A 46-year-old female presents to your office with a 2-week history of pain in her left shoulder.

She does not

recall any injury, and the pain is present when she is resting and at night. Her only chronic medical problem
is type 2 diabetes mellitus. On examination, she has limited movement of the shoulder and almost complete
loss of external rotation. Radiographs of the shoulder are normal, as is her erythrocyte sedimentation rate.
Which one of the following is the most likely diagnosis?
A. Frozen shoulder
B. Torn rotator cuff
C. Impingement syndrome
D. Chronic posterior shoulder dislocation
E. Osteoarthritis
Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and
60. Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder
stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory
tests and plain films are normal; the diagnosis is clinical (SOR C). Frozen shoulder is differentiated from
chronic posterior shoulder dislocation and osteoarthritis on the basis of radiologic findings. Both shoulder
dislocation and osteoarthritis have characteristic plain film findings. A patient with a rotator cuff tear will
have normal passive range of motion. Impingement syndrome does not affect passive range of motion, but
there will be pain with elevation of the shoulder.
Intravenous magnesium is used to correct which one of the following arrhythmias?
A. Wenckebach second-degree heart block
B. Complete heart block
C. Idioventricular rhythm
D. Reentrant supraventricular tachycardia
E. Ventricular tachycardia of torsades de pointes
A well-known use of intravenous magnesium is for correcting the uncommon ventricular tachycardia of
torsades de pointes. Results of a meta-analysis suggest that 1.210.0 g of intravenous magnesium sulfate
also is a safe and effective strategy for the acute management of rapid atrial fibrillation.
Which one of the following is a physiologic difference between males and females that can affect the
pharmacokinetics of medications with a narrow therapeutic index?
A. A consistently higher glomerular filtration rate in women
B. The typically higher BMI in women
C. Smaller fat stores in women
D. Greater gastric acid secretion in women
E. Slower gastrointestinal transit times in women
There are key physiologic differences between women and men that can have important implications for
drug activity. Gastrointestinal 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 glomerular filtration rates than men, resulting in slower
clearance of medications that are eliminated renally, such as digoxin and methotrexate.

A 52-year-old female with a 60-pack-year history of cigarette smoking and known COPD presents with a
1-week history of increasing purulent sputum production and shortness of breath on exertion. Which one of
the following is true regarding the management of this problem?
A. Antibiotics should be prescribed
B. Intravenous corticosteroids are superior to oral corticosteroids
C. Inhaled corticosteroids should be started or the dosage increased
D. Levalbuterol (Xopenex) is superior to albuterol
E. Acetylcysteine should be given if the patient is hospitalized
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. Studies have not shown a difference
between oral and intravenous corticosteroids. Inhaled corticosteroids are not helpful in the management of
an acute exacerbation. 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.
During rounds, you notice a new rash on a full-term 2-day-old white female. It consists of 1-mm pustules
surrounded by a flat area of erythema, and is located on the face, trunk, and upper arms. An examination is
otherwise normal, and she does not appear ill. Which one of the following is the most likely diagnosis?
A. Erythema toxicum neonatorum
B. Transient neonatal pustular melanosis
C. Acne neonatorum
D. Systemic herpes simplex
E. Staphylococcus aureus sepsis
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.
Which one of the following is true concerning anterior cruciate ligament (ACL) tears?
A. The incidence of ACL tears is higher in males than in females
B. ACL tears are not associated with early-onset osteoarthritis
C. The majority of ACL tears are caused by physical contact
D. Strength training can prevent ACL tears
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
osteoarthritis occurs in the affected knee in an estimated 50% of patients with ACL tears. The ACL
typically pops audibly when it is torn, usually with no physical contact.
Which one of the following is recommended to reduce the risk of sudden infant death syndrome (SIDS)?
A. The use of home cardiorespiratory monitors
B. The use of soft bedding materials
C. Having the infant sleep in a prone position
D. Having the infant sleep in a separate bed
E. Maintaining a room temperature of 78F80F when the infant is sleeping
Home cardiorespiratory monitoring has not been shown to be effective for preventing sudden infant death
syndrome (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.

A critically ill adult male is admitted to the intensive-care unit because of sepsis. He has no history of
diabetes mellitus, but his glucose level on admission is 215 mg/dL and insulin therapy is ordered. Which
one of the following is the most appropriate target glucose range for this patient?
A. 80120 mg/dL
B. 100140 mg/dL
C. 120160 mg/dL
D. 140180 mg/dL
E. 160200 mg/dL
The 2009 consensus guidelines on inpatient glycemic control issued by the American Association of
Clinical Endocrinologists and the American Diabetes Association recommend insulin infusion with a target
glucose level of 140180 mg/dL in critically ill patients. This recommendation is based on clinical trials in
critically ill patients. In the groups studied, there was no reduction in mortality from intensive treatment
targeting near-euglycemic glucose levels compared to conventional management with a target glucose level
of <180 mg/dL. There also were reports of harm resulting from intensive glycemic control, including
higher rates of severe hypoglycemia and even increased mortality.
Which one of the following is the recommended duration of dual antiplatelet therapy after placement of a
drug-eluting coronary artery stent?
A. 1 week
B. 1 month
C. 2 months
D. 3 months
E. 1 year
The recommended duration of dual antiplatelet therapy following placement of a drug-eluting coronary
artery stent is 1 year (SOR C). The recommended dosages of dual antiplatelet therapy are aspirin, 162325
mg, and 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, and 6 months with other drug-eluting stents.
A 21-year-old primigravida at 28 weeks gestation complains of the recent onset of itching. On examination
she has no obvious rash. The pruritus started on her palms and soles and spread to the rest of her body.
Laboratory evaluation reveals elevated serum bile acids and mildly elevated bilirubin and liver enzymes.
The most effective treatment for this condition is:
A. triamcinolone (Kenalog) cream
B. cholestyramine (Questran)
C. diphenhydramine (Benadryl)
D. doxylamine succinate
E. ursodiol (Actigall)
This patients 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 (SOR A) 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.
Which one of the following is an appropriate rationale for antibiotic treatment of Bordetella pertussis
infections?
A. It delays progression from the catarrhal stage to the paroxysmal stage
B. It reduces the severity of symptoms
C. It reduces the duration of illness

D. It reduces the risk of transmission to others

E. It reduces the need for hospitalization
Antibiotic treatment for pertussis is effective for eradicating bacterial infection but not for reducing the
duration or severity of the disease. The eradication of infection is important for disease control because it
reduces infectivity. Antibiotic treatment is thought to be most effective if started early in the course of the
illness, characterized as the catarrhal phase. The paroxysmal stage follows the catarrhal phase. The CDC
recommends macrolides for primary treatment of pertussis. The preferred antimicrobial regimen is
azithromycin for 35 days or clarithromycin for 7 days. These regimens are as effective as longer therapy
with erythromycin and have fewer side effects. Children under 1 month of age should be treated with
azithromycin. There is an association between erythromycin and hypertrophic pyloric stenosis in young
infants. Trimethoprim/sulfamethoxazole 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 under the age of 2 months.
Fluoroquinolones have been shown to reduce pertussis in vitro but have not been shown to be clinically
effective (SOR A).
A 16-year-old female cross-country runner has pain around both ankles. On examination, pain is elicited
on foot inversion and there is decreased motion of the hind foot and peroneal tightness. A rigid flat foot also
is observed. Which one of the following is the most likely diagnosis?
A. Non-ossification of the os trigonum
B. Severs apophysitis
C. Plantar fasciitis
D. Navicular stress fracture
E. Tarsal coalition
Tarsal coalition is the fusion of two or more tarsal bones. It occurs in mid-to late adolescence and is
bilateral in 50% of those affected. Pain occurs around the ankle, and there is decreased range of motion 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. Severs 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.
Which one of the following is true concerning breast cancer screening?
A. It is useful for detecting premalignant conditions
B. It can predict which of the discovered cancers are indolent, with a low potential for harm
C. The decrease in mortality from breast cancer can be attributed almost entirely to early detection
D. It has resulted in an increase in the diagnosis of localized disease
E. It has resulted in a significant decrease in the incidence of regional and metastatic disease
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.
You make a diagnosis of depression in a 26-year-old female. Her BMI is 32 kg/m and she has been trying
to lose weight. Which one of the following antidepressants would be LEAST likely to cause her to gain
weight?
A. Mirtazapine (Remeron)
B. Amitriptyline
C. Bupropion (Wellbutrin)
D. Paroxetine (Paxil)
E. Citalopram (Celexa)

