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Flashcards in Questions 1-50 Deck (50)
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1.  Which one of the following classes of medications for the treatment of diabetes mellitus is most likely to lead to weight loss?

A)  GLP-1 receptor agonists such as exenatide (Byetta)

B)  Meglitinides such as repaglinide (Prandin)

C)  Sulfonylureas such as glipizide (Glucotrol)

D)  Thiazolidinediones such as pioglitazone (Actos)

E)  Insulin 

ANSWER: A

GLP-1 receptor agonists are the most likely of these medications to lead to weight loss. They work by activating the GLP-1 receptors, which increases insulin secretion, decreases glucagon secretion, slows gastric emptying, and increases satiety. Other diabetes medications that may promote weight loss include metformin, amylin mimetics, and SGLT-2 inhibitors. The other medications listed have all been shown to cause weight gain. DPP-4 inhibitors are felt to be weight neutral. 

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2.  The strategy that will identify the highest percentage of previously unrecognized cases of chronic hepatitis C is to screen which one of the following?

A)  All sexually active men and women between the ages of 18 and 29

B)  Everyone born between 1945 and 1965

C)  Everyone who had a blood transfusion or organ transplant before 1992

D)  Everyone who has ever used intravenous drugs

E)  All men who have sex with men 

ANSWER: B

The hepatitis C virus is spread through contact with infected blood (usually unscreened blood transfusions, which were the norm before 1992), intravenous drug use, or high-risk sexual activity. However, studies have shown that screening only patients with high-risk medical or clinical histories will identify just 20%–33% of infected patients. As a different strategy, both the CDC and the U.S. Preventive Services Task Force have recommended one-time screening of patients born between 1945 and 1965. It is estimated that this cohort includes 75% of all patients who have chronic hepatitis C. 

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3.  A school nurse calls you for recommendations about a healthy 6-year-old female who was found to have head lice yesterday and was treated with permethrin 1% shampoo last night. The nurse reports that on examination today the child appeared well, weighed 30 kg (66 lb), and had 6 nits on her scalp.

In addition to home eradication measures and regular nit combing, you recommend which one of the following for this child?

A)  Oral ivermectin (Stromectol) and return to class today

B)  Topical lindane and return to class today

C)  Topical benzyl alcohol (Ulesfia) and return to class as soon as she is nit free

D)  Return to class today and retreatment with permethrin 1% shampoo in 6 days

E)  Retreatment with permethrin 1% shampoo in 6 days and return to class as soon as she is nit free 

ANSWER: D

Family physicians are frequently consulted by patients and institutions regarding outbreaks of head lice. Optimal treatment involves home eradication measures and medication. Permethrin 1% shampoo remains the first-line treatment. Ivermectin appears effective for treatment but is not FDA approved and is not considered first-line treatment. Lindane carries an increased risk of toxicity and should not be used in children weighing <50 kg. Topical benzyl alcohol is FDA-approved for treatment but is expensive. The current recommendation from the American Academy of Pediatrics Council on School Health and Committee on Infectious Diseases is to return children to class despite the presence of nits. 

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4.  An 82-year-old male nursing home resident is sent to the emergency department with crampy lower abdominal pain and bloody diarrhea. On examination he has mild abdominal tenderness and slightly decreased bowel sounds. He has a previous history of vascular dementia, peripheral artery disease, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding.

Which one of the following is the most likely cause of this patient’s bleeding?

A)  Peptic ulcer disease

B)  Ischemic colitis

C)  Diverticular bleeding

D)  Angiodysplasia

E)  Infectious colitis 

ANSWER: B

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

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5.  Which one of the following screening tests has the greatest potential for overdiagnosis?

A)  Fecal occult blood testing

B)  Papanicolaou testing

C)  Prostate-specific antigen

D)  Mammography

E)  Low-dose CT to detect lung cancer 

ANSWER: C

Overdiagnosis is the diagnosis of a disease that will not produce symptoms during a patient’s lifetime. It tends to occur with cancers that have very slow rates of growth. Prostate cancer is most often a slow-growing cancer and is often present without symptoms in older men. The introduction of prostate-specific antigen (PSA) screening was accompanied by a marked rise in the rate of diagnosis of prostate cancer while mortality decreased much less significantly, and this decrease was probably largely attributable to improved treatment. The problem of overdiagnosis remains a significant problem with PSA screening and was a factor in the U.S. Preventive Services Task Force’s recommendation against routine PSA-based screening for prostate cancer (D recommendation). 

