Answer 1004

B ## Footnote Health-care workers exposed to a patient with meningococcal meningitis are at increased risk of developing systemic disease and should receive **rifampin**, especially if the contact is intimate. Other appropriate chemoprophylactic agents include **minocycline** and **ciprofloxacin**. Even high doses of penicillin may not eradicate nasopharyngeal meningococci. Prednisone has no place in chemoprophylaxis. Meningococcal vaccine appears to have clinical efficacy, but it usually takes more than 5 days to become effective

Answer 1005

E ## Footnote Nonpharmacologic therapy is recommended for all patients with an overactive bladder. Pelvic floor muscle training (e.g., Kegel exercises) and bladder training are proven effective in urge incontinence or overactive bladder, as well as in stress and mixed incontinence. In motivated patients, training may be more effective than medications such as oxybutynin and newer muscarinic receptor antagonists such as solifenacin. Tamsulosin is used in benign prostatic hypertrophy and phenazopyridine is a urinary tract anesthetic that has not been recommended for treating overactive bladder

Answer 1006

C Although leukocyte scans are sensitive for the diagnosis of foot ulcers, MRI is now considered the imaging study of choice when osteomyelitis is suspected; the sensitivity and specificity of MRI in diabetic patients are 90% or greater.

Answer 1007

D ## Footnote or nausea and vomiting, however, vitamin B6 is considered **first-line** therapy, sometimes combined with doxylamine. Other measures that have been found to be somewhat useful include ginger and acupressure.

Answer 1008

C ## Footnote Interactions between the physician and patient involve the patient’s family and friends, as well as others who may be part of the patient’s social support system. These interactions, as well as the physician-patient relationship itself, are also strongly influenced by ethnic, cultural, and spiritual values and by beliefs about illness and approaches to treatment and ongoing care. Involvement of family members in a patient’s care is advantageous to good communication and helpful for both accurate diagnosis and appropriate treatment. Patient confidentiality should be protected, and the mere presence of other people accompanying the patient does not automatically constitute permission to discuss private health information with them. The physician should determine not only who is present with a patient, but also each person’s reason for being present. Speaking to relatives or friends without the patient present may be appropriate under certain circumstances but would not be the best option in this scenario. Constructing a genogram can also be helpful, but that would not be the first priority in this case.

Answer 1009

D ## Footnote Trials have not definitively shown that nutritional supplements speed ulcer healing. The head of the bed should be elevated only as necessary, and should be kept to less than 30° to reduce shearing forces.Systemic antibiotics should only be used for cellulitis, osteomyelitis, and bacteremia. Topical antibiotics may be used for periods of up to 2 weeks.

Answer 1010

E Neurally mediated syncope (also termed neurocardiogenic or vasovagal syncope) comprises the largest group of disorders causing syncope. These disorders result from reflex-mediated changes in vascular tone or heart rate. The nucleus solitarii tract of the brainstem is directly or indirectly activated by the triggering stimulus, resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone, resulting in * decreased HR and contractility, resulting in decreased CO that is significant enough to lose consciousness (this ieffect is likely secondary to enhanced parasympathetic tone) * drop in BP without much change in HR (this effect is likely secondary to withdrawal of sympathetic tone)

Answer 1011

C ## Footnote An exercise program will reduce both pain and disability in patients with osteoarthritis of the knee. There is no evidence to support the use of capsaicin cream, but NSAIDs will reduce pain and there are proven therapies that will improve function of the patients knee. While intra-articular corticosteroids are effective in relieving pain in the short term (up to 4 weeks), there is no evidence for long-term efficacy. There is not good evidence to support the use of glucosamine for treating osteoarthritis of the knee. One systematic review found it no more effective than placebo.

Answer 1012

A Pharyngitis is a common complaint, and usually has a viral cause. The scenario described is consistent with a viral infection, with no risk factors to make streptococcal infection likely; therefore, this patient should be offered symptomatic treatment for likely viral infection. Testing for other infections is not indicated unless the patient worsens or does not improve. The key factors in diagnosing streptococcal pharyngitis are a fever over 100.4 ˚ F, tonsillar exudates, anterior cervical lymphadenopathy, and absence of cough. Age plays a role also, with those

Answer 1013

c This patient has anemia of chronic disease secondary to her rheumatoid arthritis. This anemia is usually mild, with hemoglobin levels of 9.0–11.0 g/dL, and is usually normocytic-normochromic, although it can be microcytic. Characteristically, serum iron and total iron-binding capacity are decreased and ferritin is increased. The best treatment of this anemia is to treat the underlying systemic disease. Neither iron nor folic acid is effective. Since the anemia is usually mild, transfusion is not necessary.

Answer 1014

B ## Footnote A patient without apparent lung disease who develops a spontaneous “small” pneumothorax ( CT of the lung is needed in complicated cases, including patients with known lung disease or recurrent pneumothoraces. A chest tube is required only when the pneumothorax involves \>15% of lung volume.

Answer 1015

B ## Footnote Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis. **Lipase** is _more specific and more sensitive_ than the amylase level. **Amylase** elevations can be seen with other abdominal illnesses, such as inflammation of the small bowel. Alcoholics with recurrent pancreatitis may have normal serum amylase levels; in such cases, serum lipase would be a better test. There are several scoring systems for the severity of pancreatitis, including the CT severity index, the APACHE II score, the Imrie Scoring System, and Ransons Criteria, but none of these use serum amylase in their calculation. The elevation of serum amylase does not correspond well with the severity of the pancreatitis.

Answer 1016

C The symptom complex presented is typical of cholelithiasis. Plain radiography of the abdomen may reveal radiopaque gallstones, but will not reveal radiolucent stones or biliary dilatation. Abdominal ultrasonography is considered the best study to confirm this diagnosis because of its high sensitivity and its accuracy in detecting gallstones

Answer 1017

A ## Footnote People taking carbamazepine have a five-to eightfold increased risk of developing agranulocytosis. Baseline values including a CBC, serum electrolytes, and liver enzymes should be obtained before the drug is started, and the patient should be monitored with periodic hematologic testing. Aripiprazole and olanzapine carry black box warnings for an increased risk of death in the elderly. Lithium is associated with lithium toxicity and thyroid dysfunction. Imipramine carries a warning for cardiac toxicity, and EKG monitoring is recommended

Answer 1018

B ## Footnote Gastroesophageal reflux is a common cause of wheezing in infants. At 5 months of age, most infants no longer spit up several times a day, and the fact that the infant is spitting up small amounts of formula several times a day is a major clue that this child’s wheezing may be from the reflux. In addition, there is no family history of asthma and the wheezing is not related to infections.Cystic fibrosis is more likely to present with recurrent infections and failure to thrive than with intermittent wheezing.

Answer 1019

D Lung cancer is the leading cause of cancer-related deaths in the United States. In 2006, lung cancer caused more deaths than colorectal, breast, and prostate cancers combined.

Answer 1020

B Of the choices listed, only endocervical curettage is contraindicated in pregnancy. Colposcopy, cervical biopsy, cervical staining, and HPV testing can all be safely performed during pregnancy

Answer 1021

B ## Footnote Motor side effects of the antipsychotic drugs can be separated into five general categories: dystonias, parkinsonism, akathisia, withdrawal dyskinesias, and tardive dyskinesia. **Akathisia** is a syndrome marked by motor restlessness. Affected patients commonly complain of being inexplicably anxious, of being unable to sit still or concentrate, and of feeling comfortable only when moving.

Answer 1022

A The diagnosis of depression requires the presence of at least 5/8 of SIGECAPS present for ≥2 weeks: sad mood, lost of interest, guilt and feelings of worthlessness, lack of energy, diminished concentration, anorexia, sleep disturbances, and suicidal ideation. Because dementia may cause similar symptoms, distinguishing between the two is important. Dementia is insidious, with a long duration of symptoms including fluctuating mood and memory impairment for recent events. *Memory loss often precedes mood changes.*

Answer 1023

C ## Footnote Status epilepticus refers to continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period. It is an emergency and must be treated immediately, since cardiopulmonary dysfunction, hyperthermia, and metabolic derangement can develop, leading to irreversible neuronal damage. **Lorazepam, 0.1–0.15 mg/kg intravenously**, should be given as anticonvulsant therapy after cardiopulmonary resuscitation. This is **followed by phenytoin**, given via a dedicated peripheral intravenous line. Fosphenytoin, midazolam, or phenobarbital can be used if there is no response to lorazepam. Propofol has been used for refractory status epilepticus to induce general anesthesia when the initial drugs have failed, but reports of fatal propofol infusion syndrome have led to a decline in its use.

Answer 1024

C The finding of a red, raised, friable lesion on the cervix, or a well-demarcated cervical lesion, mandates a biopsy to exclude cervical carcinoma, and treatment for chronic cervicitis should not be started until the biopsy results are available. A Papanicolaou test by itself is insufficient if there is a grossly visible lesion, as false-negatives occur in 10%-50% of tests.

Answer 1025

C ## Footnote In 2008, the American Academy of Pediatrics increased its recommended daily intake of vitamin D in infants, children, and adolescents to 400 IU/day (SOR C). Breastfeeding does not provide adequate levels of vitamin D. Exclusive formula feeding probably provides adequate levels of vitamin D, but infants who consume less than 1 liter of formula per day need supplementation with 400 IU of vitamin D daily. Vitamin D supplementation should be started within the first 2 months of birth.

Answer 1026

B Black cohosh is an herbal preparation widely used in the treatment of menopausal symptoms and menstrual dysfunction. Studies have demonstrated that this botanic medicine appears to be effective in alleviating menopausal symptoms. It has not been proven effective in randomized controlled trials and should not be used to prevent osteoporosis. Questions as to its stimulating effect on endometrial tissue are as yet unanswered.

Answer 1027

A The indolent course of the sore described favors the diagnosis of cutaneous leishmaniasis. Neither malaria nor schistosomiasis produces these sores. The chancres of syphilis and trypanosomiasis are more fleeting in duration.

Answer 1028

D ## Footnote ACEi are the preferred drugs for CHF due to LV systolic dysfunction, because they are associated with the lowest mortality. The combination of hydralazine/isosorbide dinitrate is a reasonable alternative, and diuretics should be used cautiously. It is not known whether digoxin affects mortality, although it can help with symptoms.

Answer 1029

C This patient has acute bilateral otitis media, with presumed tympanic membrane perforation, and qualifies by any criterion for treatment with antibiotics. Amoxicillin, 80–90 mg/kg/day, should be the first-line antibiotic for most children with acute otitis media. Second line treatment is amoxicillin/clavulanate (augmentin).

Answer 1030

E RCTs have shown that in patients with a-fib, an initial approach of rate control is best. Patients who were stratified to the rhythm control arm of the trials did NOT have a morbidity/mortality benefit and were more likely to suffer from ADRs and increased hospitalizations. Efficacious drugs for rate control are **Ca channel blockers and ß-blockers**. Digoxin is less effective for rate control and should be reserved as an add-on option for those refractory to initial treatment, or for patients with significant LV systolic dysfunction. In patients \>65 yo or with one or more risk factors for stroke, the best choice for anticoagulation is warfarin. Of note, in patients who are successfully rhythm controlled and maintained in sinus rhythm, the thromboembolic rate is equivalent to those managed with a rate control strategy. Thus, the data suggest that patients who choose a rhythm control strategy should be maintained on anticoagulation regardless of whether they are consistently in sinus rhythm.

Answer 1031

B The most accurate maneuver for detecting an ACL tear is the * Lachman test (sensitivity 60%–100%, mean 84%) * anterior drawer test (sensitivity 9%–93%, mean 62%) * pivot shift test (sensitivity 27%–95%, mean 62%) McMurray’s test is used to detect meniscal tears.

Answer 1032

E ## Footnote Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically; surgery indicated if there is progression, hemorrhage into the retroperitoneal space or pleura, occlusion of a major aortic branch. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a β-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Without prior β-blocade, vasodilation from the nitroprusside will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta.

Answer 1033

E ## Footnote The living will, a written advance directive, allows a competent person to indicate his or her health care references while cognitively and physically healthy. A living will may list medical interventions the patient would prefer to have withheld or withdrawn when he or she becomes unable to communicate

Answer 1034

B ## Footnote Autoimmune hypothyroidism is common in elderly women. Symptoms often include fatigue, bradycardia, dry skin, brittle hair, and a prolonged relaxation phase of the deep tendon reflexes. While **replacement therapy with levothyroxine** is indicated, care must be taken in the elderly, particularly in those with coronary artery disease, to replace the deficit slowly. **Rapid replacement of thyroid hormone can increase the metabolic rate, and therefore myocardial oxygen demand, too quickly.** This can **precipitate complications of coronary artery disease** such as atrial fibrillation, angina, and myocardial infarction. Stopping a β-blocker in this setting is likely to increase the risk. Radioactive iodine ablation is indicated for some cases of hyperthyroidism.

Answer 1035

D For previously healthy patients with community-acquired pneumonia and no risk factors for drug resistance, a macrolide/azithromycin is the preferred treatment. Doxycycline is also acceptable. Patients who have been treated with antibiotics within the previous 3 months should be treated with a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin). A β-lactam plus a macrolide is also an alternative. The antibiotic chosen should be from a different class than the one used for the previous infection

Answer 1036

C ## Footnote In most patients with heavy gastrointestinal bleeding, localizing the bleeding site, rather than diagnosing the cause of the bleeding, is the most important task. A lower GI series is usually nondiagnostic during heavy, active bleeding. A small-bowel radiograph may be helpful after the active bleeding has stopped, but not during the acute phase of the bleeding. **A blood pool scan allows repeated scanning over a prolonged period of time, with the goal of permitting enough accumulation of the isotope to direct the arteriographer to the most likely source of the bleeding.** If the scan is negative, arteriography would be unlikely to reveal the active source of bleeding, and is also a more invasive procedure. Exploratory laparotomy may be indicated if a blood pool scan or an arteriogram is nondiagnostic and the patient continues to bleed heavily.

Answer 1037

B ## Footnote The characteristics of this lesion, including coral-red fluorescence under a Wood’s light, suggestsCorynebacterium infection, which is associated with erythrasma. Erythromycin, either systemic or topical, is the treatment of choice. Tinea cruris caused by Microsporuminfection fluoresces green Intertrigo and tinea cruris caused by Epidermophyton or Trichophytoninfections do not fluoresce

Answer 1038

B ## Footnote **Primary prevention** targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (vaccination programs, water fluoridation, antismoking programs, and safe sex education). **Secondary prevention** targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (routine Paps; screening for HTN, DM, or HLD). **Tertiary prevention** targets individuals with a known disease, with the goal of limiting or preventing future complications (screening diabetics for microalbuminuria, rigorous treatment of DM, and post-MI prophylaxis with β-blockers and aspirin).

Answer 1039

D ## Footnote This adolescent has findings of **Marfan syndrome**. It is associated with arachnodactly, arm span greater than height, a high arched palate, kyphosis, lenticular dislocation, mitral valve prolapse, myopia, and pectus excavatum. Cardiac examination may reveal an **aortic insufficiency**, or a **murmur associated with mitral valve prolapse**. Cardiovascular defects are progressive, and aortic root dilation occurs in 80%-100% of affected individuals. Aortic regurgitation becomes more common with increasing age.

Answer 1040

E ## Footnote For a single rescuer performing CPR on a 2-year-old, the ratio is 30 compressions to 2 ventilations. The compression rate should be approximately 100 beats/min, and the chest should be compressed one-third to one-half its depth with each compression. Compressions can be accomplished with one hand, the heel of one or both hands, or the heel of one hand with the second hand on top.

Answer 1041

D ## Footnote **Pernio (chilblains**) - localized inflammatory lesion of the skin, usually found in the extremities following exposure to nonfreezing cold temperatures. It is generally a benign condition, and is not associated with any systemic, infectious, or connective tissue diseases. These lesions are red-purple plaques with deep swelling, and are accompanied by itching or burning.

Answer 1042

A ## Footnote This patient has **galactorrhea.** It is more common in women ages 20-35 and in women who are previously parous; can also occur in men. The most common pharmacologic cause of galactorrhea is **OCs that contain estrogen**, **which can suppress prolactin inhibitory factor and stimulate the pituitary directly, both of which can cause galactorrhea.** Other medications that can cause galactorrhea include **metoclopramide, cimetidine, risperidone, methyldopa, codeine, morphine, verapamil, SSRIs, butyrophenones, dopamine-receptor blockers, tricyclics, phenothiazines, and thioxanthenes.** Nipple discharge associated with breast cancer is usually *unilateral and bloody*. Pituitary tumors are a pathologic cause of galactorrhea due to the hyperprolactinemia that is caused by the blockage of dopamine from the hypothalamus, or by the direct production of prolactin. However, patients often have symptoms such as headache, visual disturbances, temperature intolerance, seizures, disordered appetite, polyuria, and polydipsia. Patients with prolactinomas often have associated amenorrhea. These tumors are associated with marked levels of serum prolactin, often \>200 ng/mL. Hypothalamic lesions such as craniopharyngioma, primary hypothalamic tumor, metastatic tumor, histiocytosis X, tuberculosis, sarcoidosis, and empty sella syndrome are significant but infrequent causes of galactorrhea, and generally cause symptoms similar to those of pituitary tumors, particularly headache and visual disturbances. It is rare for primary hypothyroidism to cause galactorrhea in adults. Symptoms that would be a clue to this diagnosis include fatigue, constipation, menstrual irregularity, weight changes, and cold intolerance.

Answer 1043

E Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to reduce progression of the diverticular disease. Avoidance of nuts, corn, popcorn, and small seeds has not been shown to prevent complications of diverticular disease.

Answer 1044

C ## Footnote An adequate trial of antidepressant therapy is 4–6 weeks. Patients who are unresponsive to treatment may respond to another antidepressant with a different mechanism of action. Patients who are partially responsive may benefit from dosage titration or the addition of a second antidepressant in combination. Electroconvulsive therapy is the most effective treatment in patients with severe resistance to medical antidepressant therapy or those with psychotic depression.

Answer 1045

C ## Footnote The most likely diagnosis for this patient’s knee pain is OA. While he is likely to have disease in both knees, it is common for patients to have unilateral symptoms, especially early on. Although OA is mainly a clinical diagnosis, plain radiography is the diagnostic study of choice if there is concern about other diagnostic possibilities. Narrowing of the medial compartment of the knee joint is typically the first radiographic finding; osteophytes are also commonly seen on plain films. In the scenario presented here, there is no need for laboratory testing at this time.

Answer 1046

E Rifampin is the drug of choice for preventing the spread of meningococcal disease when the susceptibility of the organism is not known. In this situation, meningococcal vaccines are of no value because immunity take a few days to develop, and because they do not protect against group B meningococci, the most prevalent strain for meningococcal disease. Sulfadiazine is the drug of choice if the meningococcus is known to be susceptible to it. Chloramphenicol and penicillin, which are effective in treating the disease, are ineffective in eliminating nasopharyngeal carriers of meningococci, possibly because they do not appear in high concentrations in saliva. Culturing contacts for meningococcal carriage in the nasopharynx has no value for identifying those at risk for meningococcal disease.

Answer 1047

D ## Footnote HIT usually occurs within 1–2 weeks of heparin administration and is characterized by the presence of HIT antibodies in the serum, decrease in platelet counts, arterial or venous thrombosis, anaphylactoid reactions immediately following heparin administration, or skin lesions at the site of heparin injections. Postop patients receiving subcu unfractionated heparin prophylaxis are at highest risk for HIT. Because of this patient’s high-risk scenario and the presence of acute thrombosis, it is advisable to begin immediate empiric treatment for HIT pending laboratory confirmation. Management should include discontinuation of heparin and treatment with a non-heparin anticoagulant.

Answer 1048

B ## Footnote Polyarticular arthritis often presents with fever, knee and other joint effusions, and leukocytosis. Especially in cases where a joint effusion is accompanied by fever, diagnostic arthrocentesis should be performed to help guide therapy. A 24-hour urine collection is not routine, is difficult for the patient, and typically does not change therapy. Allopurinol should not be initiated during an acute gouty attack, but may be started after a patient has recovered. Diuretics increase uric acid levels.

Answer 1049

A ## Footnote The preferred anticoagulant for venous thrombosis during pregnancy is low molecular weight heparin. Unfractionated heparin requires more monitoring and may increase the risk of heparin-induced thrombocytopenia - *"heparin keeps fetuses heppy"* Warfarin should not be used during pregnancy but may be used in women who are breastfeeding - *"do not wage war against the fetus"*

Answer 1050

C ## Footnote Hepatotoxicity resulting from timed-release formulations of niacin has been reported in elderly individuals. Patients may be taking this supplement without their physician’s knowledge, feeling it is safe because it is a vitamin. Aspirin and vitamin C can result in gastrointestinal iron loss and anemia. The other medications listed, if used in moderation, would not be expected to alter laboratory findings.

Answer 1051

A When evaluating a patient with a solitary thyroid nodule, red flags indicating possible thyroid cancer include male gender; age 65 years; rapid growth of the nodule; **symptoms of local invasion such as dysphagia, neck pain, and hoarseness**; a history of head or neck radiation; a family history of thyroid cancer; a hard, fixed nodule \>4 cm; and cervical lymphadenopathy.

Answer 1052

A The rotavirus vaccine is an oral vaccine recommended for infants in a 3-dose schedule at ages **2, 4, and 6 months**, with the first dose should be given between 6 and 12 weeks of age and subsequent doses given at 4 to 10-week intervals. The vaccine cannot be initiated after 12 weeks of age (due to risk of intussusception, as seen with older rotavirus vaccine) and should not be administered after 32 weeks of age.

Answer 1053

D S. aureus is the most common cause of acute infectious endocarditis worldwide. Additionally, the most common cause of tricuspid valve endocarditis is IVDU, and S. aureus is the infecting organism in 80% of tricuspid valve infections. Streptococcus viridans is also a frequent cause of infectious endocarditis, with Enterococcus, Pseudomonas, and Cardiobacterium being less likely causes.

Answer 1054

C ## Footnote **Methimazole and propylthiouracil (PTU)** are the two oral antithyroid medications available. However, because of reports of severe hepatocellular damage, methimazole should be used instead of PTU unless it is contraindicated (ie pregnancy). Radioactive iodine treatment (¹³¹I) is best for patients who do not achieve remission with antithyroid medications. However, a well-recognized potential complication of ¹³¹I treatment is _worsening of preexisting orbitopathy_ as well as a _transient increase in thyroid hormone levels that can precipitate thyroid storm_. **Thus, patients with elevated free T3 or free T4 levels should be treated with methimazole prior to ¹³¹I administration.** Thyroidectomy is most often recommended for patients with thyroid nodules and those who are suspected of having cancer or who do not tolerate or refuse alternative forms of therapy. However, antithyroid medication should be given to achieve a euthyroid state prior to surgery in most patients.

Answer 1055

D ## Footnote This patient has Henoch-Schönlein purpura. This condition is associated with a palpable purpuric rash, without thrombocytopenia. Other diagnostic criteria include bowel angina (diffuse abdominal pain or bowel ischemia), age ≤20, renal involvement, and a biopsy showing predominant immunoglobulin A deposition**. The long-term prognosis depends on the severity of renal involvement.** Almost all children with Henoch-Schönlein purpura have a spontaneous resolution, but 5% may develop end-stage renal disease.

Answer 1056

E ## Footnote This patient’s symptoms and laboratory values are most consistent with intrahepatic cholestasis of pregnancy. Ursodiol has been shown to be highly effective in controlling the pruritus and decreased liver function and is safe for mother and fetus. Topical antipruritics and oral antihistamines are not very effective. Cholestyramine may be effective in mild or moderate intrahepatic cholestasis, but is less effective and safe than ursodiol.