Bupropion is the antidepressant least likely to cause weight gain, and may induce modest weight loss. All
of the other choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the
most weight gain and fluoxetine with the least. Mirtazapine has been associated with more weight gain than
the SSRIs.
Medicare pays for which one of the following?
A. Routine dental care
B. Custodial nursing-home care
C. Hearing aids
D. Screening mammography
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, nursinghome care (except limited skilled nursing care), dentures, routine dental care, eyeglasses, hearing aids,
routine physical checkups and related tests, or prescription drugs.
A 24-year-old female presents to your clinic with a 5-day history of fever to 103F. She has no localizing
symptoms or overt physical findings. Initial testing shows an elevated WBC count with a disproportionate
number of reactive lymphocytes. Which one of the following conditions is the most likely cause of these
findings?
A. Bacterial infection
B. Connective tissue disease
C. Lymphoma
D. Viral infection
The conditions that result in an absolute increase in lymphocytes are divided into primary causes (usually
neoplastic hyperproliferation) and secondary or reactive causes. The presence of reactive lymphocytes will
often be reported on a manual differential, since they have a distinctive appearance. The most common
conditions that produce a reactive lymphocytosis are viral infections. Most notable are Epstein-Barr virus,
infectious mononucleosis, and cytomegalovirus. Other viral infections known to cause this finding include
herpes simplex, herpes zoster, HIV, hepatitis, and adenovirus. Connective tissue disease can infrequently
cause a reactive lymphocytosis, but other signs or symptoms are usually present. Bacterial infections more
commonly result in an increase in neutrophils. One exception to this is Bordetella pertussis, which has been
known to cause absolute lymphocyte counts of up to 70,000/L. This infection is associated with classic
symptoms that this patient does not have.
A 70-year-old male complains of lower-extremity pain. Increased pain with which one of the following
would be most consistent with lumbar spinal stenosis?
A. Lumbar spine extension
B. Lumbar spine flexion
C. Internal hip rotation
D. Pressure against the lateral hip and trochanter
E. Walking uphill
Extension that increases lumbar lordosis decreases the cross-sectional area of the spinal canal, thereby
compressing the spinal cord further. Walking downhill 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.
Which one of the following is true concerning the use of short-acting inhaled -agonists for asthma?

A. They should be given before any inhaled corticosteroid to facilitate lung delivery
B. They are ineffective in patients taking -blockers
C. They are less effective than oral -agonists
D. They are less effective than anticholinergic bronchodilators when given with inhaled corticosteroids
E. Their effects begin within 5 minutes and last 46 hours
The effects of short-acting inhaled -agonists begin within 5 minutes and last 46 hours. In the past, giving
inhaled -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. Blockers do diminish the effectiveness of inhaled -agonists, but this effect is not severe enough to
contraindicate using these drugs together. Oral -agonists are less potent than inhaled forms. Similarly,
anticholinergic drugs cause less bronchodilation than inhaled -agonists and are not recommended as firstline therapy.
Which one of the following is true regarding NSAIDs?
A. They are cardioprotective
B. They should be avoided in persons with cirrhotic liver disease
C. They are not safe in pregnancy
D. They are not safe in lactating women
NSAIDs are prescribed commonly and many are available over the counter. It is important for clinicians to
understand when they are not appropriate for clinical use. They should be avoided, if possible, in persons
with hepatic cirrhosis (SOR C). While hepatotoxicity with NSAIDs is rare, they can increase the risk of
bleeding in cirrhotic patients, as they further impair platelet function. 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 blood pressure, and increase events such as ischemia and acute
myocardial infarction. There are no known teratogenic effects of NSAIDs in humans. This drug class is
considered to be safe in pregnancy in low, intermittent doses, although discontinuation of NSAID use
within 68 weeks of term is recommended. Ibuprofen, indomethacin, and naproxen are considered safe for
lactating women, according to the American Academy of Pediatrics.
A 5-year-old female is seen for a kindergarten physical and is noted to be below the 3rd percentile for
height. A review of her chart shows that her height curve has progressively fallen further below the 3rd
percentile over the past year. She was previously at the 50th percentile for height. The physical examination
is otherwise normal, but your workup shows that her bone age is delayed. Of the following conditions,
which one is the most likely cause of her short stature?
A. Constitutional growth delay
B. Growth hormone deficiency
C. Genetic short stature
D. Turner syndrome
E. Skeletal dysplasia
This patient has delayed bone age coupled with a reduced growth velocity, which suggests an underlying
systemic cause. Growth hormone deficiency is one possible cause for this. 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. Patients with Turner syndrome or skeletal
dysplasia have dysmorphic features, and bone age would be normal.
The preferred method for diagnosing psychogenic nonepileptic seizures is:
A. inducing seizures by suggestion
B. postictal prolactin levels
C. EEG monitoring

D. video-electroencephalography (vEEG) monitoring

E. brain MRI
Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of
psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG
monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis
of clinical and electrographic features during a captured event. Many other types of evidence have been
used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by
suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have
been found to be insufficient for the diagnosis of PNES. Elevated postictal prolactin levels (at least two
times the upper limit of normal) have been used to differentiate generalized and complex partial seizures
from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic
seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test
than was previously believed. Other serum markers have also been used to help distinguish PNES from
epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 ,
and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and
specificity have not been determined. MRI is not reliable because abnormal brain MRIs have been
documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures
often have normal brain MRIs.
A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral
intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior
pharynx. Which one of the following is the most likely diagnosis?
A. Herpangina
B. Herpes
C. Mononucleosis
D. Roseola infantum
E. Rubella
Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers
develop in the posterior pharyngeal area (SOR C). 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.
A 45-year-old female presents with a rash on the central portion of her face. She states that she has
intermittent flushing and intense erythema that feels as if her face is stinging. She has noticed that her
symptoms can be worsened by sun exposure, emotional stress, alcohol, or eating spicy foods. She has been
in good health and has taken conjugated estrogens (Premarin), 0.625 mg daily, since a hysterectomy for
benign reasons. A general examination is normal except for erythema of the cheeks and chin. No pustules
or comedone formation is noted around her eyes, but telangiectasias are present. Which one of the
following would be appropriate in the management of this problem?
A. Increasing her estrogen dosage
B. Referral to a rheumatologist
C. Low-potency non-fluorinated topical corticosteroids
D. Oral prednisone
E. Metronidazole gel (MetroGel)
Rosacea is a relatively common condition seen most often in 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. Some patients develop
rhinophyma due to hypertrophy of the subcutaneous glands of the nose. The usual presenting symptoms are
central facial erythema and flushing that many patients find socially embarrassing. Flushing can be

triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients
with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis.
Management includes avoidance of precipitating factors and use of sunscreen. Oral metronidazole,
doxycycline, or tetracycline also can be used, especially if there are ocular symptoms. These are often
ineffective for the flushing, so low-dose clonidine or a nonselective -blocker may be added. Topical
treatments such as metronidazole and benzoyl peroxide may also be effective, particularly for mild cases.
Other illnesses to consider include acne, photodermatitis, systemic lupus erythematosus, seborrheic
dermatitis, carcinoid syndrome, and mastocytosis.
Which one of the following confirmed findings in a 3-year-old female is diagnostic of sexual abuse?
A. Bacterial vaginosis
B. Genital herpes
C. Gonorrhea
D. Anogenital warts
E. Hepatitis
The diagnosis of any sexually transmitted or associated infection 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 sexually transmitted diseases. Gonorrhea, syphilis, and postnatally
acquired Chlamydia or 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 23 years. Although a
diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible
inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are
common. 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.
A 63-year-old male with type 2 diabetes mellitus is seen in the emergency department for an acute,
superficial, previously untreated infected great toe. Along with Staphylococcus aureus, which one of the
following is the most common pathogen in this situation?
A. Pseudomonas
B. Streptococcus
C. Clostridium
D. Escherichia coli
E. Adenovirus
The most common pathogens in previously untreated acute superficial foot infections in diabetic patients
are aerobic gram-positive Staphylococcus aureus and -hemolytic streptococci (groups A, B, and others).
Previously treated and deep infections are often polymicrobial.
An obese, hypertensive 53-year-old physician suffers a cardiac arrest while making rounds. He is
resuscitated after 15 minutes of CPR, but remains comatose. Which one of the following is associated with
the lowest likelihood of neurologic recovery in this situation?
A. Duration of CPR >10 minutes
B. No pupillary light reflex at 30 minutes
C. No corneal reflex at 2 hours
D. No motor response to pain at 6 hours
E. Myoclonic status epilepticus at 24 hours
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.
A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N 8.610.2) on routine
laboratory screening. To confirm the hypercalcemia you order an ionized calcium level, which is 1.49
mmol/L (N 1.141.32). Additional testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15
75) and a urine calcium excretion of 386 mg/24 hr (N 100300). Which one of the following is the most
likely cause of the patients hypercalcemia?
A. Primary hyperparathyroidism
B. Malignancy
C. Familial hypocalciuric hypercalcemia
D. Hypoparathyroidism
E. Hyperthyroidism
Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. These
conditions must be differentiated early to provide the patient with optimal treatment and an accurate
prognosis. Humoral hypercalcemia of malignancy implies a very limited life expectancyoften only a
matter of weeks. On the other hand, primary hyperparathyroidism has a relatively benign course. 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 or normal in patients with hyperparathyroidism and low
in patients with FHH.
A 40-year-old male who recently immigrated from central Africa presents to a public health clinic where
you are working. He was referred by a physician in the local emergency department, who made a diagnosis
of type 2 diabetes mellitus. The patient has no history of fever or night sweats, weight loss, or cough. He
does have a history of receiving bacille Calmette-Gurin (BCG) vaccine in the past. Screening tests for
HIV and hepatitis performed in the emergency department were negative. Which one of the following is
true regarding screening for latent tuberculosis infection by in vitro interferon-gamma release assay (IGRA)
compared to screening by the traditional targeted tuberculin skin test (TST) in this patient?
A. Both tests require subjective interpretation
B. BCG interferes with IGRA results
C. IGRA differentiates Mycobacterium tuberculosis from nontuberculous mycobacteria
D. IGRA results are valid if the sample is analyzed within 24 hours
E. IGRA should be done in tandem with TST
In vitro interferon-gamma release assays (IGRAs) are a new way of screening for latent tuberculosis
infection. One of the advantages of IGRA is that it targets antigens specific to Mycobacterium tuberculosis.
These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous
mycobacteria. Unlike skin testing, the results of IGRA are objective. It is unnecessary for IGRA to be done
in tandem with skin testing, and it eliminates the need for two-step testing in high-risk patients. 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 currently
available IGRAs.
An 11-year-old female has been diagnosed with "functional abdominal pain" by a pediatric
gastroenterologist. Her mother brings her to see you because of concerns that another diagnosis may have
been overlooked despite a very thorough and completely normal evaluation for organic causes.
Which one of the following would you recommend?

A. A trial of inpatient hospital admission

B. Increased testing and levels of referral until a true diagnosis is reached
C. Removing the child from school and activities whenever symptoms occur
D. Medications to eradicate symptoms
E. Stress reduction and participation in usual activities as much as possible
The diagnosis of functional abdominal pain 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 416 years of age. The use of medications may be helpful in reducing (but rarely eradicating)
functional symptoms, and remaining open to the possibility of a previously unrecognized organic disorder
is appropriate. However, continuing to focus on organic causes, invasive tests, or physician visits can
actually perpetuate a childs complaints and distress. It is estimated that approximately 30%50% of
children with functional abdominal pain will have resolution of their symptoms within 2 weeks of
diagnosis. Recommendations for managing this problem include focusing on participation in normal ageappropriate 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.
Amiodarone (Cordarone) is most useful for which one of the following?
A. Prophylactic perioperative use for emergency surgery
B. Primary prevention of nonischemic cardiomyopathy
C. Treatment of atrial flutter
D. Treatment of multi-focal premature ventricular contractions following acute myocardial infarction
E. Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability
Amiodarone is one of the most frequently prescribed antiarrhythmic medications in the U.S. It is useful in
the acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability.
Amiodarone is appropriate first-line treatment for atrial fibrillation only in symptomatic patients with left
ventricular 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 perioperative period of cardiac surgery. The use of prophylactic
antiarrhythmic agents in the face of warning dysrhythmias or after myocardial infarction is no longer
recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with
nonischemic cardiomyopathy.
A 72-year-old male has had persistent interscapular pain with movement since rebuilding his deck 1 week
ago. He rates the pain as 6 on a 10-point scale. A chest radiograph shows a thoracic vertebral compression
fracture.
Which one of the following would be most appropriate at this point?
A. Complete bed rest for 2 weeks
B. Markedly decreased activity until the pain lessens, and follow-up in 1 week
C. Referral for vertebroplasty as soon as possible
D. NSAIDs and referral for physical therapy
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.
On his first screening colonoscopy, a 67-year-old male is found to have a 0.5-cm adenomatous polyp with
low-grade dysplasia.
According to current guidelines, when should this patient have his next colonoscopy?

A. 6 months
B. 1 year
C. 3 years
D. 5 years
E. Screening is no longer necessary
Overuse of colonoscopy has significant costs. In response to these concerns, the American Cancer Society
and the U.S. Multi-Society Task Force on Colorectal Cancer collaborated on a consensus guideline on the
use of surveillance colonoscopy. According to these guidelines, patients with one or two small (<1 cm)
tubular adenomas, including those with only low-grade dysplasia, should have their next colonoscopy in 5
10 years (SOR B).
A 25-year-old female has been trying to conceive for over 1 year without success. Her menstrual periods
occur approximately six times per year. Laboratory evaluation of her hormone status has been negative, and
her husband has a normal semen analysis. Her only other medical problem is hirsutism, which has not
responded to topical treatment. Pelvic ultrasonography of her uterus and ovaries is unremarkable.
Of the following, which one would be the most appropriate treatment for her infertility?
A. Metformin (Glucophage)
B. Danazol
C. Medroxyprogesterone (Provera)
D. Spironolactone (Aldactone)
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
patients problems. Spironolactone will improve hirsutism and menstrual irregularities, but is not indicated
for ovulation induction.
When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a
spacer has been shown to result in which one of the following, compared to use of a nebulizer?
A. Higher hospitalization rates
B. Shorter stays in the emergency department
C. Higher relapse rates
D. Less improvement in peak-flow rates
E. Increases in the total dose of albuterol
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.
A 31-year-old female who is a successful professional photographer complains of hoarseness that started
suddenly 3 weeks ago. She says she can remember exactly what day it was, because her divorce became
final the next day. The day the problem began, she was only able to whisper from the time she woke up,
and she is able to speak only in a weak whisper while relating her history. She does not appear to strain
while speaking. She does not smoke, has had no symptoms of an upper respiratory infection, and has no
pain, cough, or wheezing. She is on a proton pump inhibitor prescribed by an urgent care provider 2 weeks
ago. This has not changed her symptoms. She takes no other medications and has no known allergies. A