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6.  A 32-year-old female has recently started a regular running program to try to lose weight. Her BMI is 29.3 kg/m2. She presents to your office with a complaint of anterior knee pain that is worse on the right, with no history of an acute injury to her knee. She is not sure exactly when the pain began. On examination the patient has normal range of motion, no pain with palpation, and no effusion. Crepitus and lateral patellar tracking are noted in both knees, somewhat greater on the right.

Which one of the following is the most appropriate treatment for her condition?

A)  Patellar taping

B)  Reducing her running distance, and physical therapy

C)  Glucosamine and chondroitin

D)  Intra-articular corticosteroid injection

E)  Knee arthroscopy 

ANSWER: B

This patient most likely has patellofemoral pain syndrome, as evidenced by her recent increased activity and anterior knee pain with increased lateral patellar tracking. The most effective treatment for patellofemoral pain syndrome is physical therapy and activity modification. Glucosamine and chondroitin have been used to treat osteoarthritis in the past but should not be used to treat symptomatic osteoarthritis of the knee, according to the American Academy of Orthopedic Surgeons. Intra-articular joint injections can be used for knee arthritis but are not indicated for patellofemoral pain syndrome. Knee arthroscopy would not be indicated for patellofemoral syndrome without evidence of internal knee derangement. The evidence for patellar taping is inconsistent, but it may be helpful as an adjunct treatment. 

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7.  A healthy 83-year-old female presents for an annual Medicare visit. Her blood pressure is 165/95 mm Hg on initial evaluation today and 160/92 mm Hg on repeat measurement. She has no health complaints.

The JNC 8 panel recommends which one of the following as the goal blood pressure for this patient?

A)  <135/85 mm Hg

B)  <140/90 mm Hg

C)  <150/90 mm Hg

D)  <160/90 mm Hg

E)  <160/100 mm Hg 

ANSWER: C

In general, all patients with hypertension, regardless of age, benefit from treatment. Patients 80 years of age who are healthy and functionally independent should be treated according to current recommendations for patients >65 years old. Available guidelines recommend a target blood pressure of <150/90 mm Hg unless the patient is frail or has numerous comorbidities. In these cases, the target blood pressure should be determined on a case-by-case basis (SOR B). 

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8.  A 55-year-old male is found to be in cardiac arrest. When the EMTs arrive they note ventricular fibrillation on the monitor. The patient began an antibiotic 3 days ago for a mild case of community-acquired pneumonia.

Which one of the following antibiotics is most commonly associated with this scenario?

A)  Doxycycline

B)  Amoxicillin

C)  Cefuroxime (Ceftin)

D)  Azithromycin (Zithromax)

ANSWER: D

The likelihood of azithromycin inducing an arrhythmia is small, but given its widespread use this possibility must be kept in mind. The arrhythmia results from prolongation of the QT interval and is also more common in patients with a prior cardiac history. The other three antibiotics have not been implicated in an increase in cardiac deaths. 

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9.  A 6-year-old male is brought to an urgent care center with a 48-hour history of left hip pain. He is noted to have a significant limp, but will walk. His father reports that the child prefers to lie on his back with his bent left knee out to the side. He is afebrile and well appearing, with an erythrocyte sedimentation rate of 10 mm/hr (N 3–13), a peripheral WBC count of 7000/mm3 (N 5000–10,000), and a C-reactive protein level of 6 mg/L (N <10). Radiographs of the left hip and knee are unremarkable.

Which one of the following would be most appropriate at this time?

A)  Ibuprofen

B)  Acetaminophen/codeine

C)  Vancomycin

D)  Physical therapy referral

E)  Urgent orthopedic consultation 

ANSWER: A

This child most likely has transient synovitis, based on the fact that he is well appearing and afebrile, and his WBC count, erythrocyte sedimentation rate, C-reactive protein level, and radiographs are all normal. This is a self-limited inflammatory condition, and he will likely respond to NSAIDs such as ibuprofen and relative rest. Physical therapy and orthopedic consultation are not required, as this condition lasts less than a week. Septic arthritis would require treatment with intravenous antibiotics, but there is no evidence that he has this condition. 

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10.  Supraventricular tachycardia may require treatment both acutely and over the long term. Which one of the following medications is useful for both of these purposes?