Answer 1057

B ## Footnote Lead-time bias is when a screening test identifies a cancer earlier, thereby increasing the time between diagnosis and death without actually prolonging life. Length-time bias is when a screening test finds a disproportionate number of cases of slowly progressive disease and misses the aggressive cases, thereby leading to an overestimate of the effectiveness of the screening. A false-positive test is one that suggests cancer when no cancer exists. The positive predictive value is the proportion of positive test results that are true positives. Attributable risk is the amount of difference in risk for a disease that can be accounted for by a specific risk factor

Answer 1058

C ## Footnote Sympathomimetic agents can **elevate BP and IOP**, **worsen existing urinary obstruction**, and adversely interact with ß-blockers, methyldopa, TCAs, oral hypoglycemic agents, and MAOIs. They also **increase HR**. First-generation nonprescription antihistamines can enhance the anticholinergic and sedative effects of other medications.

Answer 1059

D ## Footnote This patient is experiencing **primary dysmenorrhea**. Because symptoms started at a rather young age and she has pain only during menses, *endometriosis* or other significant pelvic pathology is unlikely. An *infection* is doubtful, considering that she is not sexually active and that symptoms have been present for 2 years. In the absence of red flags, a pelvic examination, laboratory evaluation, and pelvic US are not necessary at this time. However, they can be ordered if she does not respond to simple treatment. NSAIDs such as naproxen have a slight effect on platelet function, but because they inhibit prostaglandin synthesis they actually decrease the volume of menstrual flow and lessen the discomfort of pelvic cramping. Acetaminophen would have no effect on prostaglandins.

Answer 1060

C ## Footnote Inhaled corticosteroids will _not_ reduce mortality or affect long-term progression of COPD. However, they do **reduce the number of exacerbations and the rate of decline in the quality of life**. These agents do have side effects, including candidal infection of the oropharynx, hoarseness, and an **increased risk of developing pneumonia** There appears to be no increase in cataract formation or rate of fracture.

Answer 1061

E ## Footnote **Henoch-Schonlein purpura -** IgA-mediated small-vessel vasculitis that classically presents with the triad of **nonthrombocytopenic palpable purpura, colicky abdominal pain**, and **arthritis**. Kawasaki disease is manifested by conjunctival injection, mucosal erythema, rash, and lymphadenopathy. Takayasu arteritis has numerous manifestations, including night sweats, fatigue, weight loss, myalgia, and arthritis. Later findings may include hypertension, skin lesions, and cardiac disorders. Wegener granulomatosis causes constitutional symptoms also, including weight loss and fatigue, with later findings including respiratory problems, ophthalmologic lesions, neuropathies, glomerulonephritis, and skin lesions. Polyarteritis nodosa is another disease that causes constitutional symptoms such as fatigue, fever, and myalgias. It also causes skin lesions, GI symptoms such as postprandial abdominal pain, and cardiac lesions.

Answer 1062

C ## Footnote Dupuytren’s contracture is characterized by **progressive thickening and nodule formation in the palmar fascia** that can progress to a **contracture of the associated finger**. The **fourth finger** is most commonly affected. **Pitting or dimpling** can occur over the nodule because of the connection with the skin. Degenerative joint disease is not associated with a palmar nodule. Trigger finger is related to the tendon, not the palmar fascia, and causes the finger to lock and release. Ganglions also affect the tendons or joints, are not located in the fascia, and are not associated with contractures. Flexor tenosynovitis, an inflammation, is associated with pain, which is not usually seen with Dupuytren’s contractures.

Answer 1063

A ## Footnote Some hypothyroid patients who are treated with appropriate dosages of levothyroxine and whose TSH levels are in the appropriate range continue to have persistent symptoms such as fatigue, depressed mood, and weight gain. **If the TSH is in the appropriate range then no adjustment is necessary and annual serum TSH testing is recommended**. Patients who remain symptomatic on an appropriate dosage of levothyroxine, as determined by a TSH not likely to benefit from combination triiodothyronine/thyroxine therapy. Desiccated thyroid hormone preparations are not recommended by the American Association of Clinical Endocrinologists for the treatment of hypothyroidism. A meta-analysis of 11 randomized, controlled trials of combination T3/T4 therapy versus T4 monotherapy showed no improvements in pain, depression, or quality of life.

Answer 1064

C Adnexal masses in women under 45 years of age are benign in 80%–85% of cases. The specific findings of this case also strongly suggest a benign etiology, namely a thin-walled, simple cyst, a lesion that is less than 8 cm in size, and a patient of relatively young age. No aggressive means are indicated in these situations unless there are significant clinical symptoms such as pain, abdominal pressure, urinary symptoms, or gastrointestinal symptoms. Most experts currently recommend a conservative approach with repeat US in 2 months, during which time the vast majority of benign cysts resolve spontaneously.

Answer 1065

A ## Footnote The patient shows classic symptoms of **early Alzheimer’s disease**, with difficulties in at least two cognitive domains that are severe enough to influence daily living. Normal aging changes can decrease one’s ability to retrieve information but do not influence daily living and are usually noticed more by the patient than by family members. Depression was previously thought to cause “pseudodementia” with significant regularity. However, several recent studies have shown that treating depressive symptoms does not result in significantly improved cognitive performance. It is now believed that progressive memory loss frequently results in depressive symptoms, rather than the converse. Lewy body dementia is associated with physical findings of parkinsonism and often the presence of visual hallucinations, both of which are absent in this patient. There are no signs of multiple infarcts on brain imaging, effectively ruling out this diagnosis.

Answer 1066

B ## Footnote Ingestion of grapefruit juice can increase absorption and serum levels of statins via CYP450, leading to an increased risk of muscle injury. Starfruit juice and pomegranate juice can have a similar effect. These juices contain an irreversible inhibitor of intestinal CYP3A4, and increase the bioavailability of **atorvastatin, lovastatin,** and **simvastatin**. Grapefruit juice reduces CYP3A4 activity by 50% within 4 hours of ingestion, and activity is reduced by 30% for as long as 24 hours after ingestion. Several studies document that consuming 600 mL of double-strength juice for 3 days produces a more than tenfold increase in the area under the curve for simvastatin and lovastatin, but only a 250% increase in atorvastatin.

Answer 1067

B ## Footnote (+) Lachman test indicates that the ACL may be torn. The posterior drawer test evaluates PCL stability. The McMurray and Thessaly assessments test for meniscal tears. The ballottement test is for detecting intra-articular knee effusion.

Answer 1068

D ## Footnote Considering relative risk reduction without also considering the absolute rate can distort the importance of a therapy. A useful way to assess the importance of a therapy is to determine the number-needed-to-treat for that therapy. To calculate this number, the **percentage of absolute risk reduction of a particular therapy is divided into 100. I**n the case in question, the absolute risk reduction would be 0.5% (0.5x.01). Thus, the number-needed-to-treat for the example cited would be 200 (100/0.5)

Answer 1069

A ## Footnote Based on this patient’s reported frequency of asthma symptoms, she should be classified as having intermittent asthma. The preferred first step in managing intermittent asthma is an inhaled short-acting β-agonist as needed Daily medication is reserved for patients with persistent asthma (symptoms \>2 days per week for mild, daily for moderate, and throughout the day for severe) and is initiated in a stepwise approach, starting with a **_daily low-dose inhaled corticosteroid or leukotriene receptor antagonist_** and then progressing to a **_medium-dose inhaled corticosteroid_** or **_low-dose inhaled corticosteroid plus a long-acting inhaled β-agonist._**

Answer 1070

A ## Footnote The absolute rate of stroke depends on age and comorbid conditions. The stroke risk index CHA2DS2-VASc , used to quantify risk of stroke for patients who have atrial fibrillation and to aid in the selection of antithrombotic therapy CHF, HTN, Age \>75, DM, Stroke/TIA. Vascular dz, Age 65-74, Sex F Low risk = score of 0 -\> treat w/ aspirin Intermediate risk = 1 or 2 -\> treat w/ warfarin High risk = score 3. Experts typically prefer treatment with aspirin rather than warfarin when the risk 2 of stroke is low. The patient in this question has a CHADS score of 0, which is low risk. Treatment with aspirin is therefore appropriate.

Answer 1071

A Pharyngitis is a common complaint, and usually has a viral cause. The key factors in diagnosing streptococcal pharyngitis are a fever \> 100.4°F, tonsillar exudates, anterior cervical lymphadenopathy, and _absence_ of cough. The scenario described is consistent with a viral infection, with no risk factors to make streptococcal infection likely; therefore, this patient should be offered symptomatic treatment only. Testing for other infections is not indicated unless the patient worsens or does not improve.

Answer 1072

A ## Footnote The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury. Sesamoiditis is often hard to differentiate from sesamoid fractures. Xrays should be obtained, but at times they are nondiagnostic. Treatment, fortunately, is similar, unless the fracture is open or widely displaced. Limiting weight bearing and flexion to control discomfort is the first step. More complex treatments may be needed if the problem does not resolve in 4-6 weeks. Gout commonly involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton’s neuroma commonly occurs between the third and fourth toes, causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized.

Answer 1073

B ## Footnote When family dynamics lead to conflict during an office visit, it is best for the physician to attempt to remain neutral by avoiding triangulation, which occurs when the two sides in conflict each attempt to align with a third party. Priority should be given to the patient’s right to privacy and confidentiality, and the physician should ask permission from the patient to discuss his or her health issues with other people. Physicians should always remember who they are primarily responsible to.

Answer 1074

B ## Footnote This patient has pleuritic chest pain, and the fact that it is worse when supine and is accompanied by dyspnea creates additional concern. Supine pain could be due to pericarditis, which may be evident on an EKG. Dyspnea increases suspicion for pneumonia, PE, PTX, and MI, and a CXR and EKG are recommended to evaluate these possibilities. The lack of any significant medical history does not rule out any of these problems. Once these problems have been ruled out, a diagnosis of pleurisy would be reasonable and can be treated with an NSAID. A CBC would only indicate the possibility that infection or anemia is the cause of the problem. Omeprazole or a bronchodilator would be inappropriate treatment, as asthma and reflux are not likely in this patient.

Answer 1075

B ## Footnote Dysthymic disorder is characterized by depressed mood for at least 2 years in addition to at least two of the following: change in appetite, alteration in sleep, low energy, low self-esteem, poor concentration, or feelings of hopelessness. There must be no history of a manic or hypomanic episode, substance abuse, a chronic psychotic disorder, or an organic cause. Symptoms of major depression are similar to those of dysthymia and can occasionally be difficult to distinguish from dysthymia. This patient’s lifelong history of a depressed mood not triggered by any particular depressing event, and the predominance of patient complaints as opposed to objective signs, indicate that major depression is not the diagnosis in this case.

Answer 1076

D ## Footnote Genital warts can proliferate and fragment during pregnancy, and many specialists recommend that they be eliminated. CDC recommends cryotherapy with liquid nitrogen, rather than a cryoprobe, to avoid possible vaginal perforation and subsequent fistula formation. Imiquimod, podophyllin, and podofilox are _not_ recommended for use during pregnancy. An alternative is the use of trichloroacetic acid or bichloroacetic acid carefully applied to the lesions to avoid damage to adjacent tissue. IFN is no longer recommended for routine use in treating genital warts, due to a high frequency of systemic adverse effects.

Answer 1077

C Postcholecystectomy pain associated with jaundice (which can cause itching) is a classic presentation for a retained common duct stone. Acetaminophen toxicity is usually painless, and is associated with ingestion of large amounts of the drug and/or alcohol, or other potentially hepatotoxic drugs. Viral hepatitis is usually painless and accompanied by other systemic symptoms. Hydrocodone can cause pruritus but not pain and jaundice.

Answer 1078

D ## Footnote Acute otitis externa is treated with topical antibiotics. Although no preparation has been shown to be most effective, a fluoroquinolone does not create a risk of ototoxicity if the tympanic membrane is not intact. Topical corticosteroids may hasten symptom reduction. Oral antibiotics are not appropriate unless the infection has spread beyond the ear canal, or if the patient has diabetes mellitus or is immunocompromised.

Answer 1079

C ## Footnote Alcoholic ketoacidosis generally occurs in a patient who has been drinking heavily *without* eating. Blood glucose levels are usually low or normal, and volume depletion associated with N/V and abdominal pain. Patients typically have high osmolal and anion gaps. Treatment of alcoholic ketoacidosis includes **vigorous volume repletion with normal saline**, along with **administration of thiamine and glucose**. If there is marked acidemia (pH bicarbonate thought to be necessary. Though insulin levels may be low, hyperglycemia is seldom found. N-acetylcysteine and pyridoxine are not used for the treatment of alcoholic ketoacidosis. Levels of glucagon and hydrocortisone are typically elevated in patients with alcoholic ketoacidosis.

Answer 1080

B ## Footnote Physicians should avoid reacting to laboratory values without considering the clinical scenario. This patient presented with mild dehydration and normal laboratory values. Although he is improving clinically, his laboratory values show multiple unexpected results. The most noticeable is the severely elevated glucose, because he has no history of diabetes mellitus or use of medications that could cause this effect. Similarly, the elevated potassium and decreased sodium suggest profound electrolyte abnormalities. Most likely, the laboratory technician drew blood from the patients indwelling port without discarding the first several milliliters. Thus, the blood was contaminated with intravenous fluids, resulting in the erroneous results. A repeat blood test from a peripheral vein should give more accurate results.

Answer 1081

E Serum neuron-specific enolase (NSE) _AND_ spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors.

Answer 1082

B ## Footnote Outbreaks of Norwalk gastroenteritis occur in a wide variety of settings, involve all ages, and are more likely to involve high-risk groups such as immunocompromised patients or the elderly. **Not only does viral shedding of the Norwalk virus often precede the onset of illness, but it can continue long after the illness has clinically ended.** The virus persists on environmental surfaces and can tolerate a broad range of temperatures. There are multiple strains of the virus, so a single infection does not confer immunity, and repeated infections occur throughout life. It is the most common cause of diarrhea in adults

Answer 1083

A ## Footnote **Intoeing** is usually caused by **internal tibial torsion** and is believed to be **caused by sleeping in the prone position and sitting on the feet.** In 90% of cases internal tibial torsion gradually resolves without intervention by the **age of 8.** Avoiding sleeping in a prone position enhances resolution of the problem. Night splints, orthotics, and shoe wedges are ineffective. Surgery (osteotomy) has been associated with a high complication rate, and is therefore not recommended in mild cases before the age of 8.

Answer 1084

A ## Footnote Hypertrophic pyloric stenosis is the most likely diagnosis in this case. If it is allowed to progress untreated, there may be signs of malnutrition, constipation, oliguria, and profound hypochloremic metabolic alkalosis. As the child vomits chloride and hydrogen-rich gastric contents, hypochloremic alkalosis sets in. After feeding, there may be a visible peristaltic wave that progresses across the abdomen. However, since the point of obstruction is proximal to the small and large intestines and affected infants lose weight, the abdomen is usually flat rather than distended, especially in the malnourished infant.

Answer 1085

A TPN is indicated for * patients with poorly functioning GI tracts who cannot tolerate other means of nutritional support * those with high caloric requirements that cannot otherwise be met. Patients who cannot swallow because of an esophageal motility problem and those who are resistant to feeding can be managed with tube feedings. Peripheral alimentation, which provides fewer calories than TPN or liquid tube feedings, would be more appropriate over the short term in patients recovering from surgery.

Answer 1086

B ## Footnote This patient has a mallet fracture caused by an axial load to the tip of an extended finger that causes forced flexion at the DIP joint. The most appropriate treatment of a mallet fracture is to splint the DIP joint in extension for 8 weeks. The joint should remain in full extension for optimal healing. Any flexion of the finger may affect healing and extend the treatment time.

Answer 1087

D Hormone replacement therapy (HRT) improves the urogenital symptoms of menopause, such as vaginal dryness and dyspareunia. Recent research regarding HRT has not shown a benefit for reducing coronary events, slowing the progression of Alzheimer’s disease, improving depression, or improving urinary incontinence.

Answer 1088

B ## Footnote Diazepam (VALIUM) - 70 h Lorazepam (ATIVAN) - 70 h Clonazepam (KLONOPIN) - 50 h Alprazolam (XANAX) - 15 h Chlordiazepoxide (LIBRIUM) - 48 h Oxazepam (SERAX) - 15 h Temazepam (RESTORIL) - 12 h Midazolam (VERSED) - 4 h Triazolam (HALCION) - 5 h

Answer 1089

A ## Footnote The clinical history and laboratory findings presented are consistent with a diagnosis of **narcolepsy**. Methylphenidate and other stimulant drugs remain the pharmacologic agents of choice in managing this disorder. Since there is no evidence of obstructive sleep apnea, weight reduction would not be expected to address his sleep problem. In general, sedatives, hypnotics, and alcohol should be avoided. Periodic daytime naps may help to reduce symptoms.

Answer 1090

B ## Footnote Although breast milk is the ideal source of nutrition for healthy term infants, supplementation with 200 IU/day of vitamin D is recommended beginning at 2 months of age and continuing until the child is consuming at least 500 mL/day of formula or milk containing vitamin D. The purpose of supplementation is to prevent rickets. Unless the baby is anemic or has other deficiencies, neither iron nor a multivitamin is necessary. Parents often mistakenly think babies need additional water, which can be harmful because it decreases milk intake and can cause electrolyte disturbances. Cereal should not be started until 4 to 6 months of age.

Answer 1091

D ## Footnote SSRIs are the most appropriate first-line pharmacologic treatment for depression in nursing-home residents TCA/Amitriptyline, doxepin, MAOi, and clomipramine should be avoided in nursing-home patients.

Answer 1092

B Education of asthmatic patients is critically important in their follow-up care. This includes informing patients about the severity of their asthma in addition to instruction about appropriate treatment modalities. * **Intermittent**: Symptoms _2x weekly, nighttime awakenings ≤2 times/month, short-acting β-agonist usage ≤2 days/week, no interference with daily activities, and normal FEV1 and FEV1/FVC ratio at baseline_ * **Mild Persistent**: Symptoms \>2 days/week but not daily, nighttime awakenings 3-4 times/month, short-acting β-agonist usage \>2 days/week but not more than once daily, minor limitation to daily activities, FEV1 ≥80% predicted, and normal FEV1/FVC ratio * **Moderate Persistent**: _Daily_ symptoms, nighttime awakenings greater than once weekly but not nightly, _daily_ use of a short-acting β-agonist, some limitation to daily activity, FEV1 \>60% but * **Severe Persistent**: Symptoms *throughout* the day, nighttime awakenings nightly, short-acting β-agonist usage *several times daily*, extremely limited daily activities, FEV1 5% * **Status asthmaticus -** medical emergency and requires emergent treatment in a hospital setting.

Answer 1093

C ## Footnote Noncontiguous or “skip” lesions that are transmural in nature and are found throughout the GI tract make a diagnosis of Crohn’s disease. Corticosteroids are more effective in inducing remission than placebo and 5-ASA products. Anti-TNF agents such as infliximab should be considered in patients with moderate to severe Crohn’s disease who do not respond to initial corticosteroid or immunosuppressive therapy, but these are not recommended for initial treatment. Surgical intervention should be considered in patients with ulcerative colitis, but surgery is not indicated for Crohn’s disease.

Answer 1094

E ## Footnote It is recommended that caregivers establish food rules, such as healthy scheduled meals and snacks, and apply them consistently. Parents should control what, when, and where children are being fed, whereas children should control how much they eat at any given time in accordance with physiologic signals of hunger and fullness. No food or drinks other than water should be offered between meals or snacks. Food should not be offered as a reward or present. Parents can be reassured that a normal child will learn to eat enough to prevent starvation. If malnutrition does occur, a search for a physical or mental abnormality should be sought.

Answer 1095

B ## Footnote While there is significant overlap in the symptoms of each condition, there are some signs and symptoms that help the family physician determine whether a terminally ill patient is experiencing grief or has major depression. This distinction is important because the terminally ill patient with depression would likely benefit from antidepressant medication, whereas a patient with end-of-life grief is generally best managed without psychotherapeutic medications. The key clinical feature in distinguishing the two conditions is in the **pervasiveness of symptoms in depression, particularly the** **loss of pleasure or interest in all activities.** Episodic feelings of guilt, anxiety, and helplessness, and even thoughts of wanting to die can and do occur with grief reactions, but *these* *feelings are not constant and over time the symptoms gradually wane.* Terminally ill patients with major depression feel helplessly hopeless all the time, but they often respond to and significantly benefit from antidepressant medication.

Answer 1096

A ## Footnote Women who will be pregnant during the influenza season should receive the inactivated vaccine, and it can be given in any trimester. Coexistent illness is not required for this indication. There appears to be some protective effect for the infant up to the age of 6 months. The live intra-nasal vaccine is not approved for use in pregnancy. Immunization of family members is sometimes recommended for immunocompromised patients. In the absence of other indications, however, it has not been recommended for family members of pregnant patients.

Answer 1097

C Severe type I hypersensitivity reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little warning. Anaphylactic reactions result from a massive release of histamine and start with: * pruritus around the mouth, on the scalp, and on the palms and soles * flushing of the face and neck * rhinitis and conjunctivitis * angioedema of the oral mucosa, especially of the pharynx and larynx * severe urticaria * dyspnea and bronchospasm (especially in known asthmatics) * hypotension, shock, and death Type IV reactions usually result in benign, diffuse erythematous macules on the trunk and proximal extremities, often referred to as a drug rash.

Answer 1098

B Dementia with Lewy bodies is considered one of the most common etiologies of dementia in elderly patients, representing up to 20%-30% of those with significant memory loss. The clinical presentation consists of parkinsonian symptoms (rigidity, tremor), ***_fluctuating_*** levels of alertness and cognitive abilities, and behavior sometimes mimicking acute delirium. Visual hallucinations are common, and delusions and auditory hallucinations are seen to a lesser degree. On pathologic examination, Lewy bodies are present diffusely in the cortex. There is currently no specific treatment.

Answer 1099

B ## Footnote In 2008 the FDA issued a public health advisory for parents and caregivers, recommending that over-the-counter cough and cold products not be used to treat infants and children younger than 2 years of age, because serious and potentially life-threatening side effects can occur from such use. These products include decongestants, expectorants, antihistamines, and antitussives.

Answer 1100

A ## Footnote A history of migraine with aura is classified as category 4 (condition that represents an unaccetable health risk) for oral contraceptives. Women with a history of migraines are 2–4 times as likely to have a stroke compared to women without migraines, and women who have an aura associated with their migraines are at even higher risk. Migraine without aura is classified as category 2 in women younger than 35 and category 3 in women 35 or older. Nonmigrainous headaches are category 1, as is chronic hepatitis C.

Answer 1101

D Up to **40°** of volar angulation is acceptable for fifth metacarpal fractures. For second and third metacarpal fractures, less angulation is acceptable. Appropriate treatment is a gutter splint.

Answer 1102

D Iron deficiency is almost certainly the diagnosis in this child. The patient’s response to a therapeutic trial of iron would be most helpful in establishing the diagnosis. Additional tests might be necessary if there is no response.

Answer 1103

B ## Footnote Conservative, supportive, and palliative therapy replace definitive reconstructive surgical therapy. Surgical correction of a hammer toe and bunionectomy could be disastrous in an elderly patient with a small ulcer and peripheral vascular disease. The best approach with this patient is to prescribe custom-made shoes and a protective shield with a central aperture of foam rubber placed over the hammer toe. Metatarsal pads are not useful in the treatment of hallux valgus and a rigid hammer toe.

Answer 1104

B ## Footnote Testosterone increases hematocrit and can cause polycythemia. In patients receiving testosterone supplementation, hematocrit should be monitored every 6 months for the first 18 months, then annually. Testosterone should be discontinued if there is more than a 50% rise in hematocrit. Testosterone also causes an increase in lean body mass, and may increase bone density.