head and neck examination, including indirect laryngoscopy, is within normal limits. Which one of the
following is the most likely diagnosis?
A. Muscle tension aphonia
B. Laryngopharyngeal reflux
C. Spasmodic dysphonia
D. Vocal abuse
E. Conversion aphonia
This patient has conversion aphonia. In this condition, the patient loses his or her spoken voice, but the
whispered voice is maintained. The vocal cords appear normal, but if observed closely by an
otolaryngologist, 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) (SOR C).
Muscle tension aphonia presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It
is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including
poor breath control and stress, for example. The patient with laryngopharyngeal reflux presents with a
raspy or harsh voice. The 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. The patient with spasmodic
dysphonia (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct
neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal
laryngeal spasm. The hoarseness of vocal abuse is usually worse later in the day after effortful singing or
talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other
situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this
condition.
A 62-year-old diabetic with stage 2 renal dysfunction is evaluated for knee pain that has mildly interfered
with his usual activities over the past 3 months. On examination he is mildly tender over the medial joint
line. A knee radiograph shows moderate medial joint space narrowing. In addition to low-impact exercise,
which one of the following would you recommend initially?
A. Intra-articular hyaluronic acid
B. Intra-articular corticosteroids
C. Celecoxib (Celebrex)
D. Naproxen
E. Acetaminophen
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. Renal dysfunction is a contraindication to the use of NSAIDs. Acetaminophen is the firstline treatment in this case.
A 24-year-old female presents with pelvic pain. She says that the pain is present on most days, but is worse
during her menses. Ibuprofen has helped in the past but is no longer effective. Her menses are normal and
she has only one sexual partner. A physical examination is normal.
Which one of the following should be the next step in the workup of this patient?
A. Transvaginal ultrasonography
B. CT of the abdomen and pelvis
C. MRI of the pelvis
D. A CA-125 level
E. Colonoscopy
The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for
gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a -hCG level, and pelvic
ultrasonography. CT and MRI are not part of the recommended initial diagnostic workup, but may be
helpful in further assessing any abnormalities found on pelvic ultrasonography. 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
gastrointestinal source for the pain after the initial evaluation.
A 7-year-old male presents with a fever of 38.5C (101.3F), a sore throat, tonsillar inflammation, and
tender anterior cervical adenopathy. He does not have a cough or a runny nose. His younger sister was
treated for streptococcal pharyngitis last week and his mother would like him to be treated for streptococcal
infection. Which one of the following is true concerning this situation?
A. Empiric antibiotic treatment for streptococcal pharyngitis is warranted.
B. The chance of this patient having a positive rapid antigen detection test for Streptococcus is <50%.
C. There is a generalized consensus among the various national guidelines for management of pharyngitis.
D. The patient should have a tonsillectomy when he recovers from this infection.
E. The family dog should be treated for streptococcal infection.
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 -hemolytic streptococcal
(GABHS) pharyngitis, and empiric treatment with antibiotics is warranted. Various national and
international organizations disagree about the best way to manage pharyngitis, with no consensus as to
when or how to test for GABHS and who should receive treatment. The minimal benefit seen with
tonsillectomy in reducing the incidence of recurrent GABHS pharyngitis does not justify the risks or cost of
surgery. Treatment of pets for the prevention of GABHS infection has proven ineffective.
A 24-year-old female with a 2-year history of dyspnea on exertion has been diagnosed with exerciseinduced asthma by another physician. Which one of the following findings on pulmonary function testing
would raise concerns that she actually has vocal cord dysfunction?
A. A good response to an inhaled -agonist
B. Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase
C. Flattening of the expiratory portion of the flow-volume loop, but a normal inspiratory phase
D. Flattening of both the inspiratory and expiratory portion of the flow-volume loop
E. A decreased FEV1 and a normal FVC
The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced
asthma who do not have a good response to -agonists before exercise. Pulmonary function testing with a
flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase (SOR C). A
decreased FEV1 and normal FVC would be consistent with asthma.
A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the
medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and
with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform
a single-leg heel raise. Which one of the following is true regarding this problem?
A. The patient most likely has a medial ankle sprain
B. NSAIDs will improve the long-term outcome
C. Injecting a corticosteroid into the tendon sheath of the involved tendon is recommended
D. A lateral heel wedge should be prescribed
E. Immobilization in a cast boot for 3 weeks is indicated
The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendons 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. The patient
usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This
is most commonly seen in women over the age of 40. 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.
A 70-year-old male presents to your office for a follow-up visit for hypertension. He was started on
lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC
and a complete metabolic panel, were normal except for a serum creatinine level of 1.5 mg/dL (N 0.61.5).
A follow-up renal panel obtained yesterday shows a creatinine level of 3.2 mg/dL and a BUN of 34 mg/dL
(N 825).
Which one of the following is the most likely cause of this patients increased creatinine level?
A. Bilateral renal artery stenosis
B. Coarctation of the aorta
C. Essential hypertension
D. Hyperaldosteronism
E. Pheochromocytoma
Classic clinical clues that suggest a diagnosis of renal-artery stenosis include the onset of stage 2
hypertension (blood pressure >160/100 mm Hg) after 50 years of age or in the absence of a family history
of hypertension; hypertension associated with renal insufficiency, especially if renal function worsens after
the administration of an agent that blocks the renin-angiotensin-aldosterone system; hypertension with
repeated hospital admissions for heart failure; and drug-resistant hypertension (defined as blood pressure
above the goal despite treatment with three drugs of different classes at optimal doses). The other
conditions mentioned do not cause a significant rise in serum creatinine after treatment with an ACE
inhibitor.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 23 weeks.
A 58-year-old male presents with a several-day history of shortness of breath with exertion, along with
pleuritic chest pain. His symptoms started soon after he returned from a vacation in South America. He has
a history of deep-vein thrombosis (DVT) in his right leg after surgery several years ago, and also has a
previous history of prostate cancer. You suspect pulmonary embolism (PE.). Which one of the following is
true regarding the evaluation of this patient?
A. CT angiography would reliably either confirm or rule out PE
B. Compression ultrasonography of the lower extremities will reveal a DVT in the majority of patients
with PE
C. No further testing is needed if a ventilation-perfusion lung scan shows a low probability of PE
D. No further testing is needed if a D-dimer level is normal
E. An elevated D-dimer level would confirm the diagnosis of PE
This patient has a high clinical probability for pulmonary embolism (PE). About 40% of patients with PE
will have positive findings for deep-vein thrombosis in the lower extremities on compression
ultrasonography. A normal ventilation-perfusion lung scan rules out PE, but inconclusive findings are
frequent and are not reassuring. A normal D-dimer level reliably rules out the diagnosis of venous
thromboembolism in patients at low or moderate risk of pulmonary embolism, 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.
A 30-year-old white gravida 2 para 1 who has had no prenatal care presents for urgent care at 33 weeks
gestation. Her symptoms include vaginal bleeding, uterine tenderness, uterine pain between contractions,
and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term.
Which one of the following is the most likely diagnosis?
A. Uterine rupture

B. Vasa previa
C. Placenta previa
D. Placental abruption
E. Cervical cancer
Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental
insufficiency and/or premature birth. The condition described here is placental abruption (separation of the
placenta from the uterine wall before delivery). There are several causes of vaginal bleeding that can occur
in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as
cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the
syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother.
Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section
or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign
of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable
presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the
membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of
amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress.
The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental
implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal
bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically
painless, unless labor or placental abruption occurs.
A 43-year-old female complains of a several-month history of unpleasant sensations in her legs and an urge
to move her legs. These symptoms only occur at night and improve when she gets up and stretches. The
sensations often awaken her, and she feels very tired. She has no other medical problems and takes no
medication. Laboratory tests reveal a serum calcium level of 8.9 mg/dL (N 8.510.5), a serum potassium
level of 4.1 mmol/L (N 3.55.0), a serum ferritin level of 15 ng/mL (N 10200), and a serum magnesium
level of 1.5 mEq/L (N 1.42.0). Which one of the following may improve her symptoms?
A. Iron supplementation
B. Magnesium supplementation
C. Antihistamines
D. Stopping calcium supplementation
E. Amitriptyline
This patient has restless legs syndrome, which includes unpleasant sensations in the legs and can cause
sleep disturbances. The symptoms are relieved by movement. Recommendations for treatment include
lower-body resistance training and avoiding or changing medications that may exacerbate symptoms (e.g.,
antihistamines, caffeine, SSRIs, tricyclic antidepressants, etc.). It is also recommended that patients with a
serum ferritin level below 50 ng/mL take an iron supplement (SOR C). Magnesium supplementation does
not improve restless legs syndrome. Ropinirole may be used if nonpharmacologic therapies are ineffective.
A 56-year-old female with well-controlled diabetes mellitus and hypertension presents with an 18-hour
history of progressive left lower quadrant abdominal pain, low-grade fever, and nausea. She has not been
able to tolerate oral intake over the last 6 hours. An abdominal examination reveals significant tenderness in
the left lower quadrant with slight guarding but no rebound tenderness. Bowel sounds are hypoactive.
Rectal and pelvic examinations are unremarkable.
Which one of the following is recommended as the initial diagnostic procedure in this situation?
A. CT of the abdomen and pelvis
B. Abdominal and pelvic ultrasonography
C. A barium enema
D. Colonoscopy
E. Laparoscopy