A)  Adenosine (Adenocard)

B)  Amiodarone (Cordarone)

C)  Esmolol (Brevibloc)

D)  Procainamide

E)  Verapamil (Calan, Verelan) 

ANSWER: E

Calcium channel blockers such as verapamil or diltiazem can be used acutely to decrease heart rate and terminate supraventricular tachycardia (SVT) and chronically to prevent SVT recurrence. Adenosine, amiodarone, esmolol, and procainamide all can be used to treat SVT acutely, but they are not suitable for long-term therapy. 

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11.  A 16-year-old female is brought to your office by her mother, who is concerned that her daughter has seemed tired lately. The patient denies any specific health concerns or recent illnesses. She is taking an oral contraceptive and reports that her menstrual bleeding is light in flow. Recent laboratory findings include a TSH level of 1.44 MuU/mL (N 0.5–5.0), a hematocrit level of 38% (N 36–46), a mean corpuscular volume of 71 Mum3 (N 78–102), an RBC count of 5.7 million/mm3 (N 4.10–5.10), and ovalocytes on a peripheral smear.

Which one of the following is most likely to explain this patient’s initial laboratory abnormalities and lead to a diagnosis?

A)  A vitamin B12 level

B)  A ferritin level

C)  A free T4 level

D)  Hemoglobin electrophoresis

E)  A fluorescent spot test 

ANSWER: D

This presentation is consistent with B-thalassemia minor trait in a generally asymptomatic patient. Hemoglobin electrophoresis will be abnormal, with HbA2 increased and HbA decreased. The free T4 level is likely to be normal in a patient with a normal TSH level. A ferritin level is also likely to be normal given the normal levels of hemoglobin and hematocrit. A fluorescent spot test is used to screen for G-6-PD deficiency, which would be associated with bite cells and Heinz bodies. A vitamin B12 level would be useful for evaluating macrocytosis, which is not present in this patient. 

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12.  An 80-year-old male is admitted to the hospital for pneumonia. He develops what the nurses describe to you as “sundowning” behavior that includes nighttime disorientation and some mild agitation. His wife says he is not like this at home. During morning rounds he is pleasant and answers questions appropriately except he forgets why he is in the hospital. His examination, including a neurologic examination, is normal except for crackles on chest auscultation consistent with the pneumonia. He is not able to say the days of the week backwards.

Which one of the following is most likely in this patient?

A)  Alzheimer’s disease

B)  Delirium

C)  Vascular dementia

D)  Encephalitis

E)  Stroke 

ANSWER: B

A diagnosis of delirium based on the Confusion Assessment Method (CAM) algorithm requires the presence of an acute onset and a fluctuating course, inattention, and either an altered level of consciousness or disorganized thinking. The patient described in this question exhibits an acute onset, fluctuation, inattention, and an altered level of consciousness.

This patient’s presentation is more consistent with delirium than encephalitis, as patients with encephalitis frequently have signs of systemic illness such as fever, lethargy, seizures, and neurologic deficits, as well as a nonspecific rash in some cases. Furthermore, the fluctuations in the level of consciousness seen in delirium do not occur with encephalitis. Vascular dementia and Alzheimer’s disease develop over years, not acutely as in this case. Stroke, while a consideration and a potential cause of delirium, would not be the most likely diagnosis in an older patient hospitalized with pneumonia. 

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13.  A 40-year-old female is concerned that she may have amyotrophic lateral sclerosis (ALS). Her paternal uncle died in his forties of this disease and she has visited multiple Internet sites that have exacerbated her fears.

Which one of the following findings on examination would be considered a clinical manifestation of ALS?

A)  A bull’s-eye rash

B)  Paresthesias

C)  Pseudoclaudication

D)  Asymmetric leg weakness

E)  Charcot joint 

ANSWER: D

Amyotrophic lateral sclerosis is a pure motor disorder involving anterior horn cells in the spinal cord and their brainstem homologues. It may begin as lower motor or bulbar palsy, and the median survival is 3–5 years. Pseudoclaudication is associated with spinal stenosis, and paresthesias are caused by sensory problems. A bull’s-eye rash is associated with Lyme disease. Charcot joint is seen with conditions that involve sensory loss, such as diabetes mellitus or syphilis. 