Answer 1105

E The diagnosis is made by nasopharyngeal culture, but because the disease is uncommon and the organism is fastidious, laboratory personnel should be advised of the physician’s suspicion of pertussis. Treatment includes respiratory and nutritional supportive care, particularly for infants younger than 6 months. Antibiotic therapy is most effective in shortening the illness when given early, during the upper respiratory phase, but is indicated at any stage to reduce the spread of disease to others. The drug of choice is **erythromycin**, 40–50 mg/kg/day divided into four doses, for 14 days. Also effective are azithromycin and clarithromycin, which may be better tolerated with improved compliance.

Answer 1106

C A neutrophil count \>250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results.

Answer 1107

A In the 2001 Bethesda System, atypical squamous cells of unknown significance (ASCUS) was replaced by atypical squamous cells (ASC). ASC is divided into atypical squamous cells - cannot exclude HSIL (ASC-H) and atypical squamous cells of unknown significance (ASC-US). ASCUS–favor reactive has been downgraded to negative in the 2001 system. Atypical glandular cells of unknown significance (AGUS) has been replaced by atypical glandular cells (AGC).

Answer 1108

D ## Footnote The radiograph shows a typical slipped capital femoral epiphysis, with the epiphysis displaced posteriorly and medially. The problem usually occurs in late childhood or adolescence. Osgood-Schlatter disease involves the anterior tibial tubercle. Legg-Calvé-Perthes disease is avascular necrosis of the femoral head. Blount’s disease involves the medial portion of the proximal tibia.

Answer 1109

B ## Footnote Alkaline phosphatase is elevated in conditions affecting the bones, liver, small intestine, and placenta. The addition of elevated 5'-nucleotidase suggests the liver as the focus of the problem. Measuring 5'-nucleotidase to determine whether the alkaline phosphatase elevation is due to a hepatic problem is well substantiated, practical, and cost effective.

Answer 1110

A ## Footnote **Amenorrhea is an indicator of inadequate calorie intake**, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. Young athletes may develop a combination of conditions, including **eating disorders, amenorrhea, and osteoporosis (the female athlete triad)**. **Amenorrhea usually responds to increased calorie intake or a decrease in exercise intensity**. It is not necessary for patients such as this one to stop running entirely, however.

Answer 1111

E ## Footnote Certain antiepileptic drugs induce hepatic metabolism of estrogen + progestin (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, and topiramate). This can potentially lead to failure of any contraceptive that contains estrogen + progestin. Progestin-only pills are most effective in women who are exclusively breastfeeding. They are not as effective in pregnancy prevention in other circumstances. Another effective option for women taking antiepileptic medications would be an **IUD**. The levonorgestrel (progestin only) IUD and copper IUD are acceptable choices even for a nulligravida. The **single-rod** **implantable progestin** system also would be an acceptable choice for this patient.

Answer 1112

A In pregnant women with severe HTN, the primary objective of treatment is to prevent cerebral complications such as encephalopathy and hemorrhage. **IV hydralazine, IV labetalol**, or **PO nifedipine** may be used. Sublingual nifedipine can cause severe hypotension, and reserpine is not indicated. Nitroprusside can be used for short intervals in patients with hypertensive encephalopathy, but fetal cyanide toxicity is a risk with infusions lasting more than 4 hours. ACEi is never indicated for hypertensive therapy during pregnancy.

Answer 1113

B ## Footnote **RUQ US** is recommended as the initial imaging study for RUQ pain. KUB films can detect kidney stones but may miss gallstones. CT also may miss gallstones, and is more invasive than US. Abdominal CT with IV contrast is the preferred test for RLQ pain, and abdominal CT with IV and PO contrast is preferred for LLQ pain. MRI is preferred for detecting tumors, and is inappropriate as the initial imaging study for RUQ pain.

Answer 1114

B In children, overweight and obesity is determined by the BMI percentile for age and gender. In adults, BMI, body fat percentage, and abdominal girth are used to determine a patient’s classification.

Answer 1115

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 * 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 IVF at 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. 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 intestines.

Answer 1116

C OCs increase the risk of venous thromboembolic events. OC + smoking substantially increases the risk of CVD. In general, OC is absolutely contraindicated in women \>35 who are heavy smokers. Women who smoke not at increased risk for CVD when OCs are used.

Answer 1117

C ## Footnote SSRI and TCAs have a beneficial effect on IBS symptoms. Controlled trials did not show any benefit from the use of fiber in any type of IBS. Antibiotics have been shown to have some beneficial effects, but neomycin is used only in **constipation-predominant IBS.** Lubiprostone is a selective C-2 chloride channel activator and can be used for patients with chronic constipation. Alosetron is a 5-hydroxytryptamine 3 antagonist and is FDA approved to treat severe **diarrhea-predominant IBS** **only in women** who have not improved with conventional therapy. Alosetron is associated with ischemic colitis, constipation, death. Other potentially beneficial therapies for IBS include peppermint oil, psychological treatments, exercise, and probiotics.

Answer 1118

D ## Footnote Maintaining a protein intake of at least 1.2–1.5 g/kg/day is recommended to accelerate pressure ulcer healing in the elderly, and some authorities recommend 2 g/kg/day with stage III or IV ulcers. Increased caloric intake is also necessary to promote healing. The role of vitamins and minerals in preventing and treating pressure ulcers is unclear.

Answer 1119

D ## Footnote **Thiazides decrease the renal clearance of calcium by increasing distal tubular calcium reabsorption.** Furosemide tends to lower serum calcium levels and is used in the treatment of hypercalcemia. None of the other medications would be expected to significantly affect the serum calcium level in this patient.

Answer 1120

C ## Footnote USPSTF recommends that children over the age of 6 months receive oral fluoride supplementation if the primary drinking water source is deficient in fluoride. They cite fair evidence that such supplementation reduces the incidence of dental caries and conclude that the overall benefit outweighs the potential harm from dental fluorosis.

Answer 1121

D ## Footnote **Acute angle-closure glaucoma** is manifested by an acute onset of _severe pain_, blurred vision, halos around lights, increased IOP, red conjunctiva, a mid-dilated and sluggish pupil, and a normal or hazy cornea. Findings with **retinal detachment** include either normal vision or peripheral or central vision loss; _absence of pain_; _floaters_; and a _normal conjunctiva_, cornea, and pupil. **Central retinal artery** occlusion findings include _amaurosis fugax_, a _red conjunctiva_, a pale fundus, a cherry-red spot at the fovea, and “boxcarring” of the retinal vessels. In patients with **mechanical injury to the globe**, findings include _moderate to severe pain_, normal or decreased vision, subconjunctival hemorrhage completely surrounding the cornea, and a pupil that is irregular or deviated toward the injury

Answer 1122

E ## Footnote Most American women who have undergone hysterectomy are not at risk of cervical cancer, as they underwent the procedure for benign disease and no longer have a cervix. U.S. Preventive Services Task Force recommendations stated that routine Pap screening is unnecessary for these women. Nevertheless, data from the Behavioral Risk Factor Surveillance System (1992–2002) indicated that in the previous 3 years, some 69% of women with a previous history of hysterectomy for benign causes had undergone screening.

Answer 1123

B Use of an incentive spirometer and similar lung expansion techniques such as chest physiotherapy have been shown to have significant benefit for reducing postoperative complications. A course of preoperative corticosteroids has been shown to be beneficial for patients with COPD.

Answer 1124

B Most children will be evaluated for a febrile illness before 36 months of age, with the **majority having a self-limited viral illness**. * **Nontoxic**-appearing febrile infants **29-90 days of age** who have a negative screening laboratory workup (CBC, UA), can be sent home and followed up in 24 hours. * Observation with no follow-up is an appropriate strategy in **nontoxic children ages 3-36 months** and the temperature is **under 39°C**. * **Nontoxic children 3-36 months of age** should be reevaluated in 24-48 hours if the temperature is over 39°C. * Any **infant younger than 29 days**, and any **infant/child with a toxic** **appearance** regardless of age, should undergo a complete sepsis workup and be admitted for observation until culture results are obtained or the source of the fever is found and treated

Answer 1125

D ## Footnote The most likely diagnosis for this patient is **slipped capital femoral epiphysis (SCFE).** This is more frequent in **males** than in females, and is more common in **African-Americans** and **Pacific Islanders** than in whites. Although some patients present with pain, many present with **a painless limp or vague pain**. The average age of onset is 13.5 years for males and 12 years for females. **Obesity** is strongly associated with SCFE. The lack of systemic symptoms makes osteomyelitis, abscess, or a septic joint much less likely. Malignancy is a possibility, but night pain would be more likely. Sacroiliitis is much less likely given a negative FABER test. The patient’s age makes transient synovitis or Legg-Calvé-Perthes disease less likely. Although muscle strain is a possibility, the physical examination findings of external rotation deformity and limited internal rotation are more specific for SCFE. Once the diagnosis of SCFE is made, the patient should not bear weight and should be referred promptly for **surgery** to prevent complications.

Answer 1126

C ## Footnote Eating as little as one poppy seed muffin can produce amounts of morphine and codeine detectable by immunoassay, as well as by GC-MS. In addition to poppy seeds, substances reported to cause false-positive urine drug screens include selegiline, Vicks inhalers, NSAIDs, oxaprozin, fluoroquinolones, rifampin, venlafaxine, and dextromethorphan. Passively inhaled crack cocaine or marijuana (unless an extreme amount is inhaled), and ingested products containing hemp or other common herbal preparations do not produce positive urine drug screens.

Answer 1127

D Patients with long QT syndrome that have sudden arrhythmia death syndrome usually have either **torsades de pointes** or **ventricular fibrillation**. Sinus tachycardia would not explain the syncope, and atrial flutter and asystole are not usual in long QT syndrome

Answer 1128

A ## Footnote Most episodes of pharyngitis are caused by viral rather than bacterial infections. Five signs/symptoms to estimate the probability of acute streptococcal pharyngitis in adults with a sore throat are (1 point each) (1) absence of cough (2) swollen, tender anterior cervical nodes (3) temperature \>38.0°C (100.4°F) (4) a tonsillar exudate and swelling One point added if patients between the ages of 3 and 14 years, and one point subtracted for patients over the age of 45. Patients with a **score of zero or 1** are at very low risk for streptococcal pharyngitis and do not require testing or antibiotic therapy. Patients with a **score of 2–3** should be tested using a rapid antigen test or throat culture, and a positive result warrants antibiotic therapy. Patients with a **score of 4 or higher** are at high risk for streptococcal pharyngitis, and empiric treatment may be considered. This patient’s score is zero, and no testing or treatment is warranted.

Answer 1129

C Patients who have a low or moderate pretest probability of pulmonary embolism should have d-dimer testing as the next step in establishing a diagnosis.

Answer 1130

A Metformin and insulin are the only agents approved for treatment of type 2 diabetes mellitus in children.

Answer 1131

A ## Footnote The currently circulating novel influenza A H1N1 virus is almost always **susceptible to neuraminidase inhibitors (oseltamivir and zanamivir)** and resistant to the adamantanes (amantadine and rimantadine). Zanamivir should not be used in patients with COPD, asthma, or respiratory distress. Antiviral treatment of influenza is recommended for all persons with clinical deterioration requiring hospitalization, even if the illness started more than 48 hours before admission. Antiviral treatment should be started as soon as possible. Waiting for laboratory confirmation is not recommended.

Answer 1132

B ## Footnote Laws providing immunity from civil damages for injuries or death resulting from care deemed reasonable under the circumstance (ordinary negligence) are generally described as Good Samaritan laws. Good Samaritan statutes have been enacted in some form in all 50 states, the District of Columbia, and Puerto Rico to protect physicians from liability (in the absence of gross negligence) if they provide emergency care to individuals with whom they share no preexisting obligation to provide medical care. In most states such protection is limited to emergency care provided outside of the hospital setting, although a few states offer protection for hospital care in certain circumstances. While there is no legal obligation to provide Good Samaritan care in most states, in some states (e.g., Louisiana, Minnesota, and Vermont) not doing so is a violation of “duty to assist” laws. A preexisting obligation to provide care exists in each of the examples given, except for the provision of care at the scene of a traffic accident. Providing stabilizing care at the scene of an accident clearly fits within the protections defined by Good Samaritan laws. The obligation to provide care when volunteering at an event such as a football game or concert is implied even if it is provided without charge. An obligation to provide care for someone identified as your patient exists even outside of the office setting; a similar responsibility to provide emergency care for office employees is generally accepted. Federal law provides for similar Good Samaritan protection from liability to physicians who respond to in-flight emergencies originating in the United States. Protection is also offered by statute in the U.K., Canada, and other countries; Australian law also includes a legal obligation to provide emergency care.

Answer 1133

B ## Footnote The injury and findings described raise the possibility of globe rupture due to a fragment of steel penetrating through the cornea and pupil and into the globe. **Because of a risk of extruding intraocular fluid, tonometry (procedure that determines the IOP inside the eye) should not be attempted if globe rupture is suspected.** Relief of pain with an analgesic is appropriate before transfer. A rapid assessment of gross visual acuity (e.g., counting fingers, seeing light versus dark) may be performed. An eye shield should be placed over the affected eye to avoid putting pressure on the eye during transport to the ophthalmologist. Because the Valsalva effect from vomiting may lead to extrusion of intraocular contents, an antiemetic would be appropriate before transfer as well.

Answer 1134

A ## Footnote **AChEi** such as donepezil are considered first-line therapy for patients with *mild to moderate* Alzheimer’s disease. **Memantine** is an NMDA receptor antagonist and is often used in combination with AChEi for *moderate to severe* Alzheimer’s disease, but it has not been shown to be effective as a single agent for patients with mild to moderate disease. There is not enough evidence to support the use of selegiline, a MAOi type B, in the treatment of Alzheimer’s disease. Risperidone and other antipsychotic medications are not approved by the FDA for treatment of Alzheimer’s disease, but can sometimes be helpful in controlling associated behavioral symptoms. Studies of ginkgo biloba extract have not shown a consistent, clinically significant benefit in persons with Alzheimer’s disease.

Answer 1135

D ## Footnote PVD is a clinical manifestation of atherosclerotic disease and is caused by occlusion of the arteries to the legs. Patients with significant arterial occlusive disease will have a prominent **decrease in ABI** **from baseline following exercise**, and **a \> 20-mm Hg decrease in systolic BP**. Pain during rest and exercise and the presence of swelling and soreness behind the knee and in the calf is found in those with Baker’s cysts. Peripheral nerve pain commonly begins immediately upon walking and is unrelieved by rest. Doppler waveform analysis is useful in the diagnosis of PVD and will reveal attenuated waveforms at a point of decreased blood flow. Employment of the ABI is encouraged in daily practice as a simple means to diagnose the presence of PVD. Generally, **ABI of 0.91–1.30** are thought to be normal.

Answer 1136

D The patient has classic signs of tardive dyskinesia = Repetitive movement of the mouth and legs. This is caused by antipsychotics such as phenothiazines and haloperidol. Neuroleptic malignant syndrome consists of fever, autonomic dysfunction, and movement disorder. Acute dystonia = twisting of the neck, trunk, and limbs into uncomfortable positions. Huntington’s disease = choreic movements Oculogyric crisis = dystonic reaction where there is a prolonged, involuntary upward deviation of the eyes

Answer 1137

A (remember, this is what was recommended for you!) Latent TB infection carries a risk of progression to active disease, especially among patients who are immunosuppressed, and **Isoniazid monotherapy** is the treatment of choice. _Rifampin_ is not recommended as monotherapy in patients with HIV infection because of increased rates of resistance and drug interactions with many antiretrovirals. _Rifampin + pyrazinamide_ is no longer recommended for treatment of latent TB infection because cases of significant *hepatotoxicity* have occurred with preventive therapy. _RIPE Combination drug therapy_ is reserved for treatment of active TB in order to prevent drug resistance.

Answer 1138

B The rates of obesity and DM are disproportionately higher in Hispanics than those of non-Hispanic whites. Hypertension is closely linked to obesity, and Hispanics have higher rates of hypertension as well. Neurocysticercosis is the most common cause of seizures in Hispanic immigrants. Risk factors for osteoporosis include female gender, non-Hispanic white ethnicity, smoking, and low BMI.

Answer 1139

B ## Footnote Many dental conditions causing inflammation do not require antibiotic therapy. Dental caries, reversible pulpitis, gingivitis, periodontitis, and periapical abscesses usually are treated with local procedures without antibiotics. Cellulitis, however, requires either outpatient antibiotics or inpatient antibiotic treatment if the cellulitis spreads to the deeper spaces of the head and neck. The antibiotic of choice, especially for outpatient treatment, is oral penicillin G, 500 mg 3 times daily.

Answer 1140

A ## Footnote Prescribe hormonal contraception after performing a **review of the medical history + initial BP measurement, with regular BPs follow-ups scheduled.** Requiring that patients undergo pelvic and breast examinations leads many young women to avoid this most reliable method of contraception, resulting in a much higher rate of unwanted pregnancy. Often, younger women will be willing to undergo Paps and STD screening later, and periodic follow-up must be scheduled. Sexually active adolescents should have annual screening for cervical cancer and STDs, but these are not necessary before prescribing oral contraceptives.

Answer 1141

E ## Footnote **Functional abdominal pain** - diagnosis is made when no structural, infectious, inflammatory, or biochemical cause for the pain can be found. It is the most common cause of recurrent abdominal pain in children 4–16 years of age. Recommendations for managing this problem include focusing on participation in normal age-appropriate activities, reducing stress and addressing emotional distress, and teaching the family to cope with the symptoms in a way that prevents secondary gain on the part of the child. Continuing to focus on organic causes, invasive tests, or physician visits can actually perpetuate a child’s complaints and distress.

Answer 1142

E Smoking cessation is the single most important therapeutic intervention in patients with this condition and should be the priority of care. No existing medications have been shown to modify the long-term decline in lung function that is typical of COPD, but smoking cessation does prevent this decline. Long-term use of oxygen in COPD patients who also have chronic, severe hypoxia (

Answer 1143

A A post-traumatic air-fluid level in the sphenoid sinus is associated with basilar skull fractures. This finding is frequently noted on cervical spine films. Orbital floor fractures may be associated with diplopia and fluid in the maxillary sinus. Epidural hematomas are associated with skull fractures in the area of the MMA. Zygomatic arch fractures are associated with swelling and lateral orbital bruising. Mandible fractures may be associated with dental misalignment or bleeding.

Answer 1144

B This patient has pleurisy (inflammation of the pleura), commonly caused by viral infections spreading from the lungs to teh pleural cavity. The inflammed pleural layers rub against each other every time the lungs expand to breathe in air. Most cases of acute pleurisy are treated with NSAIDs unless the workup indicates another problem. Patients presenting with pleuritic chest pain may have life-threatening disorders, and PE, acute MI, and PTX should be excluded. While 5%-20% of patients with PE present with pleuritic chest pain, this patient has no risks for PE and the normal D-dimer level obviates the need for further evaluation. An EKG and CXR are recommended in the evaluation of acute/subacute pleuritic chest pain. The CXR will exclude pneumothorax, pleural effusion, or pneumonia. An ECHO would not be indicated if the cardiac examination and EKG are normal.

Answer 1145

A ## Footnote Polycythemia vera should be suspected in African-Americans or white females whose hemoglobin level is \>16 g/dL or whose hematocrit is \>47%. For white males, the thresholds are 18 g/dL and 52%. It should also be suspected in patients with portal vein thrombosis and splenomegaly, with or without thrombocytosis and leukocytosis. _Major criteria_ include an increased red cell mass, a normal O2 saturation,and the presence of splenomegaly. _Minor criteria_ elevated vitamin B 12 levels, elevated leukocyte alkaline phosphatase, a platelet count \>400,000/mm3 and a WBC count \>12,000/mm3 Patients with polycythemia vera may present with gout and an elevated uric acid level, but neither is considered a criterion for the diagnosis.

Answer 1146

B ## Footnote his child is experiencing simple breath-holding spells, a relatively common and benign condition that usually begins in children between the ages of 6 months and 6 years. The cause is uncertain but seems to be related to overactivity of the autonomic nervous system in association with emotions such as fear, anger, and frustration. The episodes are self-limited and may be associated with pallor, cyanosis, and loss of conciousness if prolonged. There may be an association with iron deficiency anemia, but this child had a recent normal hemoglobin level.

Answer 1147

E Lithium is the classic mood stabilizer. It has been shown to have antimanic efficacy, prophylactic efficacy in bipolar disorder, and some efficacy in prophylaxis against bipolar depression. Lithium remains the drug of choice for long-term treatment of the majority of patients with bipolar illness. ECT is an effective treatment the severe depression and/or mania of bipolar disorder. It reserved for patients with severe mood syndromes who may be unable to wait for mood-stabilizing drugs to take effect. Neuroleptic (antipsychotic) drugs are effective in acute mania, but are not recommended for long-term use because of side effects. Bipolar depression generally responds to TCAs, SSRIs, and MAOi, but when used as long-term therapy these drugs may induce episodes of mania. Anticonvulsants, such as carbamazepine, valproic acid, and benzodiazepines, have been useful adjuncts combined with lithium in patients with breakthrough episodes of mania and/or depression.

Answer 1148

C When the just-delivered fetal head retracts firmly against the perineum, shoulder dystocia is apparent. This is an obstetric emergency that requires appropriate assistance and a calm but timely approach to ensure a safe delivery. While all of the maneuvers described are steps in managing shoulder dystocia, the McRoberts maneuver by itself (maximal flexion and abduction of the maternal hips) relieves the impaction of the anterior shoulder against the maternal symphysis in a large percentage of cases, especially when combined with suprapubic pressure.

Answer 1149

C ## Footnote **Symptomatic placenta previa** usually manifests as *painless bleeding* in the late second or third trimester. It can be *painful bleeding* if it is associated with labor or abruption, and these patients will be admitted for evaluation. Most neonatal morbidity and mortality associated with placenta previa is due to the risks associated with preterm birth. **Corticosteroids** should be given to women who present with bleeding from a placenta previa between 24 - 34 weeks GA. It induces surfactant production. **Tocolytic agents such as Mg or Ca channel blockers** would be appropriate in patients who have vaginal bleeding associated with preterm contractions. The goal with tocolytic treatment would be to prolong the pregnancy until fetal lung maturity is achieved. This patient is not having preterm contractions so tocolytics would not be appropriate. The fetal heart rate is stable and the mother is hemodynamically stable, so there is no indication for an urgent cesarean section. Antibiotics do not have a role in the management of symptomatic placenta previa.

Answer 1150

A This patient likely has herpes zoster ophthalmicus. In addition to treatment with a systemic antiviral agent, it is important that the patient see an ophthalmologist to be evaluated for corneal disease and iritis, as vision can be lost. This is a viral infection, so corticosteroids could worsen the infection. Mupirocin or metronidazole would not resolve the infection.

Answer 1151

D Analgesics are considered the mainstay of therapy for acute sinusitis. Other treatments should be considered if symptoms are prolonged (\>7 days) or severe (two or more localizing symptoms or signs of serious bacterial complications). There is little evidence of effectiveness for antihistamines, oral decongestants, vasoconstrictor sprays, or nasal lavage.

Answer 1152

E Most chronic back pain is nonspecific or idiopathic in origin; treatment options that have the best evidence for effectiveness include **analgesics** (acetaminophen, tramadol, NSAIDs), **multidisciplinary rehab**, and **acupuncture**

Answer 1153

B SIDS is the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2–4 months of age and a quick dropoff by the age of 6 months. Evidence of terminal activity may be present, such as clenched fists or a serosanguineous, blood-tinged, or mucoid discharge from the mouth or nose. Lividity and mottling are frequently present in dependent areas.