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. Ultrasonography may be helpful in suggesting other diagnoses,
but it is not as specific or as sensitive for diverticulitis as CT. Limited-contrast studies of the distal colon
and rectum 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 inflammatory bowel disease, 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.
Which one of the following is true concerning Norwalk virus?
A. Outbreaks occur mostly in settings with large numbers of children, such as schools and day-care centers
B. Viral shedding continues long after the acute illness
C. The virus does not survive long on most environmental surfaces
D. An episode of Norwalk gastroenteritis leads to long-lasting immunity
E. It is a less common cause of diarrhea in adults than Shigella
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.
Patient-centered medical home is a term used to describe which one of the following developments in
medical care?
A. A federally imposed restriction on family medicines role in providing care
B. A physician-led team of care providers taking responsibility for the quality and safety of an individuals
health
C. A practice without walls that provides primary care services in the homes of patients
D. A small group of patients paying an annual fee to have a physician be available to them at all times
E. Improving the dignity of care for nursing-home residents
The patient-centered medical home (PCMH) is a development in primary care that stresses a personal
physician leading a multidisciplinary team that takes responsibility for integrating and coordinating an
individuals care. Quality and safety are hallmarks of the PCMH, which stresses outcome-based and
evidence-supported practices. This concept was originated by organizations in the field of pediatrics and
was further developed by a collaboration of the major academies of primary care. There are institutions that
accredit individual and group practices as fulfilling the role of a PCMH, which are now being compensated
at a higher level by third-party payers, including Medicare.
Which one of the following Mantoux tuberculin skin test results should be read as NEGATIVE for latent
tuberculosis infection?
A. 7 mm induration on an individual having recent household contact with a tuberculosis patient
B. 8 mm induration on an HIV-positive individual who has no documented previous test result
C. 10 mm induration on a nursing-home resident
D. 12 mm induration on a homeless individual
E. 9 mm induration on a hospital-based nurse who had a test with 2 mm induration 1 year ago

Three different cutoff levels defining a positive reaction on a tuberculin skin test are recommended by the
CDC, each based on the level of risk and consideration of immunocompetence. For those who are 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 increase in induration of 10 mm or more within a 2-year period would be considered positive
and an indication of a recent infection with Mycobacterium tuberculosis. A nurse with a 9-mm induration
would be considered to have a negative PPD.
The Health Insurance Portability and Accountability Act (HIPAA):
A. sets a federal minimum on the protection of privacy
B. requires that privacy notices be acknowledged and signed at each office visit
C. allows the patient to inspect and obtain a copy of his/her record without exception
D. requires privacy notices prior to giving emergency care
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.
Estimating the 10-year risk of developing coronary heart disease with the Framingham Heart Study Score
Sheet would be most reliable when applied to which one of the following individuals?
A. A 19-year-old female with a strong family history of cardiac disease
B. An obese 50-year-old male with a history of a previous myocardial infarction
C. An otherwise healthy 36-year-old white male smoker
D. A postmenopausal 54-year-old female with angina
E. A 78-year-old male with a history of hypertension
The 10-year risk of developing coronary heart disease can be effectively predicted with the algorithmic
calculator developed using multivariable data collected over a period of more than half a century as part of
the Framingham Heart Study. This iconic study defined what are now commonly known as major risk
factors: elevated blood pressure, cigarette smoking, cholesterol levels, diabetes mellitus, 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 3074 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.
A 53-year-old male presents to your office with a several-day history of hiccups. They are not severe, but
have been interrupting his sleep, and he is becoming exasperated. What should be the primary focus of
treatment in this individual?
A. Drug treatment to prevent recurrent episodes
B. Decreasing the intensity of the muscle contractions in the diaphragm
C. Finding the underlying pathology causing the hiccups
D. Improving the patients quality of sleep
E. Suppressing the current hiccup symptoms

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. In one study, 66% of patients who experienced hiccups for longer than 2
days had an underlying physical cause. Identifying and treating the underlying disorder should be the focus
of management for intractable hiccups.
An 82-year-old male nursing-home resident is sent to the emergency department with lower abdominal pain
and bloody diarrhea. He has a history of multi-infarct dementia, 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 patients bleeding?
A. Peptic ulcer disease
B. Ischemic colitis
C. Diverticular bleeding
D. Angiodysplasia
E. Infectious colitis
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.
A 62-year-old female undergoes elective surgery and is discharged on postoperative day 3. A week later she
is hospitalized again with pneumonia. A CBC shows that her platelet count has dropped to 150,000/mm3
(N 150,000300,000) from 350,000 /mm3 a week ago. She received prophylactic heparin postoperatively
during her first hospitalization.
The patient is started on intravenous antibiotics for the pneumonia and subcutaneous heparin for deep-vein
thrombosis prophylaxis. On hospital day 2, she has an acute onset of severe dyspnea and hypoxia; CT of
the chest reveals bilateral pulmonary emboli. Her platelet count is now 80,000/mm3.Which one of the
following would be most appropriate at this point?
A. Continue subcutaneous heparin
B. Discontinue subcutaneous heparin and start a continuous intravenous heparin drip
C. Discontinue heparin and give a platelet transfusion
D. Discontinue heparin and start a non-heparin anticoagulant such as argatroban or desirudin (Iprivask)
E. Discontinue unfractionated heparin and start a low molecular weight heparin such as enoxaparin
(Lovenox)
This patient needs prompt evaluation and treatment for probable heparin-induced thrombocytopenia (HIT).
HIT is a potentially life-threatening syndrome that usually occurs within 12 weeks of heparin
administration and is characterized by the presence of HIT antibodies in the serum, associated with an
otherwise unexplained 30%50% decrease in the platelet count, arterial or venous thrombosis,
anaphylactoid reactions immediately following heparin administration, or skin lesions at the site of heparin
injections. Postoperative patients receiving subcutaneous unfractionated heparin prophylaxis are at highest
risk for HIT. Because of this patients 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.
A 64-year-old male presents with a 3-month history of difficulty sleeping. A history and physical
examination, followed by appropriate ancillary testing, leads to a diagnosis of chronic primary insomnia.
Which one of the following would be most appropriate for managing this patients problem?

A. An SSRI
B. A small glass of wine 1 hour before bedtime
C. Cognitive-behavioral therapy
D. Watching television at bedtime, with the timer set to turn off in 60 minutes
E. Reading in bed with a soft light
Chronic insomnia is defined as difficulty with initiating or maintaining sleep, or experiencing
nonrestorative sleep, for at least 1 month, leading to significant daytime impairment. Primary insomnia is
not caused by another sleep disorder, underlying psychiatric or medical condition, or substance abuse
disorder. Cognitive-behavioral therapy is effective for managing this problem, and should be used as the
initial treatment for chronic insomnia. 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.
Which one of the following would be most appropriate for stroke prevention in a patient with hypertension,
diabetes mellitus, and atrial fibrillation?
A. Clopidogrel (Plavix)
B. Aspirin
C. Dipyridamole (Persantine)
D. Warfarin (Coumadin)
E. Enoxaparin (Lovenox)
The CHADS2 score is a validated clinical prediction rule for determining the risk of stroke and who should
be anticoagulated. Points are assigned based on the patients comorbidities. One point is given for each of
the following: history of congestive heart failure (C), hypertension (H), age 75 (A), and diabetes mellitus
(D). Two points are assigned for a previous stroke or TIA (S2 ). For patients with a score of 0 or 1, the risk
of stroke is low and warfarin would not be recommended. Warfarin is the agent of choice for the prevention
of stroke in patients with atrial fibrillation and a score 2. In these patients, the risk of stroke is higher than
the risks associated with taking warfarin. Enoxaparin is an expensive injectable anticoagulant and is not
indicated for the long-term prevention of stroke.
An elevation of serum methylmalonic acid is both sensitive and specific for a cellular deficiency of which
vitamin?
A. Vitamin A
B. Vitamin B 6
C. Vitamin B 12
D. Vitamin D
E. Folate
An elevation in serum methylmalonic acid is both sensitive and specific for cellular vitamin B12
deficiency.
According to the guidelines of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure, for hypertensive patients who also have diabetes mellitus, the blood
pressure goal is below a threshold of:
A. 140/95 mm Hg
B. 135/90 mm Hg
C. 130/80 mm Hg
D. 120/75 mm Hg