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14.  A 25-year-old male presents with pleuritic chest pain. He has not had a fever or symptoms of a respiratory infection. He has no risk factors for thromboembolism, and no past medical or family history of thromboembolism. His vital signs and examination are normal, including clear lungs on auscultation and no chest wall tenderness. Laboratory findings include a normal CBC and a normal D-dimer level. A chest radiograph is also normal.

Which one of the following is the most appropriate next step in this patient’s management?

A)  An NSAID

B)  An anticoagulant pending further imaging

C)  C-reactive protein and antinuclear antibody levels, and corticosteroids

D) A rib belt 

ANSWER: A

Causes of pleuritic chest pain include pneumonia, chest wall trauma, pulmonary embolus, and vasculitis. If these conditions are deemed unlikely based on the history, physical examination, and limited laboratory studies, a chest radiograph is obtained. If this is within normal limits then viral pleuritic pain is most likely, and can be treated with an NSAID. Given that the history and physical findings are not suspicious for thromboembolism and a D-dimer is negative, anticoagulation is inappropriate. With no other systemic symptoms or findings of collagen-vascular disease, corticosteroids are not indicated. Since there is no rib tenderness and no radiographic findings of an acute rib fracture, a rib belt is not indicated. 

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15.  A 65-year-old white female with terminal cancer and severe hepatic dysfunction has musculoskeletal and neuropathic pain at the end of life. Which one of the following medications should not be used in this patient because of her hepatic dysfunction?

A)  Fentanyl

B)  Hydromorphone (Dilaudid)

C)  Methadone

D)  Morphine

E)  Oxycodone (OxyContin) 

ANSWER: C

Methadone has a widely variable half-life (7–72 hours) and bioavailability, as well as an inactive sedating metabolite. It is metabolized and cleared by the liver, and should therefore not be used in patients with severe hepatic impairment. It is, however, a reasonable option for patients with severe renal impairment (SOR C). Morphine, oxycodone, fentanyl, and hydromorphone can be used cautiously in patients with hepatic impairment, with reductions in the initial dosage and close monitoring (SOR C). 

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16.  A 55-year-old female with hypertension sees you for a routine follow-up visit. A physical examination is normal except for a BMI of 34.0 kg/m2. Laboratory findings are notable for an ALT (SGPT) of 53 U/L (N 7–35), and an AST (SGOT) of 28 U/L (N 10–34). She had a similar elevation a month ago when she was seen in the emergency department. Her comprehensive metabolic panel is otherwise normal, and a CBC is also normal. She has had negative hepatitis B surface antigen and hepatitis C antibody testing in the past. She does not drink alcohol or take medications that affect liver function.

Which one of the following is the most appropriate test for evaluating this patient?

A)  Anti–smooth muscle antibody

B)  Ceruloplasmin

C)  Hepatitis D antibody

D)  Iron studies

E)  A liver biopsy 

ANSWER: D

This patient is obese and has an isolated elevation of ALT. The initial history and workup, including testing for chronic hepatitis, a medication review, and alcohol screening, have all been conducted. Current guidelines suggest iron studies to screen for hemochromatosis as part of the initial evaluation (SOR C). Anti–smooth-muscle antibody and ceruloplasmin levels can detect more rare causes of hepatocyte inflammation (autoimmune hepatitis and copper deposition from Wilson’s disease). These tests can be considered in persistent transaminitis based on clinical judgment (SOR C). Hepatitis D is a superinfection seen in patients with hepatitis B, and is not a consideration in this patient. A liver biopsy may also be considered in persistent transaminitis, especially in the setting of clinical or serologic evidence of advanced liver fibrosis, but is not recommended at this stage (SOR C). Patients with fatty liver disease are at increased risk for developing liver cirrhosis. 

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17.  Pregnant women who empty cat litter boxes are at increased risk for which one of the following?

A)  Toxoplasmosis

B)  Toxocara mystax (Toxocara cati) infection

C)  Chagas disease

D)  Cysticercosis

E)  Aspergillosis 

ANSWER: A

Cats that are infected with Toxoplasma gondii can shed the virus for weeks when newly infected. Cleaning the cat’s litter box is a high-risk activity, and transmission to the fetus can occur. Toxocara cati infection is less common and usually results from ingesting contaminated cat meat or soil containing cat feces. Chagas disease is spread by insect bites. Cysticercosis is generally acquired by eating contaminated pork. Aspergillosis usually occurs in immunocompromised people who inhale the spores found in soil (SOR A). 