Answer 1154

A This patient’s symptoms are highly suggestive of influenza: a sudden onset of malaise, myalgia, headache, fever, rhinitis, sore throat, and cough. While influenza is typically self-limited, it can result in severe complications, including encephalitis, pneumonia, respiratory failure, and death. CDC recommends antiviral treatment for patients with: * _confirmed_ or _suspected_ influenza who have severe, complicated, or progressive illness or who require hospitalization. * confirmed or suspected influenza who are at _higher risk for influenza complications_ _based on their age or underlying medical conditions_. * confirmed or suspected influenza w/o known risk factors for severe illness, if _treatment can be initiated within 48 hours of illness onset._ Many rapid influenza tests produce false-negative results, and more accurate assays can take more than 24 hours. **Thus, treatment of patients with a clinical picture suggesting influenza is recommended, even if a rapid test is negative**. Delaying treatment until further test results are available is not recommended.

Answer 1155

D ## Footnote Diverticulitis commonly affects the LLQ in the elderly and may present as an abscess. Crohn’s disease primarily affects the distal small intestine (regional enteritis), most typically in a young person, and usually in the second or third decade of life. Ulcerative colitis usually presents with a longer history and does not typically present with a mass. A 2-week history of a palpable mass is not a typical presentation for lymphoma. Celiac disease does not cause a palpable left lower quadrant mass.

Answer 1156

B In patients with grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction. **Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide.** Chlorthalidone, a thiazide diuretic, is not recommended. Large-volume paracentesis is the recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is followed by salt restriction and diuretics.

Answer 1157

D ## Footnote The history and physical findings in this patient are consistent with gingivostomatitis due to a primary or initial infection with herpes simplex virus type 1 (HSV-1). After a primary HSV-1 infection with oral involvement, the virus invades the neurons and replicates in the trigeminal sensory ganglion, leading to recurrent herpes labialis and erythema multiforme, among other things. Although some clinicians might choose to use oral anesthetics for symptomatic care, it is not a specific therapy.

Answer 1158

B ## Footnote **Multiple myeloma** can be asymptomatic, but it becomes symptomatic when there is organ damage or other abnormalities, including renal insufficiency, elevated calcium, anemia, and bone disease. The majority of patients have bone pain, but hypocalcemia is not common. Hypokalemia almost never occurs, and both hepatic failure and insomnia are not usual signs of multiple myeloma. Anemia typically occurs either because of renal failure or infiltration of the bone marrow by myeloma cells. Polycythemia does not occur.

Answer 1159

A ## Footnote Surgery for rotator cuff tears is most beneficial in young, active patients. In cases of acute, traumatic, complete rotator cuff tears, repair is recommended in less than 6 weeks, as muscle atrophy is associated with reduced surgical benefit. Advanced age and limited strength are also associated with reduced surgical benefit. NSAIDs are used for analgesia. Corticosteroid injections will not improve a complete tear. Some experts also recommend avoiding their use in partial or complete tendon tears. Therapeutic ultrasound does not add to the benefit from range-of-motion exercises and exercises to strengthen the involved muscle groups.

Answer 1160

A This patient has been clinically stable despite losing what appears to be a fair amount of blood into his pleural space after fracturing two ribs, a condition referred to as hemothorax. The treatment of choice in this condition is to remove the bloody fluid and re-expand the associated lung. This therapy is felt to decrease any ongoing blood loss by having the lung pleura put a direct barrier over the site that is bleeding. It also prevents the development of empyema or fibrosis, which could occur if the blood were to remain.

Answer 1161

A ## Footnote **Dupuytren’s disease** - shortening and thickening of the palmar fascia. It is initially asymptomatic, but may progress and cause difficulty with function of the hand, and may eventually lead to contracture. Early asymptomatic disease does not require treatment. **Cortisone injections** over a period of months may lead to disease regression, and is useful in patients with mild to moderate symptoms. **Surgery** is indicated if a metacarpal joint contracture reaches 30°, or with a PIP joint contracture of any degree. If surgery is delayed, irreversible joint contracture may occur. There is a strong association between **diabetes mellitus** and Dupuytren’s disease, with up to a third of diabetic patients having evidence of the disease. It is also associated with **alcohol use** and **smoking**. Patients requiring surgery have an increased risk of dying from cancer, probably related to smoking, alcohol use, or diabetes mellitus, but a search for cancer at the time of diagnosis is not indicated.

Answer 1162

C Otosclerosis typically presents between **30-50 yo**, and is more common in **women**. The chief feature of otosclerosis is a **progressive conductive hearing loss**. Occasionally, when lesions impinge on the stapes footplate, a sensorineural loss may occur. All of the other choices are exclusively sensorineural in character. Meniere’s disease also causes fluctuating hearing loss. Noise-induced hearing loss frequently and characteristically is accompanied by tinnitus. Perilymphatic fistula is associated with sudden unilateral hearing loss with tinnitus and vertigo. Acoustic neuroma is associated with tinnitus and gradual hearing impairment.

Answer 1163

B Hypothyroidism is associated with **delayed bone age** relative to height/chronologic age In CF, bone age and height age are equivalent, but both lag behind chronologic age. Children with chromosomal anomalies such as trisomy 21 (Down syndrome) or XO have a *delayed height age* which is delayed relative to bone age; pattern is also seen as a result of maternal substance abuse

Answer 1164

E ## Footnote Syncope with exercise is a manifestation of organic heart disease (ex: severe aortic stenosis) in which CO is fixed and does not rise (or even fall) with exertion. Vasovagal syncope is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, *sustained* upright posture, heat, hunger, and acute blood loss. Transient ischemic attacks are not related to exertion. Orthostatic hypotension is associated with changing from a sitting or lying position to an upright position. Atrial myxoma is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.

Answer 1165

B ## Footnote The appropriate management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms is **elliptical excision of the hemorrhoid and overlying skin** under local anesthesia **Incision and clot removal** may provide **in**adequate drainage, resulting in rehemorrhage and clot reaccumulation. *Most thrombosed hemorrhoids contain multilocular clots that may not be accessible through a simple incision*. **Rubber band ligation** is an excellent technique for management of internal hemorrhoids, and infrared coagulation is also used for this purpose. Banding an external hemorrhoid would cause exquisite pain. If the pain is already subsiding or more time has elapsed, and if there is no necrosis or ulceration, measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may be helpful. Some local anesthetics carry the risk of sensitization. Counseling to avoid precipitating factors such as prolonged standing/sitting, constipation, and delay of defecation is also appropriate.

Answer 1166

D ## Footnote **kava -** can be used in the short-term treatment of anxiety disorders (up to 24 weeks), including generalized anxiety disorder. kava has a safety profile similar to those of FDA-approved treatments for anxiety disorders. Care should be taken with any concurrent use of kava and medications metabolized by the liver, and patients should be discouraged from using alcohol while taking kava.

Answer 1167

C CT has demonstrated superiority over transabdominal US for identifying appendicitis, associated abscess, and alternative diagnoses. However, US is indicated for the evaluation of women who are pregnant and women in whom there is a high degree of suspicion for gynecologic disease.

Answer 1168

B The use of low-molecular-weight heparin allows patients with acute deep vein thrombosis (DVT) to be managed as outpatients. The dosage is 1 mg/kg subcutaneously twice daily. Patients chosen for outpatient care should have good cardiopulmonary reserve, normal renal function, and no risk for excessive bleeding. Oral anticoagulation with warfarin can be initiated on the first day of treatment after heparin loading is completed. The INR should be maintained at 2.0–3.0 in this patient. The 2.5–3.5 range is used for patients with mechanical heart valves. The therapeutic INR should be maintained for 3–6 months in a patient with a first DVT related to travel. Monotherapy with warfarin is inappropriate. The incidence of thrombocytopenia with low–molecular-weight heparin is lower than with conventional heparin.

Answer 1169

B ## Footnote In patients with ischemic chest pain, the EKG is important for determining the need for fibrinolytic therapy. Myocardial infarction is diagnosed by ST elevation ≥1 mm in two or more limb leads and ≥2 mm in two or more contiguous precordial leads. In a patient with an MI, new left bundle branch block suggests occlusion of the left anterior descending artery, placing a significant portion of the left ventricle in jeopardy. Thrombolytic therapy could be harmful in patients with ischemia but not infarction – they will show ST-segment depression only. Frequent unifocal ventricular ectopy may warrant antiarrhythmic therapy, but not thrombolytic therapy.

Answer 1170

E ## Footnote This child is entering puberty. In the 6- to 12-month period before menarche, girls often develop a physiologic vaginal discharge secondary to the increase in circulating estrogens. The gray-white discharge is non-irritating. When physiologic discharge is examined with the microscope, sheets of vaginal epithelial cells are seen. The only treatment necessary is reassurance of both parents and child that this is a normal process that will subside with time. The other conditions listed are pathologic and have other associated symptoms and findings not seen in this case. Pinworms normally cause perianal and vulvar pruritus and irritation. The findings in sexual abuse range from an inflamed vulvovaginal area, to evidence of sexually transmitted diseases, to evidence of local trauma. Trichomoniasis would cause vulvovaginal irritation and microscopic examination of the discharge would show Trichomonas organisms. A vaginal foreign body would usually present with a foul and/or bloody vaginal discharge.

Answer 1171

E in Graves’ disease there is a predominance of TSH receptor antibodies. In Hashimoto’s disease TSH receptor–blocking antibodies are more predominant.

Answer 1172

C ## Footnote **Patellofemoral pain syndrome** is a common overuse injury associated with **inadequate hip aBductor and core strength**; observed in adolescent girls. The condition is characterized by anterior knee pain associated with activity. The pain is exacerbated by going up or down stairs or running in hilly terrain. Treatment involves rehabilitation program. Surgical intervention is rarely required.

Answer 1173

E The FREEDOM study concluded that in patients with DM and advanced CAD, a CABG was superior to percutaneous coronary intervention (PCI) in that it significantly reduced rates of death and MI, although stroke rates were higher in the 30-day perioperative period

Answer 1174

B Although oral vancomycin was once the initial drug of choice for C. difficile, oral metronidazole is now the first-line agent because of cost considerations and because of concerns about the development of vancomycin-resistant organisms. If the patient has refractory symptoms despite treatment with oral metronidazole, then oral vancomycin would be appropriate. Vancomycin given orally is not absorbed, leading to high intraluminal levels of the drug.

Answer 1175

E ## Footnote In one study, 32% of patients with dermatomyositis had cancer. The risk of cancer was highest at the time of diagnosis, but remained high into the third year after diagnosis. The cancer types most commonly found were ovarian, pulmonary, pancreatic, gastric, and colorectal, as well as non-Hodgkin’s lymphoma. Cancer rates in patients with rheumatoid arthritis, systemic lupus erythematosus, and scleroderma were above those of the general population, but much lower than for patients with dermatomyositis. In Sjögren’s syndrome, the risk of non-Hodgkin’s lymphoma is 44 times higher than in the general population, with an individual lifetime risk of 6%–10%.

Answer 1176

E ## Footnote While all of the options listed may have some value in evaluating the preoperative status of a patient with long-standing rheumatoid arthritis, imaging of the patient’s cervical spine to detect atlantoaxial subluxation would be most important for preventing a catastrophic spinal cord injury during intubation. In many cases, cervical fusion must be performed before other elective procedures can be contemplated.

Answer 1177

E ## Footnote Plans that exclude patient compliance as a factor can lead to withholding of physician incentives because of patient nonadherence, or to physicians selectively removing such patients from their panels.

Answer 1178

E Patients with diabetes mellitus, atherosclerosis, and end-organ damage benefit from ACE inhibitors and angiotensin receptor blockers (ARBs) equally when they are used to prevent progression of diabetic nephropathy. **Combining an ACEi with an ARB is not recommended, as it provides no additional benefit and leads to higher creatinine levels, along with an increased likelihood that dialysis will become necessary.**

Answer 1179

E HIPAA legislation states that a patient’s personal medical and financial information cannot be released unless the patient authorizes such a release in writing. The exceptions to this standard are the following: * coordination of care between providers and those involved in the patient’s case (i.e., caretakers, nurses, consulting physicians); * arranging payment for medical services rendered * health-care operations such as evaluating a provider or system’s competency or quality. The privacy rule allows some discretion to a physician in “coordinating care,” even allowing a physician to speak with family members if that physician “in his or her professional judgment” feels it is in the patient’s best interest. In such situations it is advisable to ask the patient’s permission to do so if possible, and the information should be related on a need-to-know basis.

Answer 1180

C Cigarette smoking is the only nonsexual behavior consistently and strongly correlated with cervical dysplasia and cancer, independently increasing the risk two- to fourfold.

Answer 1181

A Foods that have the highest association with latex allergy include avocados, bananas, chestnuts, and kiwi.

Answer 1182

B ## Footnote The best predictor of drug efficacy is the trough serum concentration, which is the lowest level that a medicine is present in the body. **For vancomycin, the trough serum concentration should be \> 10 mg/L to prevent development of bacterial resistance**. Peak serum concentration is not a predictor of efficacy or toxicity. Monitoring for ototoxicity is not currently recommended. Older vancomycin products had impurities, which apparently caused the ototoxicity seen with these early formulations of the drug.

Answer 1183

D ## Footnote Acetazolamide is an effective prophylactic agent (SOR B), but is contraindicated in patients with a sulfa allergy. If used, it should be started a minimum of one day before ascent and continued until the patient acclimatizes at the highest planned elevation. Dexamethasone is an effective prophylactic and alternate treatment agent for those with sulfa allergies

Answer 1184

D ## Footnote The diagnosis of multiple myeloma is based on evidence of **myeloma-related end-organ impairment** in the presence of M protein, monoclonal plasma cells, or both. This may include **hypercalcemia, renal failure, anemia, or skeletal lesions**. Monoclonal gammopathy of undetermined significance does not progress steadily to multiple myeloma. There is a stable 1% annual risk of progression.

Answer 1185

E This patient has iron deficiency anemia. There are several substances that decrease the absorption of iron, including antacids, soy protein, calcium, tannin (which is in tea), and phytate (which is found in bran). Since an acidic environment increases iron absorption, **ascorbic acid (vitamin C) can enhance absorption of an iron supplement.**

Answer 1186

B ## Footnote Polypharmacy is common in the elderly population, but the use of numerous medications is necessary in some elderly patients. However, some medications have been identified as having a considerably higher potential to cause problems when prescribed to elderly patients. In the case described, acetaminophen/diphenhydramine would be an appropriate medication to stop initially. The older antihistamines cause many adverse CNS effects such as cognitive slowing and delirium in older patients. These effects are more pronounced in elderly patients with some degree of preexisting cognitive impairment. The anticholinergic properties of older antihistamines produce effects such as dry mouth, constipation, blurred vision, and drowsiness. The sedative effect of older antihistamines also increases the risk of falls. Hip fracture and subsequent death have been reported in patients who use older antihistamines such as diphenhydramine. Sertraline is an SSRI, a preferred class for the treatment of depression in the elderly compared to the TCAs, which are associated with several side effects. Dipyridamole is associated with hypotension in elderly patients, but it benefits some individuals by preventing strokes. It can be used in the elderly, but patients should be monitored for side effects. Therefore, until further information is obtained, it is appropriate to continue the dipyridamole/aspirin in this patient. When used in elderly patients with heart failure, digoxin should be given in a dosage no greater than 0.125 mg daily; the low dosage used in this individual should not be considered inappropriate until the reason for its use is clarified. While omeprazole can cause problems in the elderly with long-term use, 20 mg/day is a relatively low dose and the decision to discontinue its use should be delayed until more history is available.

Answer 1187

E Rosacea * women between the ages of 30 and 60 * **central facial** **erythema** and **telangiectasias** are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules. * Facial edema also may occur * Rhinophyma due to hypertrophy of the subcutaneous glands of the nose. * **Facial flushing** can be triggered by food, environmental, chemical, or emotional triggers. * **intermittent inflammatory conjunctivitis +/- blepharitis** - occur in half of patients with rosacea Management * avoidance of precipitating factors * sunscreen * Topical metronidazole and benzoyl peroxide may also be effective, particularly for mild cases * Oral **metronidazole, doxycycline, or tetracycline** also can be used, especially if there are ocular symptoms * low-dose clonidine or a nonselective β-blocker may be added for facial flushing

Answer 1188

B ## Footnote HPV vaccine is given as a three-dose series, so this patient is due for her third dose. The recommended interval between the first and third doses is 6 months, with approximately 4 months recommended between the second and third doses; however, the series can safely be completed at longer intervals. The patient received her second dose at age 12 and she is now 14 years of age, so it has been over 4 months. She was up to date on all immunizations at age 8, so it can be assumed that she has received her rubella, measles, and polio vaccinations. There is currently not a vaccine approved for hepatitis C.

Answer 1189

B ## Footnote Tinea capitis is an infection of the scalp caused by a variety of superficial dermatophytes. The treatment of choice for this infection is oral **griseofulvin**. It has the fewest drug interactions, a good safety record, and anti-inflammatory properties. **Terbinafine** has equal effectiveness and requires a significantly shorter duration of therapy, but it is only available in tablet form. Since tinea capitis most commonly occurs in children, tablets would have to be cut and/or crushed prior to administration. Oral itraconazole, fluconazole, and ketoconazole have significant side effects. Topical antifungals such as ketoconazole and miconazole are ineffective against tinea capitis. Topical acyclovir is used in the treatment of herpesvirus infections, and oral cephalosporins are used in the treatment of bacterial skin infections.

Answer 1190

C ## Footnote ARDs may be caused by sepsis or injury to the lungs that results in a massive release of inflammatory mediators. The syndrome has an acute onset and is manifested by rapidly developing profound hypoxia with bilateral pulmonary infiltrates. Early recognition and prompt treatment with intubation and mechanical ventilation is necessary to improve chances for survival. Patients with ARDS should be started at **lower** tidal volumes (6 mL/kg) instead of the traditional volumes (10–15 mL/kg). These patients also often require **higher** positive end-expiratory pressure settings.

Answer 1191

E For patients who are expected to live only a few days, psychostimulants such as methylphenidate should be used. For those who are expected to survive longer, SSRIs are a good choice.

Answer 1192

A ## Footnote Behavioral interventions, especially those including telephone counseling and/or a dental examination, have been shown to be helpful for promoting smokeless tobacco cessation. Studies examining mint snuff as a tobacco substitute, bupropion, and nicotine replacement in patch or gum form did not show any significant benefit.

Answer 1193

C The risk of pulmonary embolism continues in the postpartum period, and may actually increase during that time. For patients who have had a deep-vein thrombosis during pregnancy, treatment should be continued for 6 weeks after delivery, with either warfarin or low molecular weight heparin.

Answer 1194

D This patient’s age and his history of hypertension give him a CHADS2 score of 2, which implies that the patient is at a higher risk of thromboembolism and should be anticoagulated with warfarin and not aspirin. The patient should be fully anticoagulated for a minimum of 3 weeks prior to any attempt at cardioversion.

Answer 1195

D Fluoroquinolones such as ciprofloxacin have been shown to significantly reduce the duration and severity of traveler’s diarrhea when given for 1–3 days. Sulfacetamide is available only in a topical form for use in the eye. Penicillin and erythromycin are not effective against the most common cause of traveler’s diarrhea, ETEC

Answer 1196

C ## Footnote Mood disorders, including depression, mania, and schizoaffective disorder, must be excluded in order to diagnose schizophrenia.

Answer 1197

E ## Footnote A number of measures for managing spinal compression fractures have been evaluated. The evidence for recommending kyphoplasty is weak, and the evidence for recommending against vertebroplasty is strong. The data on bracing is inconclusive, as is the recommendation for bed rest. Calcitonin has been shown to reduce the incidence of recurrent fractures and may be useful in the relief of pain.

Answer 1198

D A positive result on the second, but the not the first, step of a two-step Mantoux tuberculin skin test indicates long-standing, latent infection.

Answer 1199

C ## Footnote Parkinson’s disease and essential tremor are the primary concerns in a person of this age who presents with a new tremor. A coarse, resting, pill-rolling tremor is characteristic of Parkinson’s disease. Essential tremor is primarily an action tremor and is a common movement disorder, occurring in members of the same family with a high degree of frequency. Alcohol intake will temporarily cause marked reduction in the tremor. β-Adrenergic blockers have been the mainstay of treatment for these tremors, but this patient is intolerant to these drugs. **Primidone** has been effective in the treatment of essential tremor, and in head-to-head studies with propranolol has been shown to be superior after 1 year.

Answer 1200

C ## Footnote This patient meets the criteria for frontotemporal dementia (FTD), a common cause of dementia in patients **younger than 65**, with an **insidious onset**. Unlike with Alzheimer’s disease, **memory is often preserved**, even though **insight is commonly impaired**. There are three subtypes of frontotemporal dementia: behavioral variant FTD, semantic dementia, and progressive nonfluent aphasia. This patient would be diagnosed with the **behavioral variant** due to his loss of **executive functioning leading to personality change (apathy) and inappropriate behavior.** Patients with FTD often are mistakenly thought to have major depressive disorder due to their apathy and diminished interest in activities. However, ***patients with depression do not usually exhibit inappropriate behavior and lack of restraint*.** Dementia with Lewy bodies and Alzheimer’s dementia are both characterized predominantly by memory loss. Alzheimer’s dementia is most common after age 65, whereas FTD occurs most often at a younger age. Lewy body dementia is associated with parkinsonian motor features. Patients diagnosed with schizophrenia exhibit apathy and personality changes such as those seen in FTD. However, the age of onset is much earlier, usually in the teens and twenties in men and the twenties and thirties in women.

Answer 1201

A ## Footnote In the symptomatic patient with uterine fibroids unresponsive to medical therapy, myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future. Uterine fibroid embolization requires a shorter hospitalization and less time off work. General anesthesia is not required, and a blood transfusion is unlikely to be needed. Uterine fibroids can recur or develop after either myomectomy or embolization.

Answer 1202

C Electroconvulsive therapy has been shown to be more effective than psychiatric therapy, pharmacologic therapy, and other interventions in depressed older patients. It would be particularly appropriate in this case given the patient’s age, his failure to respond to medications, and the need for rapid improvement to decrease the risk of further suicide attempts.

Answer 1203

C This patient's presentation is most consistent with pseudogout. Having a normal uric acid level suggests against gout, but does not rule it out. Also, gout is seven times more likely to be seen in males, whereas pseudogout is 1.5 times more frequent in females. Pseudogout most often affects the elderly, and usually affects the knee, wrist, and ankle. Gout presents most commonly in the first metatarsophalangeal joint and insteps of the feet, but also can occur in the knee, wrist, finger, and olecranon bursa. Differentiating between gout and pseudogout can be difficult and is best done by analysis of joint fluid. In patients with gout, this fluid contains highly negative birefringent, needle-shaped urate crystals, whereas in pseudogout the fluid contains rhomboid-shaped, weakly positive birefringent calcium pyrophosphate crystals. Acute monoarthritis in adults is most commonly caused by infection, trauma, or crystal deposition. Rheumatoid arthritis seldom presents as monoarthritis, and more often has a subacute course with multiple, symmetric joints involved. Although osteoporosis may result in a fracture of the knee joint without trauma at this age, there is no reason to believe that this patient has a torn anterior cruciate ligament. Gonococcal arthritis is one of the most common causes of septic arthritis, but is highly unlikely in this elderly, sexually inactive patient. Nongonococcal septic arthritis (especially due to staphylococcal and streptococcal bacteria) is still a consideration and should be ruled out by aspiration of fluid to be sent for culture

Answer 1204

C ## Footnote Postural orthostatic tachycardia syndrome (POTS) is manifested by a **rise in** **HR \>30 beats/min** _or_ **\>120 beats/min within 10 minutes of being in the upright position.** Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enough. The recommended management is adequate fluid/ salt intake, followed by regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers. This condition is most prevalent in white females between the ages of 15 and 50 years old. Often these patients are hardworking, athletic, and otherwise in good health.