Hypertension and diabetes mellitus are very common, both separately and in combination. End-organ
damage to the heart, brain, and kidneys is more common in patients with both diabetes mellitus and
hypertension, occurring at lower blood pressure levels than in patients with only hypertension. JNC 7, an
evidence-based consensus report, recommends that patients with diabetes and hypertension be treated to
reduce blood pressure to below 130/80 mm Hg, as opposed to 140/90 mm Hg for other adults. It should be
noted, however, that the recently published ACCORD blood pressure trial found no significant
cardiovascular benefit from targeting systolic blood pressure at <120 mm Hg rather than <140 mm Hg in
patients with type 2 diabetes. This finding may affect the JNC 8 guidelines, which are currently being
developed.
A hospitalized patient is being treated with vancomycin for an infection due to methicillin-resistant
Staphylococcus aureus (MRSA). Which one of the following is most important to monitor?
A. Hepatic function
B. Trough serum levels
C. Peak serum levels
D. Audiograms
The best predictor of vancomycin efficacy is the trough serum concentration, which should be over 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.
A 35-year-old male amateur rugby player seeks your advice because right hip pain of several months
duration has progressed to the point of interfering with his athletic performance. The pain is accentuated
when he transitions from a seated to a standing position, and especially when he pivots on the hip while
running, but he cannot recall any significant trauma to the area and finds no relief with over-the-counter
analgesics. On examination his gait is stable. The affected hip appears normal and is neither tender to
palpation nor excessively warm to touch. Although he has a full range of passive motion, obvious
discomfort is evident with internal rotation of the flexed and adducted right hip. Which one of the following
is most strongly suggested by this clinical picture?
A. Osteoarthritis
B. Avascular necrosis
C. Bursitis
D. Impingement
E. Pathologic fracture
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 range-of-motion examination by manipulating the hip into a
position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding.
Special radiographic imaging of the flexed and adducted hip can emphasize the anatomic abnormalities
associated with impingement that may go unnoticed on standard radiographic series views. Although the
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 than this patient, and the pain produced 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.
A 39-year-old African-American multigravida at 36 weeks gestation presents with a temperature of 40.0C
(104.0F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but
there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in
clumps, as well as numerous bacteria. Of the following, the most appropriate therapy at this time would be:
A. oral trimethoprim/sulfamethoxazole (Bactrim, Septra)

B. oral nitrofurantoin (Macrodantin)

C. oral levofloxacin (Levaquin)
D. intravenous doxycycline
E. intravenous ceftriaxone (Rocephin)
Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually
straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital
with parenteral agents, at least until the patient is stabilized and cultures are available. Ampicillin plus
gentamicin or a 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 childs 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.
A patient who takes fluoxetine (Prozac), 40 mg twice daily, develops shivering, tremors, and diarrhea after
taking an over-the-counter cough and cold medication. On examination he has dilated pupils and a heart
rate of 110 beats/min. His temperature is normal. Which one of the following medications in combination
with fluoxetine could contribute to this patients symptoms?
A. Dextromethorphan
B. Pseudoephedrine
C. Phenylephrine
D. Guaifenesin
E. Diphenhydramine (Benadryl)
Dextromethorphan is commonly found in cough and cold remedies, and is associated with serotonin
syndrome. SSRIs such as fluoxetine are also associated with serotonin syndrome, and there are many other
medications that increase the risk for serotonin syndrome when combined with SSRIs. The other
medications listed here are not associated with serotonin syndrome, however.
Brain natriuretic peptide (BNP) is a marker for which one of the following?
A. Renal failure
B. Acute adrenal insufficiency
C. Cerebrovascular accident
D. Heart failure
E. Ureteral obstruction
Brain-type natriuretic peptide (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. In
addition, the availability of a bedside assay makes BNP useful for evaluating patients in the emergency
department.
An 82-year-old male presents to your office because his blood pressure has been high when taken by a
friend on several occasions. His blood pressure in your office is 173/94 mm Hg, which is similar to the
levels his friend recorded. The history and physical examination are otherwise unremarkable, and a CBC,
metabolic panel, and urinalysis are normal. Which one of the following is most consistent with current
evidence?
A. This patients mortality will not be affected by treatment of his hypertension
B. Treating this patient with an ARB for hypertension would be ineffective and dangerous
C. Treatment with a thiazide diuretic will lower this patients risk of death

D. In this age group, treatment of hypertension in males does not reduce stroke and heart failure as it does
in females
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.
A 68-year-old female presents with a several-month history of weight loss, fatigue, decreased appetite, and
vague abdominal pain. The most appropriate initial test to rule out adrenal insufficiency is:
A. morning serum cortisol
B. a cosyntropin (ACTH) stimulation test
C. MRI
D. an insulin tolerance test
E. a metyrapone test
A single morning serum cortisol level >13g/dL reliably excludes adrenal insufficiency. If the morning
cortisol level is lower than this, further evaluation with a 1g ACTH stimulation test is necessary, although
the test is somewhat difficult. It requires dilution of the ACTH prior to administration, and requires multiple
blood draws. The insulin tolerance test and metyrapone test, although historically considered to be gold
standards, are not widely available or commonly used in clinical practice. MRI does not provide
information about adrenal function.
A healthy 48-year-old female consults you about continuing the use of her estrogen/progestin oral
contraceptives. She has regular menstrual periods, is not hypertensive or diabetic, and does not smoke.
What advice would you give her?
A. She should stop the oral contraceptives
B. She should switch to a progestin-only pill
C. She should discontinue the contraceptive for 1 month, and if FSH is then elevated to postmenopausal
levels, the pills should be stopped
D. She can safely continue to take the contraceptive if screening for thrombophilic conditions is negative
E. It is safe to continue the oral contraceptives
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.
Which one of the following is necessary to make a diagnosis of polymyalgia rheumatica?
A. Joint swelling
B. Early morning stiffness
C. Reduction of symptoms with high-dose NSAID therapy
D. An erythrocyte sedimentation rate 60 mm/hr
E. Bilateral shoulder or hip stiffness and aching
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.
The Centers for Disease Control and Prevention currently recommends that all patients between the ages of
13 and 64 years be screened for:
A. tuberculosis
B. hepatitis B

C. human papillomavirus infection

D. elevated serum cholesterol levels
E. HIV infection
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 United States with
HIV, and 25% are undiagnosed. Only 36.6% of adults have had an HIV test. Screening for hepatitis B and
for tuberculosis 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.
A 71-year-old female with end-stage lung cancer was recently extubated and is awaiting transfer to hospice.
She is awake and confused and has significant respiratory secretions. Which one of the following
medications used for reducing respiratory secretions is LEAST likely to cause central nervous system
effects such as sedation?
A. Atropine
B. Transdermal scopolamine (Transderm Scop)
C. Hyoscyamine (Levsin)
D. Glycopyrrolate (Robinul)
Glycopyrrolate does not cross the blood-brain barrier, and is therefore least likely to cause central nervous
system effects such as sedation. The other medications listed do cross the blood-brain barrier.
A 25-year-old female comes to your office requesting a referral to an otolaryngologist for surgery on her
nose. She states that her nose is too large and that something must be done. She has already seen multiple
family physicians, as well as several otolaryngologists. She is 168 cm (66 in) tall and weighs 64 kg (141
lb). A physical examination is normal, and even though she initially resists a nasal examination, it also is
normal. The size of her nose is normal. Which one of the following is the most likely cause of this patients
concern about her nose?
A. Obsessive-compulsive disorder
B. Anorexia nervosa
C. Depression
D. Body dysmorphic disorder
Body dysmorphic disorder is an increasingly recognized somatoform disorder that is clinically distinct from
obsessive-compulsive disorder, eating disorders, and depression. 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.
A 78-year-old male presents for a routine follow-up visit for hypertension. He is a smoker, but has no
known coronary artery disease and is otherwise healthy. On examination you note an irregular pulse. An
EKG reveals multiple premature ventricular contractions (PVCs), but no other abnormalities. Current
guidelines recommend which one of the following?
A. Amiodarone (Cordarone) for suppression of PVCs
B. Flecainide (Tambocor) for suppression of PVCs
C. Evaluation for underlying coronary artery disease
D. No further evaluation or treatment
In patients with no known coronary artery disease (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. The American College of Cardiology and the American