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18.  Which one of the following has been shown to result from the use of continuous prophylactic antibiotics in patients with moderate COPD?

A)  A clinically significant reduction in COPD exacerbations

B)  A clinically significant improvement in quality-of-life scores

C)  A demonstrable decrease in the number of resistant organisms in the sputum

D)  The development of conduction defects, including prolonged QT intervals

E)  An increased incidence of tinnitus 

ANSWER: A

A review of multiple studies has revealed that continuous daily macrolide antibiotic use for 1 year decreased the number of exacerbations in older patients with COPD (SOR A). Quality of life did not show improvement, however, and resistance to macrolide and quinolone antibiotics rose. There was no increase in conduction abnormalities or tinnitus, but the incidence of hearing loss increased with the use of azithromycin. 

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19.  Which one of the following services must be covered by any insurance purchased through the insurance marketplace, as long as the patient sees an in-network provider?

A)  Preventive dental care

B)  Annual eye examinations by an optometrist or ophthalmologist

C)  Colorectal cancer screening

D)  Travel immunizations for work-related travel

E)  Bariatric surgery for morbidly obese patients 

ANSWER: C

Patients with new health insurance plans or policies purchased under the Patient Protection and Affordable Care Act are expected to be covered for certain services. Preventive services with a U.S. Preventive Services Task Force grade of A or B, such as colorectal cancer screening, are covered without cost-sharing when performed by an in-network provider. Although coverage for vaccines such as diphtheria, tetanus, and influenza is required with these plans, those that are needed only for travel are not covered. In addition, although consumers can purchase vision and dental coverage in addition to health coverage through the marketplace, they are not a required part of coverage. While coverage for obesity counseling is required, coverage for bariatric surgery still varies by state. 

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20.  A 65-year-old male has severe liver cirrhosis from a combination of hepatitis C infection and alcohol abuse. He previously underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure.

While the TIPS procedure reduces the likelihood of most complications of cirrhosis, it may increase the risk for which one of the following?

A)  Anasarca

B)  Ascites

C)  Hepatic encephalopathy

D)  Upper gastrointestinal bleeding from esophageal varices

E)  Upper gastrointestinal bleeding from portal hypertensive gastropathy 

ANSWER: C

The transjugular intrahepatic portosystemic shunt (TIPS) procedure, by shunting blood destined for the liver into the systemic circulation, lowers pressure in the portal veins, thereby decreasing portal system hypertension and making variceal bleeding and portal hypertensive gastropathy less likely. TIPS may decrease the likelihood of variceal bleeding by as much as 90%. TIPS also reduces the pressure that leads to ascites and lower extremity edema, or the massive edema of anasarca. The diversion of blood from the liver circulation compromises the liver’s role in removing toxins, including the serum marker ammonia. This may make patients more vulnerable to episodes of hepatic encephalopathy. 

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21.  A 77-year-old white male tells you he has had urinary incontinence for more than a year. The incontinence occurs with sudden urgency. No association with coughing or positional change has been noted, and there is no history of fever or dysuria. He underwent transurethral resection of the prostate (TURP) for benign prostatic hyperplasia a year ago, and he says his urinary stream has improved. A rectal examination reveals a smoothly enlarged prostate without nodularity, and normal sphincter tone. No residual urine is found with post-void catheterization.

Which one of the following is the most likely cause of this patient’s incontinence?

A)  Detrusor instability

B)  Urinary tract infection

C)  Overflow

D)  Fecal impaction

E)  Recurrent bladder outlet obstruction 

ANSWER: 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.

Infection is unlikely to be the cause of persistent incontinence in this patient in the absence of fever or symptoms of urinary tract infection. Overflow is unlikely in the absence of residual urine. Impaction is a relatively rare cause of urinary incontinence, and associated findings would be present on the rectal examination. Normalization of the urinary stream and the absence of residual urine reduce the likelihood of recurrent obstruction. The prostate would be expected to remain enlarged on rectal examination after transurethral resection of the prostate (TURP). 

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22.  A 45-year-old female with a BMI of 50.0 kg/m2 comes to your office to discuss treatment of her chronically elevated fasting glucose levels. Recent test results include a hemoglobin A1c of 6.0%. In the past she was not able to tolerate metformin (Glucophage) and would like to try another medication to reduce her risk of developing diabetes mellitus.

Which one of the following medications would be most appropriate for this patient?