Answer 1205

E ## Footnote Cardiovascular disease is the leading cause of death among women: 29.3% of deaths in females in the U.S. in 2001 were due to cardiovascular disease and 21.6% were due to cancer, with most resulting from lung cancer. Breast cancer is the third most common cause of cancer death in women, and ovarian cancer is the fifth most common.

Answer 1206

C Much like with tampons, leaving diaphragms in place for more than 24 hours is associated with toxic shock syndrome.

Answer 1207

B A patient over the age of 35 who experiences abnormal vaginal bleeding must have an endometrial biopsy to exclude endometrial hyperplasia or cancer. A laboratory evaluation for thyroid dysfunction or hemorrhagic diathesis is appropriate if no cancer is present on an endometrial biopsy and medical therapy fails to halt the bleeding. The other options listed can be used as medical therapy to control the bleeding once the histopathologic diagnosis has been made.

Answer 1208

E This patient has **patellofemoral stress syndrome**. It is often called runner's knee or anterior knee pain. The best initial treatment is **physical therapy**. Bracing, taping, and medications are unlikely to have better outcomes. Arthroscopic surgery is not indicated.

Answer 1209

D ## Footnote Persistent ventricular fibrillation (VF) should be treated with electrical defibrillation, CPR, _and_ vasopressor (either epinephrine or vasopressin). **Amiodarone** should be considered for treatment of VF unresponsive to shock delivery, CPR, _and_ vasopressor administration. Lidocaine is an alternative antiarrhythmic agent, but should be used only when amiodarone is not available. Magnesium may terminate/ prevent torsades de pointes in patients who have a prolonged QT interval during normal sinus rhythm. Adenosine is used for the treatment of narrow complex, regular tachycardias and is not used in the treatment of ventricular fibrillation.

Answer 1210

C ## Footnote Head trauma is a known cause of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). This patient’s course has been very acute, with hyponatremia developing within 48 hours. Such a precipitous drop in serum sodium may lead to cerebral and pulmonary edema. If left untreated the patient can have seizures, become obtunded, and die from brain herniation. These dangers require immediate treatment with **hypertonic saline** to correct the falling levels of sodium. This must be done cautiously so as to not overcorrect the sodium level too quickly, which could lead to osmotic demyelination syndrome. An increase in serum sodium levels of about 6 mEq/L should be enough to reduce symptoms and prevent progressive cerebral edema.

Answer 1211

E The sympathetic nervous system acts as a positive chronotropic (increases heart rate) and inotropic (increases contractility) agent. This additional work by the heart will increase metabolic demand and coronary flow rate. The increased heart rate will decrease the time intervals between electrical events shown on an EKG.

Answer 1212

E ## Footnote In women 30–65 years old, screening for cervical cancer with cervical cytology and HPV testing is recommended every 5 years. An alternative screening recommendation is to perform cervical cytology only, at 3-year intervals.

Answer 1213

B ## Footnote The most common side effects of calcium channel blockers, such as amlodipine, are due to vasodilation, one result of this may be peripheral edema, but it can also cause dizziness, nausea, hypotension, cough, and pulmonary edema. These problems may decrease with time, with reductions in dosage, or with the addition of a diuretic or second calcium antagonist. Other classes of drugs are not associated with these problems.

Answer 1214

A ## Footnote “fight bite” - **xrays** are needed to determine if there is a distal metacarpal fracture so that it can be treated appropriately. Because human bites commonly cause infection, **prophylactic antibiotics** are recommended with any break in the skin. If the skin break is superficial, this is sufficient. Deeper wounds should be explored by a surgeon, but superficial wounds should not be probed indiscriminately.

Answer 1215

B ## Footnote Marfan syndrome is an autosomal dominant disease manifested by skeletal, ophthalmologic, and cardiovascular abnormalities. Men taller than 72 in. and women taller than 70 in. who have two or more manifestations of Marfan syndrome should be screened by ECHO for associated cardiac abnormalities. These signs and symptoms include cardiac murmurs or clicks, kyphoscoliosis, anterior thoracic deformity, arm span greater than height, upper to lower body ratio more than 1 standard deviation below the mean, myopia, and an ectopic lens. Athletes with a family history of Marfan syndrome should also be screened, whether they have manifestations themselves or not. **Patients with Marfan syndrome who have ECHO evidence of aortic abnormalities should be placed on β-blockers and monitored with echocardiography every 6 months.**

Answer 1216

E Because of their favorable side-effect profile, ACEi (e.g., enalapril) are the drugs of first choice for the majority of hypertensive patients. ACEi are not associated with depression or sedation, and they are safe to use in patients with DM. Centrally-acting α-blockers can be associated with depression. Calcium-channel blockers, β-blockers, and other sympatholytic drugs affect cardiac conductivity. β-Blockers are contraindicated in patients with asthma, and are also associated with impotence. Thiazide diuretics raise uric acid and blood glucose levels.

Answer 1217

A When simple spirometry (ie one that is done in the office) suggests a restrictive ventilatory problem, the patient should undergo full pulmonary function testing for static lung volume measurements and diffusing capacity of the lung for carbon monoxide. If spirometry suggests an obstructive problem, it should be repeated after administering an inhaled bronchodilator.

Answer 1218

B ## Footnote **Raloxifene -** SERM; it increases **risk of venous thromboembolism,** indicated in this patient to decrease the risk of invasive breast cancer. **Bisphosphonates** inhibit osteoclastic activity. **Zoledronic acid, alendronate, and risedronate** decrease both hip and vertebral fractures, whereas ibandronate decreases fracture risk at the spine only. **Calcitonin nasal spray** is an antiresorptive spray that decreases the incidence of vertebral compression fractures. **Teriparatide** is a recombinant PTH with *potent bone anabolic activity*, effective against vertebral and nonvertebral fractures. **Hormone replacement therapy** is recommended for osteoporosis only in women with moderate or severe vasomotor symptoms. The lowest possible dose should be used for the shortest amount of time possible

Answer 1219

C PPV refers to the % of patients with a positive test for a disease who actually have the disease. NPV is the proportion of patients with negative test results who do not have the disorder. Sensitivity - % of patients with a disorder who have a positive test for that disorder Specificity - % of patients without a disorder who have a negative test for that disorder

Answer 1220

C ## Footnote The initial management of hypercalcemia of malignancy includes fluid replacement with normal saline to correct the volume depletion that is invariably present and to enhance renal calcium excretion. Loop diuretics (furosemide) should be restricted to patients in danger of fluid overload, since these drugs can aggravate volume depletion and are not very effective alone in promoting renal calcium excretion. Although IV pamidronate has become the mainstay of treatment for the hypercalcemia of malignancy, it is considered only ***after*** the hypercalcemic patient has been rendered euvolemic by saline repletion. The same is true for the other calcium-lowering agents listed.

Answer 1221

B ## Footnote This patient has **unilateral serous otitis** and is unlikely to have delayed language from decreased hearing on one side. The patient should be **observed for now**. Hearing loss of **longer than 3 months -\> tympanostomy tubes.** Surgical treatment has been shown to be helpful, but should be reserved for patients with chronic effusion. Audiometry is not needed to make a decision about surgery at this point. The mother's judgment is likely correct about his current hearing loss, so a hearing test most likely would not add any useful information. Numerous studies have shown that all medical treatments for serous otitis are ineffective, including antihistamine and decongestant therapy, and corticosteroids by any route.

Answer 1222

A ## Footnote Fetal distress with prolonged, variable, or late decelerations and bradycardia is the most common, and often only, sign of uterine rupture. The other signs listed are unreliable and often absent.

Answer 1223

D ## Footnote Iron and B12 deficiencies develop in more than 30% of patients after Roux-en-Y gastric bypass

Answer 1224

A **Frozen shoulder** * idiopathic * commonly affects patients age 40-60 * DM is the most common risk factor. * Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. * labs and plain films are normal - diagnosis is clinical

Answer 1225

D Medicare pays for some preventive measures, including pneumococcal vaccine, influenza vaccine, annual mammography, and a Papanicolaou test every 3 years. Medicare does not pay for custodial care, nursing-home care (except limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids, routine physical checkups and related tests, or prescription drugs.

Answer 1226

B ## Footnote HRT that includes estrogen has been shown to decrease osteoporosis and bone fracture risk. The risk for colorectal cancer also is reduced after 5 years of estrogen use. The risk for myocardial infarction, stroke, breast cancer, and venous thromboembolism increases with long-term use.

Answer 1227

B Tibial fractures are the most common lower extremity stress fractures in both children and adults, accounting for about half of all stress fractures.

Answer 1228

A ## Footnote This is a typical presentation of staphylococcal food poisoning. The symptoms usually begin 1–6 hours after ingestion and resolve within 24–48 hours. Foodborne botulism is most commonly found in homecanned foods, and symptoms begin 18–36 hours after ingestion. Clostridium perfringens is transmitted in feces and water, and symptoms begin 6–24 hours after ingestion. Clostridium difficile is associated with antibiotic use. Actinomycosis causes local abscesses, not gastroenteritis.

Answer 1229

D ## Footnote A history of gestational diabetes mellitus (GDM) is the greatest risk factor for future development of diabetes mellitus. It is thought that GDM unmasks an underlying propensity to diabetes. While a healthy pregnancy is a diabetogenic state, it is not thought to lead to future diabetes. Obesity and family history are risk factors for the development of diabetes, but having GDM leads to a fourfold greater risk of developing diabetes, independent of other risk factors. It is thought that 5%–10% of women who have GDM will be diagnosed with type 2 diabetes within 6 months of delivery. About 50% of women with a history of GDM will develop type 2 diabetes within 10 years of the affected pregnancy.

Answer 1230

C ## Footnote Hospital admission is not always necessary, esp. if the apneic episode was short, self-correcting and associated with feeding. Given the history of not breathing for 20–25 seconds, having a blue tongue and lips, and being limp, admitting the child for observation is appropriate. Although child abuse is a concern, referral to child protective services is not mandatory. Laryngoscopy would not be routine, but might be appropriate in some cases depending on the history and physical findings. Many groups recommend home apnea monitoring after discharge for patients with more severe or undiagnosed cases.

Answer 1231

D ## Footnote Results of randomized clinical trials demonstrate that medications such as SSRIs, TCAs, and MAOi alleviate the symptoms of PTSD and are associated with improvements in overall functioning. ***SSRIs are a first-line medication*** because they are safer and better tolerated than other types of psychotropic medications. **Sertraline** and **paroxetine** are the only agents that have been approved by the FDA for the treatment of PTSD.

Answer 1232

B ## Footnote Because glycogen is the primary energy source for muscles during the first 20 minutes of exercise, **at least 30 minutes** of exercise is necessary to begin burning fat stores. The CDC and the American College of Sports Medicine recommend a minimum of 30 minutes of exercise **5 days per week**. Twenty minutes of exercise daily or three 10-minute sessions daily does improve cardiovascular fitness, but does not cause significant weight loss. Walking, on land or in water, and stationary biking are equivalent in benefit.

Answer 1233

D Exercise-induced bronchoconstriction (EIB) is defined as a 10% decrease of FEV1 secondary to bronchoconstriction when challenged with exercise. EIB is much more common in high-ventilation sports, such as track and cross-country skiing, and winter sports, because of the inspiration of cold, dry air. A physical examination and PFTs (at rest and before/after bronchodilators) will be normal unless there is underlying asthma. **Bronchoprovocative testing can be ordered, but if it is not available a trial with an albuterol inhaler is reasonable.** Cardiomyopathy or valvular dysfunction not found during the physical examination is possible, but much less likely. Psychological stresses are also a possible etiology, but should not receive undue attention, especially when simple questioning is not productive and more likely diagnoses have not been ruled out. Poor training methods are also possible, but in a competitive athlete this is not the most likely cause.

Answer 1234

C ## Footnote Recent reports of epidemics of gastroenteritis on cruise ships are consistent with Norovirus infections 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.

Answer 1235

D ## Footnote Studies have shown no significant risk of congenital anomalies from SSRI use in pregnancy, except for paroxetine, which is linked to increased risk of congenital cardiac malformations from first-trimester exposure (category D) Lithium is known to be teratogenic. Benzodiazepines such as alprazolam has a possible link to cleft lip/palate. Bupropion is linked to an increased risk of spontaneous abortion.

Answer 1236

B psychostimulants reduce symptoms of depression within days, making methylphenidate a good choice for this patient. Electroconvulsive therapy is contraindicated due to her brain lesions. Mirtazapine, fluoxetine, and nortriptyline all take at least 3–4 weeks to have any antidepressant effects, and would not be appropriate given the patient’s life expectancy

Answer 1237

B ## Footnote **Genital herpes** is the most common sexually transmitted genital ulcer disease in the U.S. It can occur at any age, and data suggest that it may be the most common STD in women over the age of 50 years. Extragenital sites are involved in one-fourth of infected women, and the **sacrum and buttocks** are frequent locations. Sacral nerve innervation from the vaginal area provides a pathway for the virus. Prevention of transmission depends upon cogent patient education advising abstinence from skin-to-skin contact when active lesions are present.

Answer 1238

E ## Footnote ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction, regardless of severity, as they have been shown to reduce both morbidity and mortality in both symptomatic and asymptomatic patients in RCTs. β-Blockers are also recommended in heart failure patients with systolic dysfunction, except those who have dyspnea at rest or who are hemodynamically unstable. A diuretic such as furosemide may be indicated to relieve congestion in symptomatic patients. Aldosterone antagonists such as spironolactone are also indicated in patients with symptomatic heart failure. In addition, they can be used in patients with a recent myocardial infarction who develop symptomatic systolic dysfunction and in those with diabetes mellitus. Digoxin currently is recommended for patients with heart failure and atrial fibrillation, and can be considered in patients who continue to have symptoms despite maximal therapy with other agents.

Answer 1239

E ## Footnote It is theorized that either auto-inoculation of group A streptococcal from mouth to hand to perineum occurs, or that the bacteria is transmitted through the GI tract. The condition usually presents with itching and a beefy redness around the anus and/or vulva and will not clear with medications used to treat candidal infections. In one study, the average age of patients with this disease varied from 1 to 11 years, with a mean of 5 years. Girls and boys were almost equally affected. The incidence is estimated to be about 1 in 200 pediatric visits and peaks in March, April, and May in North America

Answer 1240

B The FDA has approved more than 90% of the drugs available from Canada. Most of these drugs come from the same manufacturers as drugs in the U.S. Health Canada takes longer, on average, to approve a drug for release than does the FDA, and most drugs discontinued for safety reasons by the FDA between 1992 and 2001 had not been approved for use in Canada. Websites advertising Canadian drugs may be selling counterfeit drugs from unregulated sources

Answer 1241

A Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest in children and in women of childbearing age (especially pregnant women)

Answer 1242

B ## Footnote TZDs are associated with fluid retention, and their use can be complicated by the development of heart failure. Caution is necessary when prescribing TZDs in patients with known heart failure or other heart diseases, those with preexisting edema, and those on concurrent insulin therapy. TZDs should not be used in patients with New York Heart Association class III or IV heart failure. Metformin is often contraindicated because of renal insufficiency or heart failure.

Answer 1243

A ## Footnote Lithium therapy can elevate calcium levels by **elevating parathyroid hormone secretion from the parathyroid gland** --\> **elevated calcium**. This duplicates the laboratory findings seen with mild primary hyperparathyroidism. If possible, lithium should be discontinued for **3 months** before reevaluation. This is most important for avoiding unnecessary parathyroid surgery. Vitamin D and calcium supplementation could contribute to hypercalcemia in rare instances, but they would not cause elevation of parathyroid hormone. Raloxifene has actually been shown to mildly reduce elevated calcium levels, and furosemide is used with saline infusions to lower significantly elevated calcium levels.

Answer 1244

A ## Footnote Patients who are not currently experiencing unstable coronary syndrome, severe valvular disease, uncompensated congestive heart failure, or a significant arrhythmia are not considered at high risk, and should be evaluated for most surgery primarily on the basis of their functional status. If these patients are capable of moderate activity (greater than 4 METs) without cardiac symptoms, they can be cleared with a resting 12-lead EKG, which is also recommended for males over 45, females over 55, and patients with diabetes, symptoms of chest pain, or a previous history of cardiac disease.

Answer 1245

A This patient has restless legs syndrome, which includes unpleasant sensations in the legs and can cause sleep disturbances. The symptoms are relieved by movement. **It is also recommended that patients with a serum ferritin** Mg supplementation does not improve restless legs syndrome. Ropinirole may be used if nonpharmacologic therapies are ineffective.

Answer 1246

C Tinea capitis requires systemic therapy to penetrate the affected hair shafts.

Answer 1247

A ## Footnote In this setting, a threefold or greater elevation of alanine transaminase has a positive predictive value of 95% for acute gallstone pancreatitis. High levels of CRP are associated with pancreatic necrosis. Hepatitis C is identified by antibody detection or PCR testing.

Answer 1248

E ## Footnote **Acute urticaria** occurs when an allergen activates mast cells in the skin, and is commonly caused by oral and parenteral drugs, food, and, less frequently, infections. Topical agents and physical abuse are unlikely to present in this manner, and hereditary angioedema is more a systemic illness than a skin disorder

Answer 1249

B ß blockers, antidepressants, anticonvulsants, CA channel blockers, NSAIDs, and serotonin antagonists are the major classes of drugs used for preventive migraine therapy. All of these medications result in about a 50% reduction in the frequency of headaches. The other drugs listed are useful for the **treatment** of acute migraine; not for prevention.

Answer 1250

D Organisms that can persist in water environments and survive disinfection, especially chlorination, are most likely to cause disease outbreaks related to drinking water. **Cryptosporidium oocysts** and **Giardia cysts** are resistant to chlorine and are important causes of gastroenteritis from drinking water. **Entamoeba histolytica** and **hepatitis A virus** are also relatively chlorine resistant. The other organisms listed are chlorine sensitive.

Answer 1251

C ## Footnote RMSF - transmitted by ticks. The diagnosis is based on clinical criteria that include fever, hypotension, rash, myalgia, vomiting, and HA. Rash usually appears 2–4 days after the onset of fever and begins as small, pink, blanching macules on the ankles, wrists, or forearms that evolve into maculopapules. It can occur anywhere on the body, including the palms and soles, but the face is usually spared. Mucocutaneous lymph node syndrome is a similar condition in children (usually Leptospirosis is usually accompanied by severe cutaneous hyperesthesia. Scarlet fever usually has prominent pharyngitis and a fine, papular, erythematous rash. Toxic shock syndrome may present in a similar fashion, but usually in postmenarchal females.

Answer 1252

A ## Footnote CT of the chest or abdomen leads to significantly more radiation exposure and cancer risk than CT of the brain. Younger patients, including neonates, have a greater lifetime risk of developing cancer after radiation exposure, and CT imaging carries substantially more risk than plain radiographs of the same area. Women are at greater risk for developing lung cancer after a chest CT than men, and CT also increases their risk of developing breast cancer.

Answer 1253

D The most common age of onset for inflammatory bowel disease is during adolescence and young adulthood, with a second peak at 50–80 years of age. Systemic s/s and perianal dz is common in Crohn’s disease.

Answer 1254

E ## Footnote This patient has obesity-hypoventilation syndrome, often referred to as Pickwickian syndrome. These patients are obese (BMI \>30 kg/m 2 ), have sleep apnea, and suffer from chronic daytime hypoxia and CO2 retention. They are at increased risk for significant respiratory failure and death. Treatment consists of nighttime positive airway pressure in the form of continuous (CPAP) or bi-level (BiPAP) devices, as indicated by sleep testing. The more hours per day that patients can use this therapy, the less CO2 retention and less daytime hypoxia will ensue.

Answer 1255

A Patients with severe sleep apnea (apnea-hypopnea index \>29) and concomitant cardiovascular disease benefit the most from treatment for obstructive sleep apnea. Because it is relatively easy to implement and has proven efficacy, continuous positive airway pressure (CPAP) is considered first-line therapy for severe apnea.

Answer 1256

D Varenicline, a clinically effective smoking-cessation product, has been associated with patient mood changes following the initiation of therapy, including suicidal thoughts and aggressive and erratic behavior.

Answer 1257

B ## Footnote Trazodone may be useful for insomnia, but is not recommended as a primary antidepressant because it causes sedation and orthostatic hypotension at therapeutic doses. Bupropion would aggravate this patient’s insomnia. Tricyclic antidepressants may be effective, but are no longer considered first-line treatments because of side effects and because they can be cardiotoxic. **Mirtazapine has serotonergic and noradrenergic properties and is associated with increased appetite and weight gain. It may be particularly useful for patients with insomnia and weight loss.**

Answer 1258

B ## Footnote The concept of “double effect” is used to justify medical treatment designed to relieve suffering when death is an unintended but foreseeable consequence. It is based on two basic presuppositions: first, that the **doctor’s motivation is to alleviate suffering**, and second, that the **treatment is appropriate to the illness** Distributive justice relates to the allocations of resources. Death with dignity is a recently introduced concept and is not a factor in the scenario described here. Futility refers to using a treatment for which there is no rational justification. Autonomy refers to the patient’s ability to direct his or her own care,which is n ot an issue in this case.

Answer 1259

A ## Footnote Patients who require inhalation therapy with β2-adrenergic-receptor agonists _more than twice weekly_ but not daily have mild persistent asthma. Long-term control with inhaled corticosteroids is recommended for adults with persistent asthma.

Answer 1260

D Individuals with sickle cell disease, those with anatomic or functional asplenia, immunocompromised persons with renal failure or leukemia, and HIV-infected persons should receive polysaccharide vaccine on this schedule and should be revaccinated at least 5 years after the first dose.

Answer 1261

A ## Footnote This patient most likely has either **adhesive capsulitis** or a **degenerative rotator cuff tendinopathy.** It is important to rule out osteoarthritis with radiographs. Treatment typically includes NSAIDs, subacromial cortisone injections, and physical therapy. These problems take months to treat and should not be referred quickly for surgical evaluation, unless the diagnosis is in question.

Answer 1262

C ## Footnote The accuracy of fetal weight estimates declines as pregnancy proceeds, and the actual size may be as much as 15% different from the estimate. Delivery of a large infant results in shoulder dystocia more often than delivery of a smaller infant, but most large infants are delivered without complications. ACOG recommends consideration of C-section if the estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the absence of diabetes. Frequent ultrasonography is often performed to reduce anxiety for both patient and physician, but the problem of accuracy of weight estimates remains an issue even with repeated scans at term.

Answer 1263

A ## Footnote Aggressive neurosurgical intervention is not indicated to evacuate clots in patients with intracerebral hemorrhage except in those with a cerebellar hemorrhage, which is always an indication for neurosurgical consultation. The use of various forms of osmotherapy, including mannitol, to prevent the development of cerebral edema has not been shown to improve outcomes. The data regarding hypothermia induction is unclear. Patients with an INR \>1.5 should receive therapy to replace vitamin K–dependent factors and have their warfarin withheld.

Answer 1264

A ## Footnote This woman most likely has primary hyperparathyroidism due to a parathyroid adenoma or hyperplasia, based on elevated PTH and elevated calcium levels Secondary hyperparathyroidism is unlikely with normal renal function, a normal vitamin D level, and hypercalcemia. Tertiary hyperparathyroidism is unlikely with normal renal function. The parathyroid hormone level is suppressed with hypercalcemia associated with bone metastases. Parathyroid hormone–related protein, produced by cancer cells in humoral hypercalcemia of malignancy, is not detected by the assay for parathyroid hormone.