Heart Association recommend evaluation for CAD in patients who have frequent PVCs and cardiac risk
factors, such as hypertension and smoking (SOR C). Evaluation for CAD may include stress testing,
echocardiography, and ambulatory rhythm monitoring (SOR C). Strong evidence from randomized,
controlled trials suggests that PVCs should not be suppressed with antiarrhythmic agents. The CAST I trial
showed that using encainide or flecainide to suppress PVCs increases mortality (SOR A).
While playing tennis, a 55-year-old male tripped and fell, landing on his outstretched hand with his elbow
in slight flexion at impact. Pronation and supination of the forearm are painful on examination, as are
attempts to flex the elbow. There is tenderness of the radial head without significant swelling. A radiograph
of the elbow shows no fracture, but a positive fat pad sign is noted. Appropriate management would
include:
A. a long arm cast for 2 weeks, followed by use of a brace
B. mobilization of the elbow beginning 3 weeks after the injury
C. a posterior splint for 6 weeks
D. a posterior splint and a repeat radiograph in 12 weeks
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 57 days, followed by early
mobilization and a sling for comfort. Sometimes the joint effusion may be aspirated for pain relief and to
increase mobility. One study compared immediate mobilization with mobilization beginning in 5 days and
found no differences at 1 and 3 months, but early mobilization was associated with better function and less
pain 1 week after the injury. Radiographs should be repeated in 12 weeks to make sure that alignment is
appropriate.
The best available evidence supports which one of the following statements regarding the cardiovascular
effects of hypoglycemic agents?
A. Sulfonylureas increase cardiovascular events
B. Metformin (Glucophage) reduces cardiovascular mortality rates
C. Incretin mimetics reduce the risk of cardiovascular events
D. -Glucosidase inhibitors have no effect on cardiovascular events
Metformin is the only hypoglycemic agent shown to reduce mortality rates in patients with type 2 diabetes
mellitus. A recent systematic review concluded that cardiovascular events are neither increased nor
decreased with the use of sulfonylureas. The effect of incretin mimetics and incretin enhancers on
cardiovascular events has not been determined. The STOP-NIDDM study suggests that -glucosidase
inhibitors reduce the risk of cardiovascular events in patients with impaired glucose tolerance.
A 46-year-old female presents to your office for follow-up of elevated blood pressure on a pre-employment
examination. She is asymptomatic, and her physical examination is normal with the exception of a blood
pressure of 160/100 mm Hg. Screening blood work reveals a potassium level of 3.1 mEq/L (N 3.75.2).
You consider screening for primary hyperaldosteronism:
A. 24-hour urine aldosterone levels
B. An ACTH infusion test
C. Adrenal venous sampling
D. CT of the abdomen
E. A serum aldosterone-to-renin ratio
Primary hyperaldosteronism is relatively common in patients with stage 2 hypertension (160/100 mm Hg or
higher) or treatment-resistant hypertension. It has been estimated that 20% of patients referred to a
hypertension specialist suffer from this condition. Experts recommend screening for this condition using a
ratio of morning plasma aldosterone to plasma renin. A ratio >20:1 with an aldosterone level >15 ng/dL
suggests the diagnosis. The level of these two values is affected by several factors, including medications
(especially most blood pressure medicines), time of day, position of the patient, and age. Patients who are

identified as possibly having this condition should be referred to an endocrinologist for further
confirmatory testing.
Pay-for-performance (P4P) programs provide financial incentives for meeting predetermined quality
targets. Contracts with major payors often include these programs. When considering P4P programs in such
contracts, physicians should negotiate for which one of the following?
A. Guidelines developed by academic medicine researchers
B. Guidelines based on consensus opinions
C. Mandatory physician participation
D. Reporting of negative performance results to licensure boards
E. Taking patient compliance into account when performing the evaluation
Pay-for-performance programs are becoming a critical part of the health care reform debate, and when the
discussion began in 2005, over 100 such programs were in existence. The objective is to reward physicians
for achieving goals that should lead to improved patient outcomes. In addition to evaluating clinical
performance, many programs now also evaluate efficiency and information technology. However, many
programs are not based on outcomes data, and have less desirable aspects such as inadequate incentive
levels, withholding of payment, limited clinical focus, or unequal or unfair distribution of incentives. 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. As the exact
process is still being defined, all family physicians should be actively engaged in learning more about these
programs, and in negotiating for appropriate measures to be included. The AAFP has seven main principles
in its support for pay-for-performance programs: (1) the focus should be on improved quality of care; (2)
physician-patient relationships should be supported; (3) evidence-based clinical guidelines should be
utilized; (4) practicing physicians should be involved with the program design; (5) reliable, accurate, and
scientifically valid data should be used; (6) physicians should be provided with positive incentives; and (7)
physician participation should be voluntary. Ensuring that patient adherence is included helps prevent
conflicts between patients and their physicians. A pay-for-performance program should not result in a
reduction of fees paid to the physician as a result of implementing a program. Negative results should not
penalize the physician with regard to health plan credentialing, verification, or licensure.
A 45-year-old male presents with a 4-month history of low back pain that he says is not alleviated with
either ibuprofen or acetaminophen. On examination he has no evidence of weakness or focal tenderness.
Laboratory studies, including a CBC, erythrocyte sedimentation rate, C-reactive protein, and complete
metabolic profile, are all normal. MRI of the lumbosacral region shows mild bulging of the L4-L5 disc
without impingement on the thecal sac. Which one of the following has been shown to be beneficial in this
situation?
A. Traction
B. Ultrasound
C. Epidural corticosteroid injection
D. A back brace
E. Acupuncture
Most chronic back pain (up to 70%) is nonspecific or idiopathic in origin. Treatment options that have the
best evidence for effectiveness include analgesics (acetaminophen, tramadol, NSAIDs), multidisciplinary
rehabilitation, and acupuncture (all SOR A). Other treatments likely to be beneficial include herbal
medications, tricyclics, antidepressants, exercise therapy, behavior therapy, massage, spinal therapy,
opioids, and short-term muscle relaxants (all SOR B). There is conflicting data regarding the effectiveness
of back school, low-level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy,
short-wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural
corticosteroid injections (all SOR C).

A 45-year-old white female with elevated cholesterol and coronary artery disease comes in for a periodic
fasting lipid panel and liver enzyme levels. She began statin therapy about 2 months ago and reports no
problems. Laboratory testing reveals an LDL-cholesterol level of 70 mg/dL, an HDL-cholesterol level of
55 mg/dL, an alanine aminotransferase (ALT) level of 69 U/L (N 730), and an aspartate aminotransferase
(AST) level of 60 U/L (N 925). Which one of the following would be most appropriate at this time?
A. Continue the current therapy with routine monitoring
B. Decrease the dosage of the statin and monitor liver enzymes
C. Discontinue the statin and monitor liver enzymes
D. Discontinue the statin and begin niacin
E. Substitute another statin
The patient is at her LDL and HDL goals and has no complaints, so she should be continued on her current
regimen with routine monitoring (SOR C). Research has proven that up to a threefold increase above the
upper limit of normal in liver enzymes is acceptable for patients on statins. Too often, slight elevations in
liver enzymes lead to unnecessary dosage decreases, discontinuation of statin therapy, or additional testing.
The Strength-of-Recommendation Taxonomy (SORT) is used to grade key recommendations in clinical
review articles. Which one of the following grades indicates that a recommendation is based on consistent,
good-quality, patient-oriented evidence?
A. A
B. B
C. C
D. X
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. These should not be
confused with the U.S. Food and Drug Administration labeling categories for the potential teratogenic
effects of medications on a fetus: pregnancy categories A, B, C, D, and X. Strength of Recommendation
(SOR) A is a recommendation that is based on consistent, good-quality, patient-oriented evidence. SOR B
is a recommendation that is based on limited-quality patient-oriented evidence. SOR C is a
recommendation that is based on consensus, disease-oriented evidence, usual practice, expert opinion, or
case series for studies of diagnosis, treatment, prevention, or screening.
In a patient with chronic hepatitis B, which one of the following findings suggests that the infection is in
the active phase?
A. A normal liver biopsy
B. Detectable levels of HBeAb
C. Detectable levels of HBsAb
D. Elevated levels of ALT
E. Undetectable levels of HBV DNA
Chronic hepatitis B develops in a small percentage of adults who fail to recover from an acute infection, in
almost all infants infected at birth, and in up to 50% of children infected between the ages of 1 and 5 years.
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 phase 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 liver enzymes, indicating liver inflammation, and the
presence of 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.