A)  Acarbose (Precose)

B)  Bromocriptine (Parlodel)

C)  Canagliflozin (Invokana)

D)  Glipizide (Glucotrol)

E)  Sitagliptin (Januvia) 

ANSWER: A

Individuals with impaired fasting glucose or impaired glucose tolerance have a higher risk of developing diabetes mellitus in the future. Randomized, controlled trials have shown that taking metformin, "-glucosidase inhibitors (acarbose), orlistat, or thiazolidinediones significantly reduces the risk of developing diabetes mellitus. The U.S. Diabetes Prevention Program Outcomes Study demonstrated a 34% reduction in the development of diabetes mellitus at 10 years. In addition to medications, it is also recommended that patients be counseled about weight loss and engaging in moderate physical activity for at least 150 minutes per week. The other medications listed are indicated for the treatment of diabetes but have not been shown to be effective for prevention. 

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23.  A 33-year-old patient with allergic rhinitis tells you he feels drowsy when taking diphenhydramine (Benadryl) and asks if there is an alternative that will cause less sedation. You tell him that most second-generation antihistamines have a better adverse effect profile and cause less sedation than first-generation antihistamines.

Which one of the following second-generation antihistamines would you advise the patient to avoid, however, because it is known to cause sedation?

A)  Cetirizine (Zyrtec)

B)  Desloratadine (Clarinex)

C)  Fexofenadine (Allegra)

D)  Levocetirizine (Xyzal)

E)  Loratadine (Claritin) 

ANSWER: A

Desloratadine, fexofenadine, levocetirizine, and loratadine are among the second-generation antihistamines that have a better adverse effect profile and cause less sedation than first-generation antihistamines (SOR A). Second-generation antihistamines have more complex chemical structures that decrease their movement across the blood-brain barrier, reducing central nervous system adverse effects such as sedation. Although cetirizine is generally classified as a second-generation antihistamine and a more potent histamine antagonist, it is known to cause sedation (SOR A). 

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24.  The mother of a 16-year-old male calls to report that her son has a severe sore throat and has been running a fever of 102°F. As you question the mother further, which one of the following would be most specific for peritonsillar abscess?

A)  A 1-day duration of illness

B)  Ear pain

C)  Difficulty opening his mouth

D)  Hoarseness

E)  Pain with swallowing 

ANSWER: C

Trismus 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. 

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25. A 14-year-old goalkeeper dives for a save during a soccer game and strikes her head on the goalpost. She does not lose consciousness but develops a headache and is removed by the coach for the remainder of the game. She becomes nauseated and has balance problems over the next several hours but can clearly recall the event. She comes to your clinic the following day. Her school requires baseline neurocognitive testing prior to all sports participation each year and you have a copy of this year’s results.

Which one of the following would be the most appropriate recommendation at this time?

A)  CT of the head

B)  Return to practice when her symptoms are relieved by medication

C)  Neurocognitive testing at this visit

D)  Physical and cognitive rest

E)  The use of protective headgear for the remainder of the season 

ANSWER: D

There are estimated to be 1.6–3.8 million sports-related concussions each year in the United States, and appropriate management can prevent many of the long-term complications. In this scenario, the patient meets the criteria for a concussion, with headache, nausea, and imbalance following an injury. She was appropriately removed from the game. The next step in management is complete physical and cognitive rest until her symptoms resolve without medication (SOR C). Complete physical rest includes avoidance of any physical activity that exacerbates symptoms. Cognitive rest means avoidance of activities that require concentration or attention, such as schoolwork and electronics use.

Once the patient’s symptoms have resolved without medication, she should be reevaluated and can start a graded return-to-play protocol (SOR C). Reevaluation may include repeat neurocognitive testing and postural stability testing (SOR C). Both types of testing can be important in the evaluation but there is insufficient evidence that either affects outcomes.

In the initial evaluation of concussion, imaging is not indicated in the absence of focal neurologic findings, loss of consciousness for more than 60 seconds, or evidence of skull fracture (SOR C). If imaging criteria are met, CT of the head is indicated. Plain films are not indicated in the evaluation.

There is no evidence that protective gear reduces the incidence of concussion (SOR C). Even though some protective gear can prevent other types of injuries, it is not indicated for concussion prevention. Eliminating dangerous behaviors such as heading the ball in soccer can help, however. 