Answer 1265

D The most widely used initial assay for detecting hepatitis C virus (HCV) antibody is the enzyme immunoassay. A positive enzyme immunoassay should be followed by a confirmatory test such as the recombinant immunoblot assay. * If negative, it indicates a false-positive antibody test. * If positive, the quantitative HCV RNA PCR is used to measure the amount of virus in the blood to distinguish active from resolved HCV infection. In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved.

Answer 1266

C ## Footnote AHA guidelines recommend treating HTN in patients with stable heart failure with ACEi and/or β-blockers. Other agents, such as thiazide diuretics or calcium channel blockers, can be added if needed to achieve BP goals. β-Blockers with intrinsic sympathomimetic activity should be avoided, as they increase myocardial oxygen demand. **While thiazide diuretics are often a first choice for uncomplicated hypertension, BUT ß blockers is the first choice for patients with coronary artery disease. Long-acting calcium channel blockers may be used in patients who do not tolerate β-blockers, but short-acting calcium channel blockers should be avoided because they increase mortality.** ACE inhibitors are recommended as antihypertensive agents in patients already on β-blocker therapy (especially following MI), in diabetics, and in patients with left ventricular dysfunction. Although ARBs have indications similar to those of ACE inhibitors, the AHA recommends using them only in patients who do not tolerate ACE inhibitors. Long-acting nitrates are used for their anti-anginal properties and have no role in the management of hypertension.

Answer 1267

A ## Footnote This patient has **cutaneous larva migrans**, a common condition caused by **dog/cat hookworms**. Fecal matter deposited on soil or sand may contain hookworm eggs that hatch and release larvae, which are infective if they penetrate the skin. Walking barefoot on contaminated ground can lead to infection. **_Echinococcosis (hydatid disease)_** is caused by the cestodes (tapeworms) Echinococcus granulosus and Echinococcus multilocularis, found in dogs and other canids. It infects humans who ingest eggs that are shed in the animals feces and results in slow-growing cysts in the liver or lungs, and occasionally in the **brain, bones, or heart.** **_Toxoplasmosis_** is caused by the protozoa Toxoplasma gondii, found in cat feces. Humans can contract it from litter boxes or feces-contaminated soil, or by consuming infected undercooked meat. It can be asymptomatic, or it may cause **cervical lymphadenopathy, a mononucleosis-like** illness; it can also lead to a serious **congenital infection** if the mother is infected during pregnancy, especially during the first trimester. **_Toxocariasis_** due to Toxocara canis and Toxocara cati causes visceral or ocular larva migrans in children who ingest soil contaminated with animal feces that contains parasite eggs, often found in areas such as playgrounds and sandboxes.

Answer 1268

E The physiologic changes that accompany aging result in altered pharmacokinetics. Drug distribution is one important factor. In older persons, there is a * relative **increase in body fat** and a relative decrease in lean body mass, which causes **increased distribution of fat-soluble drug**s such as diazepam, which also **increases the elimination half-life** of such medications. The **volume of distribution of water-soluble compounds is decreased** such as digoxin, which means a smaller dose is required to reach a given target plasma concentration. * **predictable reduction in GFR** **and tubular secretion** with aging, which causes decreased clearance of medications in the geriatric population. The absorption of drugs changes little with advancing age. All of these changes are important factors in choosing dosages of medications in the elderly population.

Answer 1269

B CBT is an effective, nonpharmacologic treatment for chronic insomnia. It changes incorrect beliefs and attitudes about sleep (e.g., unrealistic expectations, misconceptions, amplifying consequences of sleeplessness). Techniques include **reattribution training** (goal setting and planning coping responses), **decatastrophizing** (balancing anxious automatic thoughts), **reappraisal, and attention shifting**. Routine use of OTC antihistamines is discouraged because they are minimally effective in inducing sleep, may reduce sleep quality, and can cause residual drowsiness.

Answer 1270

B ## Footnote USPSTF guideline recommends one-time screening with US for AAA in men 65-75 years of age who have _ever_ smoked. No recommendation was made for or against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.

Answer 1271

C ## Footnote No single study has evaluated the effectiveness of osteoporosis screening. USPSTF recommends universal screening for **women over the age of 65, as well as for women age 60–64 with risk factors for osteoporosis**. Multiple risk assessment scales have been studied to identify women over the age of 65 who are at increased risk for hip fracture. None of the scales, however, had good discriminatory performance. Thus, the criteria for screening women less than 65 years of age are unclear.

Answer 1272

B ## Footnote 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 Thiazolidinediones sensitize peripheral tissues to insulin Carbohydrate absorption in the small intestine is inhibited by the "-glucosidase inhibitors.

Answer 1273

A ## Footnote Maintaining adequate tissue oxygenation is an important component of the emergency management of stroke. Hypoxia leads to anaerobic metabolism and depletion of energy stores, increasing brain injury. While there is no reason to routinely administer supplemental oxygen, the potential need for oxygen should be assessed using pulse oximetry or blood gas measurement. Overzealous use of antihypertensive drugs is contraindicated, since this can further reduce cerebral perfusion. In general, these drugs should not be used unless mean blood pressure is \>130 mm Hg or systolic blood pressure is \>220 mm Hg. Antithrombotic drugs such as heparin must be used with caution, and only after intracerebral hemorrhage has been ruled out by baseline CT followed by repeat CT within 48–72 hours. Hypovolemia can exacerbate cerebral hypoperfusion, so there is no need to restrict fluid intake. Optimization of cardiac output is a high priority in the immediate hours after a stroke. Based on data from randomized clinical trials, corticosteroids are not recommended for the management of cerebral edema and increased intracranial pressure after a stroke.

Answer 1274

A ## Footnote This patient has pyogenic tenosynovitis. When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient’s infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics. A delay in treatment of these infections can lead to ischemia of the tendons and damage to the flexor tendon and sheath. This can lead to impaired function of the finger.

Answer 1275

A This patient has moderate persistent asthma. The preferred and most effective treatment is daily inhaled corticosteroids. Oral prednisone daily is not recommended because of the risk of inducing adrenal insufficiency. Short- and long-acting β-agonists are not recommended as daily therapy because either can cause tachyphylaxis and are considered rescue medications rather than preventive treatments.

Answer 1276

C ## Footnote In the case of PID, evaluation and treatment of males with a history of sexual contact with the patient during the 60 days _preceding_ the onset of symptoms is imperative because of the high risk of reinfection. Current CDC guidelines recommend empiric treatment of these male contacts with antibiotic regimens against _chlamydial and gonorrhea_, regardless of the presumed etiology of the PID.

Answer 1277

A ## Footnote Based on the history and physical examination, this patient most likely has acute diverticulitis. CT has a very high sensitivity and specificity for this diagnosis, provides information on the extent and stage of the disease, and may suggest other diagnoses. US may be helpful in suggesting other diagnoses, but it is not as specific or as sensitive for diverticulitis as CT. Barium enema may occasionally be useful in distinguishing between diverticulitis and carcinoma, but would not be the *initial* procedure of choice. Water-soluble contrast material is used in this situation instead of barium. Colonoscopy to detect other diseases, such as cancer or IBD, is ***deferred until the acute process has resolved, usually for 6 weeks.* The risk of perforation or exacerbation of the disease is greater if colonoscopy is performed acutely**. Diagnostic laparoscopy is rarely needed in this situation. Laparoscopic or open surgery to drain an abscess or resect diseased tissue is reserved for patients who do not respond to medical therapy. Elective sigmoid resection may be considered after recovery in cases of recurrent episodes.

Answer 1278

B (USPSTF) has summarized the evidence for the use of aspirin in the primary prevention of cardiovascular disease as follows: * men \>**45**–79 years of age * women \>**55**–79 years of age

Answer 1279

A ## Footnote This patient is at high risk for Clostridium difficile–associated diarrhea, based on his age and his recent broad-spectrum antibiotic use. The initial management is to stop the antibiotics. **Treatment for C.diff should _not_ be initiated unless the stool is positive for toxins A and B.** The recommended initial treatment for C. difficileenteritis is oral metronidazole. Probiotics may be useful for prevention, but their use is controversial. Loperamide should be avoided, as it can slow down transit times and worsen toxin-mediated diarrhea.

Answer 1280

C TNF inhibitors have been associated with an increased risk of infections, including TB. This class of agents includes monoclonal antibodies such as infliximab, adalimumab, certolizumab pegol, and golimumab. Patients should be screened for **TB _and_ hepatitis B/C** before starting these drugs.

Answer 1281

A ## Footnote This presentation is consistent with **bronchiolitis**, which is a response to a viral respiratory infection. American Academy of Pediatrics guidelines for the management of bronchiolitis do not recommend routine use of any treatment, recommending instead that the choice be based on the specific needs of the child. If the child responds to a trial of albuterol, then treatment can be continued; otherwise, evidence shows no benefit. Antibiotics are indicated for signs of bacterial infection. Oxygen is indicated if the O2 saturation is Corticosteroids have not been shown to be of benefit.

Answer 1282

E ## Footnote NSAIDs, pyridoxine, and diuretics have been shown to be no more effective than placebo in the treatment of patients with carpal tunnel syndrome. Splinting, physical therapy, and steroid injections have all been shown to result in short-term improvement. Patients with persistent symptoms achieve the best long-term relief with surgery.

Answer 1283

E While tobacco use is a risk factor for COPD, routine spirometry, chest radiographs, or arterial blood gas analysis is not recommended to screen for COPD in patients with a history of tobacco use.

Answer 1284

B ## Footnote Cautious **reduction of SBP by 10%-15%** while monitoring neurologic status seems to be the safest treatment goal in the setting of acute ischemic stroke when the SBP is \>220 mm Hg or the DBP is 120-140 mm Hg. According to JNC-7, more aggressive blood pressure reduction may increase cerebrovascular complications.

Answer 1285

B ## Footnote Many patients have mild hyperparathyroidism that becomes evident only with an added calcium load. Thiazide diuretics reduce calcium excretion and can cause overt symptoms in a patient whose hyperparathyroidism would otherwise have remained asymptomatic. The finding of a normal parathyroid hormone (PTH) level in a patient with hypercalcemia is diagnostic for hyperparathyroidism, since PTH should be suppressed in the presence of elevated calcium. Symptomatic hypercalcemia causes dehydration because of both intestinal symptoms and diuresis. Reversible renal insufficiency can result, and can become permanent if it is long-standing and severe Milk alkali syndrome is hypercalcemia resulting from a chronic overdose of calcium carbonate, and is becoming more common as more patients take calcium and vitamin D supplements. In milk alkali syndrome, and other causes of hypercalcemia such as sarcoidosis, the PTH level is appropriately suppressed.

Answer 1286

A ## Footnote This patient is most likely suffering from a **statin-induced myopathy**, which is associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated ESR. Guillain-Barré syndrome is associated with depressed deep tendon reflexes. This case has no clinical features or laboratory findings that suggest ketoacidosis.

Answer 1287

E ## Footnote Falling is one of the most common adverse events associated with drugs. The elderly frequently take many medications; reducing these medications also reduces the risk of falling. **SSRIs, tricyclic antidepressants, benzodiazepines, and anticonvulsants** have the strongest association with falls in the elderly. The highest risk for falling occurs immediately after hospital stays and lasts for about a month. Ambulatory BP monitoring is associated with so many false-negative and false-positive results that it cannot be recommended for all patients who fall. Arthritis and vision problems are both strongly associated with an increased risk of falls

Answer 1288

E **Cefazolin** is appropriate for intrapartum prophylaxis against GBS in penicillin-allergic patients. Depending on the antibiotic sensitivity of the GBS organism, either vancomycin or clindamycin is recommended for patients at higher risk for anaphylaxis.

Answer 1289

E This patient’s asthma is **well-controlled** according to the 2007 NHLBI asthma guidelines. The “rule of twos” is useful in assessing asthma control: in children under the age of 12, asthma is NOT well-controlled if they * have had symptoms or used a β-agonist for symptom relief *more than twice per week*, * had **two or more nocturnal awakenings** due to asthma symptoms in the past **month**, * had **two or more exacerbations requiring systemic corticosteroids** in the past **year**. For individuals over 12 years of age, there must be **more than two nocturnal awakenings** per month to classify their asthma as not well controlled. Exercise-induced asthma is considered separately. A β-agonist used as premedication before exercise is not a factor when assessing asthma control. Since this patient does not exceed the rule of twos, her asthma is categorized as well-controlled and no changes to her therapy are indicated. Asthma education should be reinforced at every visit.

Answer 1290

D ## Footnote **Familial adenomatous polyposis -** patients typically develop hundreds or thousands of polyps in their colon and rectum, usually in their teens or early adulthood. Cancer usually develops in one or more of these polyps as early as age 20. By age 40, almost **100%** people with this disorder will have developed cancer if preventive colectomy is not performed. The approximate lifetime risk of colon cancer in the general population of the United States is 6%. **Tobacco** use raises the risk of colon cancer by approximately **50%.** Patients with **UC** are at increased risk for colon cancer. A meta-analysis showed the risk of colon cancer was 2% in the first 10 years after UC develops, 8% during the first 20 years, and **18%** during the first 30 years. The evidence is still evolving regarding the level of future risk of colon cancer associated with having had an adenomatous polyp removed in the past, but it may approach a doubling of the baseline risk of colon cancer. Studies suggest a clear association with a history of multiple polyps or a single large (\>1 cm) polyp. The data is less clear for single small adenomas. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are most likely to develop into adenocarcinomas. Having a family history of a first degree relative with colon cancer raises the risk approximately 2-3x fold. If that relative was younger than age 50 at the time of diagnosis the risk is 3-4x fold higher.

Answer 1291

C An initial pneumothorax of

Answer 1292

A The criteria for severe preeclampsia specify a BP \> 160/110 mm Hg on two occasions, 6 hours apart. Other criteria include * proteinuria \> 5 g/24 hr * thrombocytopenia with a platelet count * liver enzyme abnormalities * epigastric or right upper quadrant pain, and alteration of mental status

Answer 1293

D ## Footnote Sustained-release **bupropion** has been shown to reduce the relapse rate for smoking cessation and blunt weight gain for 12 months. Beneficial effects of smoking cessation are seen even among older smokers. Evidence has now shown that smokers who switch to low-tar or low-nicotine cigarettes do not significantly decrease their health risks. **FDA approved medications for smoking cessation (sustained-release bupropion, nicotine patch, nicotine gum, nicotine inhaler, and nicotine nasal spray) have been shown to be safe and should be recommended for all patients without contraindications who are trying to quit smoking.** The nicotine patch in particular is safe, and has been shown not to cause adverse cardiovascular effects.

Answer 1294

D ## Footnote **Nondisplaced radial head fractures** can be treated by the primary care physician and do not require referral. **Conservative therapy includes placing the elbow in a posterior splint for 5–7 days, followed by early mobilization and a sling for comfort**. Sometimes the joint effusion may be aspirated for pain relief and to increase mobility. Early mobilization was associated with better function and less pain 1 week after the injury. **Radiographs should be repeated in 1–2 weeks to make sure that alignment is appropriate.**

Answer 1295

C ## Footnote Enuresis alarms should be offered as initial treatment for bed-wetting, based on randomized, controlled trials and cost-effectiveness evidence. Desmopressin can also be considered if the child or parents do not want to try an alarm. Restriction of fluids during the day should not be recommended, as it is important that children have enough to drink. Waking a child and carrying him or her to the toilet has not been shown to have a long-term effect on bed-wetting. Oxybutynin and imipramine should only be considered in cases where bed-wetting does not respond to initial treatment.

Answer 1296

A ## Footnote This patient has several risk factors for osteoporosis: Asian ethnicity, low body weight, positive family history, postmenopausal status with no history of hormone replacement, and low calcium intake. The best diagnostic test for osteoporosis is a **central DXA scan of the hip, femoral neck, and lumbar spine**. Quantitative CT is accurate, but cost and radiation exposure are issues. Peripheral DXA and calcaneal sonography results do not correlate well with central DXA. Measurement of biochemical markers is not recommended for the diagnosis of osteoporosis.

Answer 1297

D ## Footnote It is now recommended that all infants and children, including adolescents, have a minimum daily intake of **400 IU of vitamin D, beginning soon after birth**. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes mellitus and cancer.

Answer 1298

D ## Footnote Acute **subacromial bursitis** is common and is often associated with *calcific deposits in the supraspinatus tendon*, pain on abduction, and local tenderness. **Bicipital tendinitis** results in tenderness on palpation of the tendon of the long head of the biceps. A **rotator cuff tear** usually results from an injury, and affects range of motion. **Osteoarthritis** seldom causes acute, severe pain. **A frozen shoulder** may result from *subacromial bursitis* and presents with limitation of shoulder motion.

Answer 1299

D The Valsalva maneuver decreases venous return to the heart, thereby decreasing cardiac output. This causes most murmurs to decrease in length and intensity. The murmur of hypertrophic obstructive cardiomyopathy, however, increases in loudness. The murmur of mitral valve prolapse becomes longer, and may also become louder.

Answer 1300

A ## Footnote This patient has **gadolinium-associated nephrogenic systemic fibrosis**, which is associated with the **use of gadolinium-based contrast material in patients with severe renal dysfunction, often on dialysis.** Associated proinflammatory states, such as recent surgery, malignancy, and ischemia, are often present as well. This condition occurs without regard to gender, race, or age. Dermatologic manifestations are usually seen, but multiple organ systems may be involved. There is **no effective treatment**, and mortality is approximately 30%. **A deep biopsy of the affected skin is diagnostic.**

Answer 1301

A ## Footnote Children with DM are at increased risk for retinopathy, nephropathy, and HTN. They are also more likely to have immune-mediated disorders such as celiac disease and hypothyroidism. For all children and adolescents with type 1 DM, the American Diabetes Association recommends screening for **hypothyroidism, nephropathy, hypertension, celiac disease, retinopathy**, and **dyslipidemia** if there is a family history of hypercholesterolemia or cardiac events before age 55.

Answer 1302

B Obstructive sleep apnea-hypopnea syndrome is defined as the presence of at least five obstructive events per hour with associated daytime sleepiness. The prevalence in men is almost 3x that of premenopausal women and 2x that of postmenopausal women. Other factors associated with an increased prevalence are **obesity, older age, and hypertension.**

Answer 1303

A ## Footnote Enoxaparin is eliminated mostly by the kidneys. When it is used in patients with severe renal impairment the dosage must be significantly reduced. For some indications the dose normally given every 12 hours is given only every 24 hours. Metoprolol and carvedilol are metabolized by the liver.

Answer 1304

A ## Footnote **HSV** is the most common etiologic agent of erythema multiforme, a hypersensitivity reaction of the skin. Mycoplasma pneumoniae,fungal infections, medications, and vaccines may also be associated. Skin biopsy findings are _not_ specific for erythema multiforme. As opposed to the lesions of urticaria, the lesions of erythema multiforme usually are present and fixed for at least 1 week and may evolve into target lesions. The palms of the hands and soles of the feet may be involved. The lesions of erythema multiforme usually resolve spontaneously over 3–5 weeks without sequelae.

Answer 1305

B ## Footnote Screening for postpartum depression is recommended as part of the routine postpartum visit. The use of a screening tool for depression is recommended, such as the Edinburgh Postnatal Depression Scale. A CBC or urine dipstick is recommended only for patients who have an indication for them, and should not be routinely ordered. Thyroid function tests and glucose tolerance testing are recommended for patients who are either symptomatic or at high risk for disease.

Answer 1306

E ## Footnote The diagnosis of giardiasis is suggested by its most characteristic symptoms: foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and the virtual absence of mucus or blood in the stool. Stools are usually mushy between exacerbations, though constipation may occur. If eosinophilia occurs, it is more likely to be related to some other concomitant cause rather than to giardiasis.

Answer 1307

D ## Footnote Biguanides/thiazolidinediones - insulin sensitizers that decrease hepatic glucose production and increase insulin sensitivity. **Sulfonylureas/ meglitinides - stimulate pancreatic insulin secretion** DPP-4 inhibitors - prevent GLP-1 breakdown and slow the breakdown of some sugars. GLP-1 mimetics - stimulate insulin secretion, suppress glucagon secretion, and promote β-cell production. Amylin analogs - act with insulin to **delay gastric emptying** and they also inhibit glucagon release.

Answer 1308

E ## Footnote Acetaminophen is the first-line treatment in this case, since renal dysfunction is a contraindication to the use of NSAIDs. Intra-articular injections should not be considered first-line treatment for symptomatic osteoarthritis of the knee. They are recommended for short-term pain control, with the evidence for hyaluronic acid being somewhat weak.

Answer 1309

A ## Footnote There is no immunization against toxoplasmosis, and the use of antibiotics is limited to cases in which there is known maternal infection with the protozoa. Screening pregnant women for seroconversion (not with urine antigen testing) is controversial, and recommendations by various professional groups differ. Currently, ACOG does _not_ recommend routine screening except in patients who are known to be HIV+. However, because the infection is thought to be passed primarily from **undercooked meat** or through **infected animal feces**, it is universally recommended that **pregnant women avoid direct contact with cats’ litter boxes**. If avoidance is not possible, wearing gloves when handling a litter box is recommended.

Answer 1310

E ## Footnote Bariatric surgery leads to the most effective weight reduction and long-term maintenance in patients who are morbidly obese. Bariatric surgery has also been shown to significantly reduce fasting blood glucose, with resolution of diabetes mellitus in 31%–77% of lap band patients and 72%–100% of gastric bypass patients. Bariatric surgery is a safe and effective means for long-term weight loss and should be considered in adults with a BMI \>40, or \>35 with obesity-related comorbidities.

Answer 1311

B ## Footnote Athletes, including swimmers, are susceptible to a number of skin infections. The pH of the external ear is normally acidic. Continued water exposure raises the pH, creating conditions for bacterial overgrowth, most often caused by either Pseudomonas aeruginosa or Staphylococcus aureus. Swimming pool folliculitis is most often attributed to colonization of water with P. aeruginosa.

Answer 1312

A ## Footnote It has been shown that CHF patients treated with ACEi survive longer. Warfarin and/or antiarrhythmic drugs should be given only to selected CHF patients. Verapamil may adversely affect cardiac function and should be avoided in patients with CHF. Hydralazine can be used, but because of its side effect profile would be a second-line agent.

Answer 1313

A Plain radiography should be the initial imaging modality to diagnose stress fractures. One algorithm advocates radiography _2 weeks after the onset of symptoms_ (if symptoms persist), with repeat radiography the following week before performing more advanced imaging. An expert panel of the American College of Radiology recommends that MRI be considered next if plain radiography is negative.

Answer 1314

C ## Footnote This patient most likely has periodontitis of the tooth’s roots with cellulitis, complicated by an apical abscess. This infection is caused by anaerobic oral bacteria. Penicillin VK, amoxicillin or amoxicillin/clavulanate is preferred for antibiotic treatment, but this patient is allergic to penicillin. Clindamycin is a good choice to cover the likely pathogens. Doxycycline, trimethoprim/sulfamethoxazole, ciprofloxacin, and cephalexin have limited effectiveness against anaerobes and would not be indicated.

Answer 1315

D Patients should be routinely screened for hepatitis C if they have a history of any of the following: intravenous drug abuse no matter how long or how often, receiving clotting factor produced before 1987, persistent alanine aminotransferase elevations, or recent needle stick with HCV-positive blood.

Answer 1316

D ## Footnote Acute exacerbations of COPD are very common, with most caused by superimposed infections. Supplemental O2, antibiotics, bronchodilators, and systemic steroids are used for management. Systemic corticosteroids, either oral or parenteral, have been shown to significantly reduce treatment failures and improve lung function and dyspnea over the first 72 hours, although there is an increased risk of adverse drug reactions.

Answer 1317

E ## Footnote The patient described has an inflammatory myopathy of the polymyositis/dermatomyositis group. Proximal muscle involvement and elevation of serum muscle enzymes such as creatine kinase and aldolase are characteristic. Corticosteroids are the accepted treatment of choice. It is extremely unlikely that Duchenne’s muscular dystrophy would present after age 30. In amyotrophic lateral sclerosis, an abnormal neurologic examination with findings of upper motor neuron dysfunction is characteristic. Patients with myasthenia gravis characteristically have optic involvement, often presenting as diplopia. The predominant symptom of aseptic necrosis of the femoral head is pain rather than proximal muscle weakness.

Answer 1318

A ## Footnote Dyspnea is a frequent and distressing symptom in terminally ill patients. In the absence of hypoxia, oxygen is not likely to be helpful. Opiates are the mainstay of symptomatic treatment.

Answer 1319

B The treatment for otitis media is a 10-day course of Amoxicillin for children under the age of 2 years if the diagnosis is certain. If the diagnosis is not certain and the illness is not severe, there is an option of observation with follow-up.

Answer 1320

D ## Footnote The symptom of an increased or abnormal sensation of one’s heartbeat is referred to as palpitations. This condition is common to primary care, but is often benign. Commonly, these sensations have their basis in anxiety or panic. However, about 50% of those who complain of palpitations will be found to have a diagnosable cardiac condition. It is recommended to start the evaluation for cardiac causes with an EKG, which will assess the baseline rhythm and screen for signs of chamber enlargement, previous myocardial infarction, conduction disturbances, and a prolonged QT interval.

Answer 1321

B ## Footnote Echinacea is a genus of native North American plants commonly known as purple coneflower. It has been recommended as a **prophylactic treatment for upper respiratory infection,** and is widely used for this indication, although it **appears to be relatively ineffective**. The research is difficult to evaluate because of the heterogeneity of the products used in various studies

Answer 1322

B Complete cervical spine series that includes five views is the correct study in a patient of any age with chronic neck pain and no history of trauma, malignancy, or surgery. If the radiographs are normal and the patient has neurologic signs or symptoms, the next step would be MRI. If MRI is contraindicated, CT myelography should be offered. A single lateral radiograph is not sufficient. Diskography is not recommended in patients with chronic neck pain.

Answer 1323

B **Carnett’s sign** - easing of the pain of abdominal palpation with tightening of the abdominal muscles. If the cause is visceral, the taut abdominal muscles could guard the source of pain from the examining hand. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.

Answer 1324

A ## Footnote This is a classic description of **rickettsial illness** (Rocky Mountain Spotted Fever): a history of outdoor activity, the sudden onset of fever, chills, and rash on the palms of the hands and the soles of the feet. Penicillin, cephalexin, and azithromycin do not cover rickettsia. Reassurance would be inappropriate because this condition can be life threatening and should always be treated.

Answer 1325

E ## Footnote For patients with bronchiolitis, evidence supports a trial of an inhaled bronchodilator, **albuterol, or epinephrine**, with treatment continued only if the initial dose proves beneficial. There is no evidence to support the use of antibiotics unless another associated infection is present (e.g., otitis media). Neither corticosteroids nor postural drainage has been found to be helpful.

Answer 1326

B SSRIs are thought to have the best safety profile. **Fluoxetine, sertraline,** and **citalopram** have extensive data to support their safety in pregnancy and should be considered first line. **Paroxetine** is the one SSRI that is thought to carry an increased risk of congenital malformations with first-trimester exposure and _should be avoided._ Tricyclic antidepressants are class D in pregnancy. SNRIs do not have as much safety data as SSRIs to support their use in pregnancy and would be considered a second-line choice. MAOIs are known teratogens and should be avoided in pregnancy. Stimulants are not first-line agents and should be avoided in pregnancy.

Answer 1327

A **polycythemia vera** - splenomegaly, elevated red cell mass, a normal arterial O2 sat (\>92%). In addition, patients usually exhibit thrombocytosis (platelet count \>400,000/mm3 ), leukocytosis (WBC\>12,000/mm3 ), a low serum EPO level, and an elevated leukocyte alk phos score, and pruritus after a hot shower. High carboxyhemoglobin levels are associated with secondary polycythemia.

Answer 1328

A ## Footnote Dementia with Lewy bodies is the second most common histopathologic type of dementia after Alzheimer’s disease. He demonstrates typical symptoms and signs, including well-formed hallucinations, vivid dreams, fluctuating cognition, sleep disorder with periods of daytime sleeping, frequent falls, deficits in visuospatial ability (abnormal clock drawing), and REM sleep disorder (vivid dreams).

Answer 1329

D Colic is a frustrating condition for parents and doctors alike. The parents would like an explanation and relief, and physicians would like to offer these things. At this time, however, in spite of numerous studies and theories, the cause of colic remains unknown

Answer 1330

D This patient has psychotic depression with suicidal ideations and has not responded to maximum doses of several antidepressants. He is more likely to respond to electroconvulsive therapy than to counseling or a change in medication.

Answer 1331

A Asthma is typically associated with an obstructive impairment that is reversible with short-acting bronchodilators. A reduced FEV1 and a decreased FEV1/FVC ratio indicates airflow obstruction. A reduced FVC with a normal or increased FEV1/FVC ratio is consistent with a restrictive pattern of lung function.

Answer 1332

A In those at low risk, such as this patient, a tuberculin skin test is now considered positive only if induration is at least 15 mm. Thus, this hospital volunteer would pose little risk to the hospital population since her 10-mm reaction falls within the guidelines of a negative test. She does not require diagnostic evaluation at this time, and isoniazid therapy is not indicated. In some persons PPD reactivity wanes with time but can be recalled by a second skin test administered 1 week or more after the first (i.e., two-step testing). For persons undergoing PPD skin testing, such as health-care workers, **initial two-step testing may preclude misclassification of persons with boosted reactions as PPD converters.**

Answer 1333

A A Heat exhaustion and heatstroke are both on the continuum of heat-related illness. Heatstroke is a much more severe condition than heat exhaustion. Evidence of central nervous system dysfunction is evidence of heatstroke rather than heat exhaustion, even if other symptoms are not severe and point to heat exhaustion. Heatstroke is a medical emergency.

Answer 1334

A ## Footnote Magnesium sulfate infusions must be carefully monitored because **respiratory depression** is a potential lethal side effect. Reflexes are usually lost first. Terbutaline and ritodrine have the potential to cause respiratory distress in the form of pulmonary edema. They do not cause respiratory depression. Indomethacin and nifedipine are rarely used tocolytics that do not depress respiration.

Answer 1335

A This patient has Bell’s palsy. **Only corticosteroids have been shown to improve the outcome.** Antiviral agents have little value in the treatment of Bell’s palsy. Thrombolytic therapy may be useful for a patient with central facial nerve weakness if it is due to a vascular event

Answer 1336

E ## Footnote Migraine is the most likely diagnosis in this scenario, because the patient is young and female; the headaches are unilateral, infrequent, and throbbing; the headaches are associated with nausea and vomiting; and sleep offers relief. Symptoms of sinusitis usually include fever, facial pain, and a purulent nasal discharge. The pain of cerebral tumor tends to occur daily and becomes more frequent and severe with time. Furthermore, the prevalence of brain tumor is far less than that of migraine. The pain of muscle tension headache is described as a pressure or band-like tightening, often in a circumferential or cap distribution. This headache also has a pattern of daily persistence, often continuing day and night for long periods of time. Cluster headache is more common in males, and presents as a very severe, constant, agonizing orbital pain, usually beginning within 2 or 3 hours after falling asleep.

Answer 1337

B US is the initial test of choice for evaluating the possibility of multiple gestation. It should be done if uterine size is larger than expected, or if pregnancy-associated symptoms are excessive. It should also be done in women who received fertility treatment. An initial sonogram that shows a single pregnancy does not rule out multiple gestation. In one study, 30 of 220 twin pregnancies had an original sonogram which showed a single pregnancy.

Answer 1338

B Severe hyperkalemia (\>7.0 mEq/L) requires aggressive treatment. * **Calcium chloride or gluconate** has no effect on the plasma potassium level, but it should be given first, as it rapidly stabilizes the membranes of cardiac myocytes, reducing the risk of cardiac dysrhythmias. * **Therapies that translocate potassium from the serum to the intracellular space** should be instituted next, as they can quickly (albeit temporarily) lower the plasma concentration of potassium. These interventions include **sodium bicarbonate, glucose with insulin,** and **albuterol.** * **Total body potassium can be lowered** with **sodium polystyrene sulfonate (Kayxelate)**, but this takes longer to affect the plasma potassium level than translocation methods. * In the most severe cases, **acute hemodialysis** can be instituted.

Answer 1339

A HIPAA regulations set a minimum standard for privacy protection. Privacy notices must be provided at the first delivery of health services, and written acknowledgement is encouraged but not required. Exceptions to patient inspections include psychotherapy notes and instances where disclosure is likely to cause substantial harm to the patient or another individual in the judgment of a licensed health professional. Although it is not necessary to provide patients with a privacy notice before rendering emergency care, it is required that patients be provided with a privacy notice after the emergency has ended.

Answer 1340

E Leukoplakia is a white keratotic lesion seen on mucous membranes. Irritation from various mechanical and chemical stimuli, including alcohol, favors development of the lesion. Leukoplakia can occur in any area of the mouth and usually exhibits benign hyperkeratosis on biopsy. On long-term follow-up, **2%-6% of these lesions will have undergone malignant transformation into squamous cell carcinoma.** Oral nystatin would not be appropriate treatment, as this lesion is not typical of oral candidiasis. Candidal lesions are usually multiple and spread quickly if untreated. A fluorescent antinuclear antibody test is also not indicated, as the oral lesions of lupus erythematosus are typically irregular, erosive, and necrotic. An idiosyncratic reaction to propranolol is unlikely in this patient

Answer 1341

E Corticosteroids are among the common secondary causes of osteoporosis in men. Other causes include excessive alcohol use, hypogonadism, vitamin D deficiency, and decreased body mass index.

Answer 1342

D ## Footnote Transdermal absorption of medications changes very little with age. Due to an increase in the ratio of fat to lean body weight, the volume of distribution changes with aging, especially for fat-soluble drugs. Both liver metabolism and renal excretion of drugs decrease with aging, increasing serum concentrations.

Answer 1343

C Vascular dementia is characterized by cognitive decline from a previously higher level of functioning, manifested by impairment of memory and of two or more cognitive domains, and evidence of cerebrovascular disease by focal signs on neurologic examination, consistent with stroke.

Answer 1344

E ## Footnote Testing for diabetes mellitus should be considered in all asymptomatic adults who have a BMI ≥25 kg/m² and have \> 1 risk factors such as physical inactivity, a first degree relative with diabetes, a high-risk ethnicity, HTN, HLD, or PCOS. In asymptomatic patients with no risk factors, screening should begin at **age 45.**

Answer 1345

D ## Footnote In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion and BP. **Norepinephrine and dopamine currently are the preferred pressor agents**; however, norepinephrine appears to be more effective and has a lower mortality rate. **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 1346

A ## Footnote Eradication of H. pylori significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy. Eradication has minimal or no effect on the symptoms of nonulcer dyspepsia and GERD. Although H. pylori infection is associated with gastric cancer, no trials have shown that eradication of H. pylori purely to prevent gastric cancer is beneficial.

Answer 1347

A Pneumococcal and meningococcal vaccines are currently recommended for patients with asplenia. Haemophilus influenzae type b (Hib) vaccine can be considered as well. Emergency splenectomy for trauma is an indication for vaccination, even though splenic remnants may persist.

Answer 1348

E ## Footnote **Fracture of the scaphoid** should be suspected in every “sprained wrist” presenting with tenderness in the anatomic snuffbox. Radiographs may be negative initially. _Fractures through the proximal third_ tend to cause loss of circulation and are slower to heal (Circulation enters the scaphoid bone through the distal half), and should be referred to an orthopedist because of the **risk of nonunion and avascular necrosis**. _Fractures through the middle or distal one-third_ can be treated with a thumb spica cast for 10–12 weeks. A wrist splint does not provide adequate immobilization. A bone scan is unnecessary, and PT is inappropriate. If there is still no evidence of union after 10 weeks of immobilization, the patient should be referred to an orthopedist for further care.

Answer 1349

A Color Doppler flow studies are useful for evaluating blood flow to the ovary in possible cases of **adnexal/ovarian torsion**. Adnexal torsion is a surgical emergency. Pelvic US, preferably with a vaginal probe, can be beneficial in the workup of ruptured ovarian cyst, pelvic abscess, and PID without abscess. The Doppler flow study is not required with these condition.

Answer 1350

E For treating acute otitis media in this patient, the current recommended dosage of amoxicillin is 80–90 mg/kg/day.

Answer 1351

E There are four types of urinary incontinence in women: * **functional**, which occurs when the patient's inability to ambulate or transfer results in loss of urine; * **stress**, which is a result of pelvic relaxation and is manifested as involuntary loss of urine with increases in abdominal pressure * **urge,** which is caused by detrusor instability or overactive bladder, which is when the urge to urinate is quickly followed by loss of urine, usually a large volume * **overflow,** which is usually caused by *neurogenic bladder*, which is marked by constant leakage of small amounts of urine. Neurogenic bladder can be caused by diabetes mellitus, multiple sclerosis, or spinal cord injury, and is usually **initially treated with a strict voluntary urination schedule**, which may be coupled with Crede's maneuver. It can be treated further by **adding bethanechol** to the regimen. Many patients have to be taught intermittent self-catheterization of the bladder. Ultimately, the patient may require resection of the internal sphincter of the bladder neck.

Answer 1352

B ## Footnote This is a classic presentation of a possible scaphoid fracture, which is important to diagnose and treat appropriately because of a high rate of non-union. If radiographs are negative, the patient should be placed in a **thumb spica splint and have repeat radiographs in 2 weeks, because initial studies may be negative**. An Ace bandage or a sugar tong splint would be inappropriate because they do not immobilize the thumb. A long arm cast for 8 weeks would immobilize the thumb, but could lead to loss of function, and may overtreat the injury if it is not truly a scaphoid fracture.

Answer 1353

A ## Footnote Clinical evaluation and a chest radiograph are recommended in asymptomatic patients with a positive PPD. Asymptomatic patients with a positive PPD and an abnormal chest film should have a sputum culture for TB, but a culture is not required if the chest film is negative. Persons with a PPD conversion should be encouraged to take INH for 9 months with proper medical supervision.

Answer 1354

B ## Footnote Galactorrhea associated with a prolactin level \>200 μg/L usually indicates a **prolactinoma**, and requires **MRI of the pituitary with gadolinium enhancement**. Many drugs can cause galactorrhea, including oral contraceptives and risperidone, but they would not elevate serum prolactin to this level. Dopamine agonists such as **bromocriptine or cabergoline** are the preferred treatment for most patients with hyperprolactinemia.

Answer 1355

C ## Footnote Natural family planning (NFP) is a potentially effective method for contraception and for determining the time of ovulation for purposes of conception. While the contraceptive effectiveness of the different NFP methods varies significantly, the success rates for typical use are as high as 92%–98%. **Monitoring the presence and consistency of cervical mucus production allows for the determination of both the beginning and end of a woman’s most fertile period.** The _symptothermal method_ also incorporates calendar calculations, basal body temperature measurement, and ovulation-related symptoms as a complement to the cervical mucus component. The _Marquette Model_ incorporates cervical mucus and basal body temperature charting with electronic monitoring of urine estrogen and LH metabolites to provide additional information to determine when ovulation has occurred.

Answer 1356

E Irritable bowel syndrome (IBS) is a benign, chronic symptom complex of altered bowel habits and abdominal pain. It is the most common functional disorder of the gastrointestinal tract. The presence of nocturnal symptoms is a red flag which should alert the physician to an alternate diagnosis and may require further evaluation. The other symptoms listed are Rome I and II criteria for diagnosing irritable bowel syndrome.

Answer 1357

D ## Footnote Fractures of the medial third of the clavicle in pediatric patients are common and are best treated by a figure-of-8 apparatus. Open surgical reduction with intramedullary fixation will minimize angular deformity at the fracture site but leaves a scar and may result in nonunion. With the rare exception of neurovascular injury accompanying the fracture, there are no indications for open reduction of a clavicular fracture in a child.

Answer 1358

C Adenosine, digoxin, and calcium channel antagonists act by blocking conduction through the AV node, which may increase the ventricular rate paradoxically, initiating ventricular fibrillation. These agents should be avoided in Wolff-Parkinson-White syndrome. **Procainamide** is usually the treatment of choice in these situations, although amiodarone may also be used.

Answer 1359

B ## Footnote All of the options listed can be assessed by US. Crown-rump length is a very accurate parameter in the first trimester, but the **biparietal diameter is the most accurate parameter during the second trimester**. Both have a 95% confidence level of being within 5–10 days of the actual gestational age when used at the proper time

Answer 1360

D ## Footnote **Low-osmolar or iso-osmolar contrast media** should be used to prevent contrast-induced nephropathy in at-risk patients. The **volume of contrast medium should be as low as possible**. Evidence also supports hydration before the procedure, preferably with **isotonic saline** or **isotonic sodium bicarbonate solution.**

Answer 1361

E ## Footnote The general requirement for enrolling an individual in hospice is that they have a terminal illness and an estimated life expectancy of 6 months or less. Given these criteria, it is not surprising that over 40% of hospice patients have a cancer diagnosis. Cancer usually has a short period of obvious decline at the end and is predictable to a degree. COPD, end-stage liver disease, and heart failure result in long-term disability with periodic exacerbations, any one of which could result in death, but far less predictably. Those with severe dementia or frailty often experience a dwindling course that is also difficult to predict.

Answer 1362

A ECT has a \>60-year history of efficacy and safety for the treatment of severe depression. There has been no evidence of brain damage secondary to ECT. The most common side effect is reversible short-term memory loss. Dementia is not listed as a side effect. Response rates are generally in the 60%–90% range.

Answer 1363

E ## Footnote This patient has become tolerant to morphine. The IV dose should be a third of the oral dose, so the starting IV dose was adequate. Addiction is compulsive narcotic use. Pseudoaddiction is inadequate narcotic dosing that mimics addiction because of unrelieved pain. Physical dependence is seen with abrupt narcotic withdrawal.

Answer 1364

B ## Footnote For a healthy nonsmoker with no chronic disease who is not in a high-risk group, pneumococcal vaccine is recommended once at age 65, or as soon afterward as possible. Persons that should be immunized before age 65 include patients with chronic lung disease, cardiovascular disease, diabetes mellitus, chronic liver disease, cerebrospinal fluid leaks, cochlear implants, immunocompromising conditions, or asplenia, and residents of nursing homes and long-term care facilities.

Answer 1365

E ## Footnote The adaptation that permits survival in chronic hyponatremia also makes the brain vulnerable to injury from overzealous therapy. When hyponatremia is corrected too rapidly, outpacing the brains ability to recapture lost organic osmolytes, osmotic demyelination can result. Osmotic demyelination syndrome can usually be avoided by limiting correction of chronic hyponatremia to **and to**

Answer 1366

C ## Footnote Campylobacter jejuni is one of the most common causes of bacterial foodborne illnesses. Undercooked or improperly handled chicken is most often implicated as the source. Symptoms typically begin 2–5 days following exposure. Diarrhea is the predominant symptom, with a lesser degree of nausea and vomiting. Up to 10 days is required for full recovery. While Escherichia coli O157:H7 and Shigella may cause a similar illness, both generally present with bloody diarrhea. E. coli O157:H7 is most often transmitted in contaminated undercooked beef, and Shigella is usually spread in a fecal-oral pattern or via contaminated water. The peripheral WBC count is typically increased substantially in shigellosis. Staphylococcus aureus produces an enterotoxin in food that causes the onset of nausea, vomiting, and diarrhea within hours of ingestion and clears within 24–48 hours. Norovirus is a very common cause of acute viral gastroenteritis, usually with more vomiting than diarrhea. It spreads person to person, and patients usually recover within 24 hours.

Answer 1367

A Vitamin D and high-potency corticosteroids were equally effective when compared head to head for the treatment of chronic psoriasis, but the corticosteroids produced fewer local reactions

Answer 1368

A BNP is a 32 a.a. polypeptide secreted from the **cardiac ventricles in response to ventricular volume expansion and pressure overload,** with its release is directly proportional to ventricular dysfunction. A BNP test is simple and time efficient, and reliably predicts the presence or absence of left ventricular dysfunction on an echocardiogram.

Answer 1369

C ## Footnote This is a common presentation for **acute paronychia**, which typically is caused by local trauma to the nail fold or cuticle, with resulting inoculation and infection. **Topical antibiotics, with or without topical corticosteroids, is one treatment option.** Other options include warm compresses, oral antibiotics, and incision and drainage; however, incision and drainage is not always necessary. Topical corticosteroids can be used alone for **chronic** paronychia, but if used for **acute** paronychia, they should be combined with antibiotics since acute paronychia is typically caused by a bacterial infection. Removal of the proximal nail fold is used to treat chronic paronychia that is not responsive to other treatments. Topical antifungals are a treatment option for **chronic** paronychia, which can be associated with a fungal infection, but not for acute paronychia.

Answer 1370

C Complaints of discomfort in the eye with blurred vision and a history of striking steel should arouse strong suspicion of an intraocular foreign body.

Answer 1371

A ## Footnote Intramuscular epinephrine is the recommended drug for anaphylactic reactions (SOR A). Epinephrine is absorbed more rapidly intramuscularly than subcutaneously.

Answer 1372

C ## Footnote **Chronic** **insomnia** - difficulty with initiating/maintaining sleep, or experiencing nonrestorative sleep, for at least 1 month, leading to significant daytime impairment. Primary insomnia - not caused by another sleep disorder, underlying psychiatric or medical condition, or substance abuse disorder. **Cognitive-behavioral therapy** should be used as the initial treatment for chronic insomnia, as it has been shown to produce *sustained improvement at both 12 and 24 months* after treatment is begun. One effective therapy is **stimulus control**, in which patients are taught to eliminate distractions and associate the bedroom only with sleep and sex. Reading and television watching should occur in a room other than the bedroom. Pharmacotherapy alone does not lead to sustained benefits. SSRIs can cause insomnia, as can alcohol.

Answer 1373

E It is difficult to establish a prognosis in a comatose patient after a cardiac arrest. The duration of CPR is not a factor, and the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours. **Myoclonic status epilepticus at 24 hours suggests no possibility of a recovery.**

Answer 1374

C ## Footnote In 50%–90% of patients, pityriasis rosea starts with an **erythematous, scaly, oval patch** a few centimeters in diameter. Within a few days, this is usually followed by **smaller patches on the trunk and sometimes the proximal extremities**. Pityriasis rubra pilaris is a rare disease with five types. The classic adult type begins with a small red plaque on the face or upper body that gradually spreads to become a generalized eruption. The other conditions listed typically begin with multiple lesions.

Answer 1375

C ## Footnote This case illustrates the classic history and physical findings of iliotibial band syndrome. Pain occurs most frequently at the site where the **tendon crosses over the lateral femoral epicondyle**. With osteoarthritis or a meniscal tear there would be pain in the joint space with palpation. Osgood-Schlatter disease is more common in younger adolescents and is characterized by tenderness of the tibial tubercle at the distal insertion of the patellar ligament. Pes anserine bursitis is characterized by pain in the medial knee distal to the joint space, at the conjoined tendon of the sartorius, gracilis, and semitendinosus.

Answer 1376

D No medication available in the United States has been shown to effectively treat cough or cold symptoms in children younger than 2 years of age. The American Academy of Pediatrics and the American Academy of Family Physicians recommend using only nasal saline, bulb suction, humidified air, and good hydration in children younger than 2 years of age.