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26.  A 70-year-old male has a smoking history of >30 pack-years. He quit 10 years ago.

Which one of the following is recommended by the U.S. Preventive Services Task Force with regard to lung cancer screening for this patient?

A)  Low-dose noncontrast chest CT one time only

B)  A standard chest radiograph and sputum cytology one time only

C)  Low-dose noncontrast chest CT annually

D)  Low-dose noncontrast chest CT every 3 years

E)  No screening 

ANSWER: C

The 2013 U.S. Preventive Services Task Force guidelines recommend annual lung cancer screening with low-dose CT for asymptomatic adults 55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit smoking within the past 15 years (grade B recommendation). Screening should be discontinued when the patient has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 

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27.  A 25-year-old primigravida at 33 weeks gestation presents to the labor suite with a complaint of painful uterine contractions every 3 minutes for the last 2 hours. A fetal monitor confirms the contraction pattern, and the fetal heart rate pattern is category 1. A fetal fibronectin test is ordered.

Thirty minutes later the contractions have stopped, but results of the fetal fibronectin test are positive. A speculum examination shows no indication of ruptured membranes. The cervix is closed and thick to palpation.

The positive result on this patient’s fetal fibronectin test

A)  has a low positive predictive value for preterm delivery

B)  indicates a high likelihood of delivery before term

C)  indicates a high likelihood of delivery within the next week

D)  indicates occult rupture of the membranes

E)  is diagnostic for preterm labor 

ANSWER: A

The fetal fibronectin test is used to help determine the risk of early delivery. Unfortunately, the positive predictive value for delivery within the next week is <20% in patients who have clinical indications of preterm labor. In a patient who does not have any features of preterm labor, it does not affect management. A negative result is reassuring, on the other hand, because the negative predictive value is >95%. In studies that tested gravidas every week, positive results had a mild correlation with preterm delivery, but not enough to guide management. False-positive test results can be caused by maternal blood or amniotic fluid, but fetal fibronectin does not indicate rupture of the membranes when other tests are negative. 

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28.  The rash associated with erythema infectiosum (fifth disease) is characterized by which one of the following?

A)  Small red papules with central umbilication

B)  Annular patches with raised borders and central clearing

C)  Pink pustules that form a thick yellow crust

D)  An erythematous “slapped cheek” facial rash

E)  A symmetrical rash in a Christmas tree pattern 

ANSWER: D

Fifth disease, caused by parvovirus B19, is a common childhood infection that typically presents with a prodrome of low-grade fever, malaise, sore throat, nausea, and headache, followed a few days later by an erythematous facial rash on the cheeks. The rash fades in a few days but a lacy, reticular rash develops on the extremities. Once the rash appears, patients are no longer considered contagious. NSAIDs and antihistamines are often used for symptom relief (SOR A). 

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29.  A 64-year-old male with nonvalvular atrial fibrillation has received anticoagulation therapy with warfarin (Coumadin) for the past 3 years but it has been difficult to maintain his INR in the therapeutic range. He has been afraid to transition to one of the newer oral anticoagulants because of the lack of a reversal medication should he develop life-threatening bleeding.

Which one of the following now has a reversal agent?

A)  Apixaban (Eliquis)

B)  Dabigatran (Pradaxa)

C)  Edoxaban (Savaysa)

D)  Rivaroxaban (Xarelto) 

ANSWER: B

Idarucizumab has been approved for the urgent reversal of the anticoagulant effect of dabigatran. The dose is two consecutive 2.5-g infusions and the cost is $3500. Apixaban, edoxaban, and rivaroxaban—all factor Xa inhibitors—are not affected by this medication and they do not currently have a reversal agent. 

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30.  Both the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists recommend that non–medically indicated (elective) inductions of labor or cesarean deliveries should be scheduled after what gestational age?

A)  37 weeks, 0 days

B)  39 weeks, 0 days

C)  40 weeks, 0 days

D)  41 weeks, 0 days

E)  42 weeks, 0 days 

ANSWER: B

The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists collaborated on the Choosing Wisely campaign recommendation regarding scheduled inductions of labor or cesarean deliveries. These organizations noted that delivery prior to 39 weeks, 0 days is associated with an increased risk of learning disabilities and may increase morbidity and mortality. While delivery prior to 39 weeks and 0 days may be indicated in certain situations, a mature fetal lung test by itself is not an indication for delivery (SOR C).