Answer 1377

D The Women’s Health Initiative Randomized Controlled Trial concluded that the health risks of HRT with combined estrogen/progestin exceeded the benefits. Absolute risk reductions per 10,000 person-years attributable to estrogen/ progestin were 6 fewer colorectal cancers and 5 fewer hip fractures. However, absolute excess risks per 10,000 person-years included 7 more coronary heart disease events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers.

Answer 1378

E ## Footnote Respiratory viruses appear to be the most common cause of acute bronchitis; however, the organism responsible is rarely identified in clinical practice because viral cultures and serologic assays are not routinely performed. Fewer than 10% of patients will have a bacterial infection diagnosed as the cause of bronchitis. For this reason, for patients with a putative diagnosis of acute bronchitis, routine treatment with antibiotics is not justified and should not be offered. Antitussive agents are occasionally useful and can be offered as therapy for short-term symptomatic relief of coughing.

Answer 1379

D ## Footnote This patient has hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and needs to be delivered. There is no reason to delay delivery in a term pregnancy. HELLP syndrome is a form of severe preeclampsia. If the patient has a favorable cervical examination, labor induction with oxytocin is appropriate. If the cervix is unfavorable, cesarean delivery should be considered to expedite delivery.

Answer 1380

A ## Footnote Ankle-brachial index (ABI) is an inexpensive, sensitive screening tool and is the most appropriate first test for peripheral vascular occlusive disease (PVOD). The ABI is the ratio of **systolic** BP measured in the ankle to systolic BP using the standard brachial measurement. A **ratio of 0.9-1.2 is normal.****Severe disease is defined as a ratio . More invasive and expensive testing using Doppler US, arteriography, or MRA may be useful if the ABI suggests an abnormality. Venous US would not detect PVOD, but it could rule out deep venous thrombosis, which is another common etiology for calf pain.**

Answer 1381

B ## Footnote Almost all glass is visible on radiographs if it is 2 mm or larger, and contrary to popular belief, it doesn’t have to contain lead to be visible on plain films. Many common or highly reactive materials, such as wood, thorns, cactus spines, some fish bones, other organic matter, and most plastics, are not visible on plain films. Alternative techniques such as ultrasonography or CT scanning may be effective and necessary in those cases. Sea urchin spines, like many animal parts, have not been found to be easily detected by plain radiography.

Answer 1382

D The actual risk of adenocarcinoma from Barrett’s esophagus is less than 1%. Endoscopy does nothing to reduce the risk of death. Patients with Barrett’s esophagus can have minimal symptoms.

Answer 1383

A ## Footnote These findings are typical of femoral neuropathy, a mononeuropathy commonly associated with diabetes mellitus. Diabetic polyneuropathy is characterized by _symmetric_ and distal limb sensory and motor deficits. Meralgia paresthetica, or _lateral femoral cutaneous neuropathy_, may be secondary to diabetes mellitus, but is manifested by numbness and paresthesia over the anterolateral thigh with no motor dysfunction. Spinal stenosis causes pain in the legs, but is not associated with the neurologic signs seen in this patient, nor with knee problems. Iliofemoral atherosclerosis, a relatively common complication of diabetes mellitus, may produce _intermittent claudication involving one or both calf muscles_ but would not produce the motor weakness noted in this patient.

Answer 1384

B In girls, pubertal development typically requires 4.5 years. Although generally the first sign of puberty is accelerated growth, breast budding is usually the first recognized pubertal change, followed by pubic hair, peak growth velocity, and menarche. Girls must have adequate nutrition and reach a critical body weight and body fat percentage before menarche occurs. There is a concordance in the age of menarche in mother-daughter pairs and between sisters. brest -\> pubic -\> height -\> menarch (BPH-M) The changes associated with puberty occur in an orderly sequence over a definite time frame. Any deviation from this sequence or time frame should be regarded as abnormal. Delayed or interrupted puberty is defined as failure to develop any secondary sex characteristics by age 13, to have menarche by age 16, or to have menarche 5 or more years after the onset of pubertal development.

Answer 1385

E ## Footnote **Pyelonephritis.** Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents until the patient is stabilized and cultures are available. **Ampicillin plus gentamicin** OR **cephalosporin** is typically used. Sulfonamides are contraindicated late in pregnancy because they may increase the incidence of kernicterus. Tetracyclines are contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth. Nitrofurantoin may induce hemolysis in patients who are deficient in G-6-PD, which includes approximately 2% of African-American women. The safety of levofloxacin in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.

Answer 1386

A ## Footnote **_Triquetral fractures_** typically occur with **hyperextension of the wrist**. **Tenderness on dorsal wrist on the ulnar side** distal to the ulnar styloid. The typical radiologic finding is a **small bony avulsion visible on a lateral view** of the wrist. Avulsion fractures respond well to **4 weeks of splinting and protection.**

Answer 1387

B ## Footnote Continuous therapy with oral terbinafine for 12 weeks has the highest cure rate and best long-term resolution rate of the therapies listed. Other agents and pulsed dosing regimens have lower cure rates. Topical creams are not appropriate for onychomycosis because the infection resides in the cell of the toenail. Antifungal nail lacquers have a lower cure rate than systemic therapy and should be used only when oral agents would not be safe. Toenail removal is reserved for patients with an isolated infected nail or in cases involving a dermatophytoma

Answer 1388

C ## Footnote β-Blockers are recommended to reduce mortality in symptomatic patients with heart failure. The role that digoxin will ultimately play in heart failure is unclear. The Digitalis Investigation Group study revealed a trend toward increased mortality among women with heart failure who were taking digoxin, but digoxin levels were higher among women than men. There is no evidence that warfarin decreases mortality in patients with heart failure. There is also no evidence that amiodarone decreases mortality from heart failure in patients with no history of atrial fibrillation. Calcium channel blockers should be used with caution in patients with heart failure because they can cause peripheral vasodilation, decreased heart rate, decreased cardiac contractility, and decreased cardiac conduction.

Answer 1389

C ## Footnote **Diabetes mellitus** and **smoking** are significant risk factors for intermittent claudication, as are **hypertension** and **dyslipidemia**. Hyperthyroidism, hypercalcemia, and hypogonadism are not closely associated with intermittent claudication. Elevation of angiotensin-converting enzyme occurs with sarcoidosis

Answer 1390

C ## Footnote Maternal hypothyroidism can have serious effects on the fetus, so thyroid dysfunction should be treated during pregnancy. Because of hormonal and metabolic changes in early pregnancy, the **levothyroxine dosage often needs to be increased at 4–6 weeks gestation i**n order to maintain her euthyroid status.

Answer 1391

A ## Footnote This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis. Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to decrease hirsutism and improve insulin resistance and menstrual irregularities. **Metformin and clomiphene alone or in combination are first-line agents for ovulation induction.** Clomiphene does not improve hirsutism, however. Progesterone is not indicated for any of this patient’s problems. Spironolactone will improve hirsutism and menstrual irregularities, but is not indicated for ovulation induction.

Answer 1392

A A positive dipstick for hemoglobin without any RBCs noted in the urine sediment indicates either free hemoglobin or myoglobin in the urine. * Since the specimen in this case was a fresh sample, significant RBC hemolysis within the urine would not be expected. If a transfusion reaction occurs, haptoglobin binds enough free hemoglobin in the serum to give it a pink coloration. Only when haptoglobin is saturated will the free hemoglobin be excreted in the urine. * Myoglobin is released when skeletal muscle is destroyed by trauma, infarction, or intrinsic muscle disease. If the hematuria were due to trauma there would be many RBCs visible on microscopic examination of the urine. Free hemoglobin resorption from hematomas does not occur. Porphyria may cause urine to be burgundy colored, but it is not associated with a positive urine test for hemoglobin.

Answer 1393

B In terminally ill patients, the most common physical symptoms are pain, fatigue, and dyspnea. Opiates are useful for controlling pain and relieving dyspnea as well. Even small doses of a weaker opiate can reduce the sensation of shortness of breath in cancer patients and in those with heart failure or chronic obstructive lung disease. Addiction is rare in terminally ill patients who are being treated with opiates for pain and/or dyspnea. A medication contract between physician and patient is not required by law and generally is not necessary in this situation, unless diversion of the medication from the patient by the caregivers is suspected. Constipation due to decreased gastrointestinal motility is a very common, if not universal, side effect. Respiratory depression is a late, not early, sign of excessive opiate dosage. Another sign of opiate excess, pinpoint pupils, occurs before respiratory depression and is therefore a useful parameter for monitoring these patients.

Answer 1394

B The ACCP recommends a starting warfarin dosage of ≤5 mg/day in elderly patients, or in patients who have conditions such as heart failure, liver disease, or a history of recent surgery. The INR should be used to guide adjustments in the dosage.

Answer 1395

D ## Footnote Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with **femoroacetabular impingement**. Reproduction of the pain on ROM exam by manipulating the hip into a position of flexion, adduction, and internal rotation (**FADIR test) is the most sensitive physical finding**. Pain associated with avascular necrosis is similarly insidious and heightened when bearing weight, tenderness is usually evident with hip motion in _any_ direction. Osteoarthritis of the hip generally occurs in individuals of more advanced age, and the _pain is typically localized to the groin area_ and can be elicited by **flexion, abduction, and external rotation (FABER test)** of the affected hip. Bursitis manifests as soreness after exercise and tenderness over the affected bursa.

Answer 1396

A ADA recommends screening for all asymptomatic adults with a BMI \>25.0 kg/m whohave one or more additional risk factors for diabetes mellitus, and screening for all adults with no risk factors every 3 years beginning at age 45. Current criteria for the diagnosis of diabetes mellitus include a * hemoglobin A1c≥6.5% * a fasting plasma glucose level ≥126 mg/dL * a 2-hour plasma glucose level ≥200 mg/dL * in a symptomatic patient, a random blood glucose level ³200 mg/dL In the absence of unequivocal hyperglycemia, results require confirmation by repeat testing.

Answer 1397

A ## Footnote **Intrahepatic cholestasis of pregnancy** classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and **elevation of serum bile acids**. Jaundice and elevated bilirubin levels may or may not be present. The GGT usually is normal or modestly elevated, which can help differentiate this condition from other cholestatic liver diseases. The prothrombin time usually is normal, but if elevated it may reflect a vitamin K deficiency from malabsorption.

Answer 1398

B Glucosamine sulfate may be used to reduce symptoms and possibly slow disease progression in patients with osteoarthritis of the knee

Answer 1399

C Sarcoidosis presents with fever, malaise, weight loss, cough, and dyspnea. The pulmonary system is the main organ system affected, and findings may include bilateral hilar lymphadenopathy and discrete, noncaseating epithelial granulomas. Before Lyme disease was recognized, **bilateral facial nerve palsy** was almost always due to sarcoidosis. Hemoptysis does not generally occur until late in the course of sarcoidosis, and is usually related to Aspergillus infection or cavitation. Renal involvement rarely results in significant proteinuria or hematuria.

Answer 1400

E ## Footnote Women who use low-dose estrogen oral contraceptives have at least a 50% lower risk of subsequent epithelial ovarian cancer than women who have never used them. Epidemiologic data also suggests other potential long-term benefits of oral contraceptives, including a reduced risk of postmenopausal fractures, as well as reductions in the risk of endometrial and colorectal cancers

Answer 1401

D ## Footnote Home cardiorespiratory monitoring has not been shown to be effective for preventing SIDs The risk of SIDS increases with higher room temperatures and soft bedding. Placing the infant in a **supine** position will significantly decrease the risk of SIDS, and is probably the most important preventive measure that can be taken. Bed sharing has been shown to increase the risk of SIDS

Answer 1402

A ## Footnote When Crohn’s disease affects primarily the distal small intestine, a most characteristic clinical pattern emerges. A young person, usually in the second or third decade, will present with a period of **episodic abdominal pain**, **largely postprandial and often periumbilical**, occasionally with **low-grade fever** and **mild diarrhea**. Anorexia, nausea, and vomiting may also be present. Weight loss is frequent. Some patients may be aware of tenderness in the right lower quadrant and even of a palpable mass in that region.

Answer 1403

D ## Footnote While it would increase the risk of urinary infection, indwelling catheter placement is most likely to provide immediate relief of this patient’s urinary retention. It will minimize or prevent further contamination of his decubitus ulcer with urine. Prostatectomy may relieve the urethral obstruction, but this patient is likely to remain incontinent due to his vascular dementia. Doxazosin or finasteride would likely be inadequate in this situation. Tolterodine is not indicated for overflow incontinence.

Answer 1404

C **_Kawasaki disease_**, or mucocutaneous lymph node syndrome, is a common form of **vasculitis** in childhood. It is typically **self-limited,** with **fever and acute inflammation lasting 12 days on average without therapy**. However, if untreated, this illness can result in **heart failure, coronary artery aneurysm, myocardial infarction, arrhythmias,** or **occlusion of peripheral arteries.** It is most common in those under the age of 5 years. To diagnose this disease, fever must be present for 5 days or more with no other explanation. In addition, at least four of the following symptoms must be present: * 1) nonexudative conjunctivitis that spares the limbus * 2) changes in the oral membranes such as diffuse erythema, injected or fissured lips, or “strawberry tongue” * 3) erythema of palms and soles, and/or edema of the hands or feet followed by periungual desquamation * 4) cervical adenopathy in the anterior cervical triangle with at least one node larger than 1.5 cm in diameter * 5) an erythematous polymorphous rash, which may be targetoid or purpuric in 20% of cases. Treatment significantly diminishes the risk of complications. Current recommendations are to hospitalize the patient for treatment with **IVIg + aspirin**. While prednisone is used to treat other forms of vasculitis, it is considered unsafe in Kawasaki disease, as a previous study showed an extraordinarily high rate of coronary artery aneurysm with its use The disease must be distinguished from **toxic shock syndrome, streptococcal scarlet fever, Stevens-Johnson syndrome, juvenile rheumatoid arthritis, measles, adenovirus infection, echovirus infection, and drug reactions**.

Answer 1405

D Pain with eye movement suggests an orbital condition. Orbital inflammation, infection, or tumor invasion can lead to such eye pain. Other findings suggestive of an orbital cause of eye pain include diplopia or proptosis. If an orbital lesion is suspected, imaging studies should be performed.

Answer 1406

B ## Footnote Women who present with symptoms of **acute dysuria + frequency + pyuria** do not always have bacterial cystitis. In cases where there is **no growth or insignificant bacterial growth** on a midstream urine culture, these are commonly **sexually transmitted urethritis** caused by **Chlamydia trachomatis, Neisseria gonorrhoeae, or HSV.** In this case, the **gradual onset**, **ø hematuria**, and **week-long duration of symptoms** suggest a STD. Empiric treatment with a tetracycline and a search for other sexually transmitted diseases would then be indicated. Another possible diagnosis is UTI with E coli or Staph species; however, the onset of these infections is usually **abrupt** and accompanied by other signs, such as **suprapubic pain** or **hematuria**. Candida is unlikely because there is no accompanying discharge or itching, and the patient’s symptoms predate the use of antibiotics.

Answer 1407

C ## Footnote Lace-up ankle support reduces pain and recovery time after an ankle sprain. Ottawa Rules state that radiography is required only if there is **pain in the malleolar or midfoot zone** and either **bony tenderness over an area of potential fracture** or an **inability to bear weight immediately after the injury and when evaluated by a physician**. This patient did not have those findings, and therefore would not need a radiograph. A cast is not necessary for an ankle sprain. An elastic compression wrap alone is not as effective as a lace-up support. Taping of the ankle for future sports participation can reduce the risk of ankle sprains during sports, but would not be appropriate for an acute injury.

Answer 1408

D ## Footnote Once considered generally beneficial to the running athlete, there is now **strong evidence that static stretching significantly slows performance in sprints up to 100 meters**, and may **adversely affects both strength and endurance in elite athletes** with little effect on amateur and casual athletes. Studies have failed to demonstrate that static stretching before running significantly decreases the likelihood of muscular injury of the lower limbs or results in a measurable reduction of delayed-onset muscle soreness. Based on current understanding of sports performance, **static stretching is of most benefit when performed during the cool-down period following exercise**, which has been found to increase flexibility, and is best avoided immediately before athletic endeavors. A preparatory aerobic warm-up combined with dynamic range-of-motion exercises may be of some benefit for runners.

Answer 1409

B Erythema multiforme usually occurs in adults 20–40 years of age, although it can occur in patients of all ages. Herpes simplex virus (HSV) is the most commonly identified cause of this hypersensitivity reaction, accounting for more than 50% of cases.

Answer 1410

D ## Footnote The diagnosis of acute rheumatic fever is based on the Jones criteria. 2 major OR 1 major + 2 minor _PLUS_ evidence of a preceding streptococcal infection, indicate a high probability of the disease. Major criteria include carditis, migratory polyarthritis, erythema marginatum, chorea, and subcutaneous nodules. Minor criteria include fever, arthralgia, an elevated ESR or CRP, and a prolonged pulse rate interval on EKG. The differential diagnosis is extensive and there is no single laboratory test to confirm the diagnosis. This patient meets one major criterion (erythema marginatum rash) and three minor criteria (fever, elevated CRP levels, and arthralgia). Echocardiography should be performed if the patient has cardiac symptoms or an abnormal cardiac examination, to rule out rheumatic carditis.

Answer 1411

B ## Footnote **Primary** - targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex). **Secondary** - targets individuals who have developed an _asymptomatic_ disease and institutes treatment to _prevent complications_ (e.g., routine Papanicolaou smears, and screening for hypertension, diabetes, or hyperlipidemia). **Tertiary** - targets individuals with a *_known_* disease, with the goal of _limiting or preventing future complications_ (e.g., screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with β-blockers and aspirin).

Answer 1412

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 been found to be one of the most common hereditary causes of thrombophilia.

Answer 1413

C ## Footnote The classic clinical presentation of **placenta previa** is **painless, bright red vaginal bleeding**. This diagnosis must be considered in all patients **\> 24 weeks GA** who present with bleeding. Threatened abortion is unlikely at this stage of pregnancy and hemorrhagic cystitis is not accompanied by brisk bleeding. Abruption of the placenta is the most common cause of intrapartum fetal death but is associated not only with brisk vaginal bleeding, but also with **marked uterine tenderness.** Clinical signs of chorioamnionitis include purulent vaginal discharge, fever, tachycardia, and uterine tenderness.

Answer 1414

A ## Footnote Allopurinol decreases the production of uric acid and is effective in reducing the frequency of acute gouty flare-ups. However, it should not be started during an acute attack since fluctuating levels of uric acid can actually worsen inflammation and intensify the patient’s pain and swelling. Colchicine inhibits white blood cells from enveloping urate crystals and is effective during acute attacks, as are NSAIDs such as indomethacin. Corticosteroids such as prednisone are also considered a first-line treatment for acute attacks. Compression as an adjunctive therapy may help control pain and swelling.

Answer 1415

A ## Footnote This patient’s symptoms and ECHO findings indicate a dilated cardiomyopathy. In patients with hypertrophic cardiomyopathy the ECHO shows left ventricular hypertrophy and a reduction in chamber size. In restrictive cardiomyopathy, findings include reduced ventricular volume, normal left ventricular wall thickness, and normal systolic function with impaired ventricular filling. Arrhythmogenic right ventricular cardiomyopathy usually presents with syncope and without symptoms of heart failure, and segmental wall abnormalities would be seen on the echocardiogram. Highly trained athletes may develop echocardiographic evidence of eccentric cardiac hypertrophy, but no symptoms of heart failure would be present.

Answer 1416

B ## Footnote Amiodarone is 37% iodine and and the iodine excess can **increase the production/release of thyroid hormone** in iodine-deficient individuals and in older persons with multinodular goiter. Additionally, like other medications such as interferon and interleukin-2, **amiodarone can trigger thyroiditis** in patients with normal thyroid glands. These characteristics combine to induce hyperthyroidism in slightly over 10% of patients treated with amiodarone. ß-Blockers such as propranolol may be useful in controlling the symptoms of hyperthyroidism. Methimazole and PTU interfere with organification of iodine, thereby suppressing thyroid hormone production; they are commonly used as antithyroid agents when treating hyperthyroidism. R esearch is ongoing to determine if methotrexate plus prednisone is an effective treatment for the ophthalmopathy associated with Graves’ hyperthyroidism.

Answer 1417

A Topical lidocaine produces very low serum levels of active drug, resulting in very few adverse effects. Hydrocodone could produce any opiate-type effect. Nortriptyline and duloxetine could aggravate this patient’s atrial arrhythmia and cause urinary retention. Celecoxib could aggravate his reflux problem.

Answer 1418

E ## Footnote A meta-analysis of antidepressant medications for the treatment of fibromyalgia syndrome concluded that short-term use of **amitriptyline and duloxetine** can be considered for the treatment of pain and sleep disturbance in patients with fibromyalgia.

Answer 1419

A ## Footnote **Loss of vision** is a neurologic sequelae that occurs with idiopathic intracranial HTN (pseudotumor cerebri, benign intracranial HTN), although it is uncommon. Sixth cranial nerve palsies may also occur as a false localizing sign. The **typical presentation of intracranial HTN is a young, obese woman with a HA, palpable tinnitus, and N/V. CT is usually normal or shows small ventricles. LP shows elevated pressure with normal fluid examination. CSF protein levels may be low.** Hearing loss and vertigo are not characteristic of this disorder. Long tract signs and facial nerve palsies have been attributed to idiopathic intracranial hypertension; they are atypical and should lead to consideration of other diagnoses.

Answer 1420

D ## Footnote for genital herpes testing, PCR testing is 95% sensitive as long as an ulcer is present, and has a specificity of 90%. The diagnosis is established by culturing the virus from an infected lesion. A Tzanck prep and Pap smear can detect cellular changes, but both have _low_ sensitivity. Serologic diagnosis is mainly an epidemiologic tool and has limited clinical usefulness. Cultures of the virus by amniocentesis have shown both false-positive and false-negative results.

Answer 1421

A Presbycusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and sensorineural.

Answer 1422

D ## Footnote Microscopic examination of synovial fluid in a patient suffering an acute attack of pseudogout shows large numbers of PMNs. Calcium pyrophosphate dihydrate crystals are frequently found extracellularly and in PMNs. When viewed with polarized light, the crystals appear as short, blunt rods, rhomboids, and cuboids. The diagnosis is made by finding typical crystals under compensated polarized light and is supported by radiographic evidence of chondrocalcinosis.

Answer 1423

A Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. Elevated creatinine levels are not an absolute contraindication to ACE inhibitor therapy. Myocardial infarction and a reduced cardiac ejection fraction are indications for ACE inhibitor therapy. ACE inhibitors do not affect asthma.

Answer 1424

B ## Footnote The three most common knee conditions in children and adolescents are patellar **subluxation, tibial apophysitis,** and **patellar tendinitis**. Gout, osteoarthritis, and popliteal cysts present in older adults. Inflammatory arthritis is more common in adults than in children.

Answer 1425

D ## Footnote All **oral hypoglycemic agents cross the placenta (_in contrast to insulin_)**, leading to the potential for severe neonatal hypoglycemia. For these reasons, plus the requirement for exquisitely tight glucose control to reduce fetal macrosomia and organ dysgenesis, the American Diabetes Association advocates the use of **human insulin for pregnant women.** Insulin requirements generally increase throughout gestation, but the precise dosage is unimportant as long as it is sufficient to maintain glucose control.

Answer 1426

D Slipped capital femoral epiphysis is the most common hip disorder between the ages of 8 and 15; more common in boys and overweight or obese children. It presents with limping and pain, and limited internal rotation of the hip is noted on physical examination. Septic arthritis would typically present with a fever. Juvenile rheumatoid arthritis, transient synovitis, and Legg-Calvé-Perthes disease are more common in younger children.

Mixed Categorical Flashcards

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