A 42-year-old male presents with anterior neck pain. His thyroid gland is markedly tender on examination,
but there is no overlying erythema. He also has a bilateral hand tremor. His erythrocyte sedimentation rate
is 82 mm/hr (N 113) and his WBC count is 11,500/mm3 (N 430010,800). His free T4 is elevated, TSH is
suppressed, and radioactive iodine uptake is abnormally low. Which one of the following treatment options
would be most helpful at this time?
A. Levothyroxine (Synthroid) and NSAIDs
B. Propylthiouracil
C. Prednisone
D. Nafcillin
E. Thyroidectomy
This patient has signs and symptoms of painful subacute thyroiditis, including a painful thyroid gland,
hyperthyroidism, and an elevated erythrocyte sedimentation rate. 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. Although
NSAIDs can be helpful for mild pain, high-dose glucocorticoids provide quicker relief for the more severe
symptoms. Levothyroxine is not indicated in this hyperthyroid state. Neither thyroidectomy nor antibiotics
is indicated for this problem.
A 60-year-old female with moderate COPD presents with ongoing dyspnea in spite of treatment with both
an inhaled long-acting -agonist and a long-acting anticholinergic agent. Your evaluation reveals an oxygen
saturation of 88% and a PaO2 of 55%. Echocardiography reveals a normal ejection fraction but moderate
pulmonary hypertension. Which one of the following would be most appropriate at this time?
A. No changes in the current medical regimen
B. Supplemental oxygen
C. Low-dose sildenafil (Revatio)
D. Nifedipine (Procardia)
E. Low-dose prednisone
This patient with moderate COPD and moderate nonpulmonary arterial hypertension pulmonary
hypertension is hypoxic and meets the criteria for use of supplemental oxygen (SOR A). 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.
A 48-year-old female with type 2 diabetes has been hospitalized for 4 days with persistent fever. Her
diabetes has been controlled with diet and glyburide (Micronase, DiaBeta). You saw her 2 weeks ago in the
office with urinary frequency, urgency, and dysuria. At that time a urinalysis showed 25 WBCs/hpf, and a
urine culture subsequently grew Escherichia coli sensitive to all antibiotics. She was placed on
trimethoprim/sulfamethoxazole (Bactrim, Septra) empirically, and this was continued after the culture
results were reported.
She improved over the next week, but then developed flank pain, fever to 39.5C (103.1F), and nausea and
vomiting. She was hospitalized and intravenous cefazolin (Kefzol) and gentamicin were started while blood
and urine cultures were performed. This urine culture also grew E. coli sensitive to the current antibiotics.
Her temperature has continued to spike to 39.5C since admission, without any change in her symptoms.
Which one of the following would be most appropriate at this time?
A. Add vancomycin (Vancocin) to the regimen
B. Order a radionuclide renal scan
C. Order intravenous pyelography
D. Order a urine culture for tuberculosis
E. Order CT of the abdomen

Perinephric abscess is an elusive diagnostic problem that is defined as a collection of pus in the tissue
surrounding the kidney, generally in the space enclosed by Gerotas fascia. Mortality rates as high as 50%
have been reported, usually from failure to diagnose the problem in a timely fashion. The difficulty in
making the diagnosis can be attributed to the variable constellation of symptoms and the sometimes
indolent course of this disease. The diagnosis should be considered when a patient has fever and persistence
of flank pain. 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. 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. This can detect perirenal fluid, enlargement of the psoas muscle (both are highly suggestive of
the diagnosis), and perirenal gas (which is diagnostic). The sensitivity and specificity of CT is significantly
greater than that of either ultrasonography or intravenous pyelography. Drainage, either percutaneously or
surgically, along with appropriate antibiotic coverage reduces both morbidity and mortality from this
condition.
A 72-year-old female sees you for preoperative evaluation prior to cataract surgery. Her history and
physical examination are unremarkable, and she has no medical problems other than bilateral cataracts.
Which one of the following is recommended prior to surgery in this patient?
A. An EKG only
B. An EKG and chest radiography
C. A CBC only
D. A CBC and serum electrolytes
E. No testing
According to a recent Cochrane review, routine preoperative testing prior to cataract surgery does not
decrease intraoperative or postoperative complications (SOR A). 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%.
You see a 9-year-old female for evaluation of her asthma. She and her mother report that she has shortness
of breath and wheezing 34 times per week, which improves with use of her albuterol inhaler. She does not
awaken at night due to symptoms, and as long as she has her albuterol inhaler with her she does not feel her
activities are limited by her symptoms. About once per year she requires prednisone for an exacerbation,
often triggered by a viral infection. Based on this information you classify her asthma severity as:
A. intermittent
B. mild persistent
C. moderate persistent
D. severe persistent
The 2007 update to the guidelines for the diagnosis and management of asthma published by the National
Heart, Lung, and Blood Institute outlines clear definitions of asthma severity. Severity is determined by the
most severe category in which any feature occurs. 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. Clinicians can use this assessment to help guide therapy.
Which one of the following is found most consistently in patients diagnosed with irritable bowel
syndrome?
A. Passage of blood per rectum
B. Passage of mucus per rectum
C. Abdominal pain
D. Constipation
E. Diarrhea

A large review of multiple studies identified abdominal pain as the most consistent feature found in irritable
bowel syndrome (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 (SOR A).
Which one of the following is diagnostic for type 2 diabetes mellitus?
A. A fasting plasma glucose level 126 mg/dL on two separate occasions
B. An oral glucose tolerance test (75-g load) with a 2-hour glucose level 160 mg/dL
C. A random blood glucose level 200 mg/dL on two occasions in an asymptomatic person
D. A hemoglobin A 1c 6.0% on two separate occasions
The American Diabetes Association (ADA) first published guidelines for the diagnosis of diabetes mellitus
in 1997 and updated its diagnostic criteria in 2010. With the increasing incidence of obesity, it is estimated
that over 5 million Americans have undiagnosed type 2 diabetes mellitus. Given the long-term risks of
microvascular (renal, ocular) and macrovascular (cardiac) complications, clear guidelines for screening are
critical. The 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 A 1c
6.5%, a fasting plasma glucose level 126 mg/dL, a 2-hour plasma glucose level 200 mg/dL, or, in a
symptomatic patient, a random blood glucose level 200 mg/dL. In the absence of unequivocal
hyperglycemia, results require confirmation by repeat testing.
A 62-year-old male is admitted to the hospital for urosepsis. His medical history is significant only for
hypertension. On examination he has a temperature of 36.5C (97.7F), a TSH level of 0.2 U/mL (N 0.4
5.0), and a free T4 level of 0.4 ng/dL (N 0.61.5).
A. Pituitary adenoma
B. Graves disease
C. Subacute thyroiditis
D. Subclinical hypothyroidism
E. Euthyroid sick syndrome
The euthyroid sick syndrome refers to alterations in thyroid function tests seen frequently in hospitalized
patients, and decreased thyroid function tests may be seen early in sepsis. These changes are statistically
much more likely to be secondary to the euthyroid sick syndrome than to unrecognized pituitary or
hypothalamic disease (SOR C). Graves disease generally is a hyperthyroid condition associated with low
TSH and elevated free T4 . Subclinical hypothyroidism is diagnosed by high TSH and normal free T4
levels. Subacute thyroiditis most often is a hyperthyroid condition.
An 8-year-old female is brought to your office because she has begun to limp. She has had a fever of
38.8C (101.8F) and says that it hurts to bear weight on her right leg. She has no history of trauma.
On examination, she walks with an antalgic gait and hesitates to bear weight on the leg. Range of motion of
the right hip is limited in all directions and is painful. Her sacroiliac joint is not tender, and the psoas sign is
negative. Laboratory testing reveals an erythrocyte sedimentation rate of 55 mm/hr (N 010), a WBC count
of 15,500/mm 3 (N 450013,500), and a C-reactiveprotein level of 2.5 mg/dL (N 0.51.0).
Which one of the following will provide the most useful diagnostic information to further evaluate this
patients problem?
A. MRI
B. CT
C. A bone scan
D. Ultrasonography

E. Plain-film radiography
This child meets the criteria for possible septic arthritis. In this case ultrasonography is recommended over
other imaging procedures. It is highly sensitive for detecting effusion of the hip joint. If an effusion is
present, urgent ultrasound-guided aspiration should be performed. Bone scintigraphy is excellent for
evaluating a limping child when the history, physical examination, 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-Calv-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.
A 17-year-old female sees you for a preparticipation evaluation. She has run 5 miles a day for the last 6
months, and has lost 6 lb over the past 2 months. Her last menstrual period was 3 months ago. Other than
the fact that she appears to be slightly underweight, her examination is normal. To fit the criteria for the
female athlete triad, she must have which one of the following?
A. A formal diagnosis of an eating disorder
B. Amenorrhea for 1 year
C. A Z-score on bone-density testing of 2.5 or less
D. Withdrawal bleeding after progesterone administration
E. A history of a stress fracture resulting from minimal trauma
The initial definition of the female athlete triad was amenorrhea, osteoporosis, and disordered eating. The
American College of Sports Medicine modified this in 2007, emphasizing that the triad components occur
on a continuum rather than as individual pathologic conditions. The definitions have therefore expanded.
Disordered eating is no longer defined as the formal diagnosis of an eating disorder. Energy
availability,defined as dietary energy intake minus exercise energy expenditures, is now considered a risk
factor for the triad, as dietary restrictions and substantial energy expenditures disrupt pituitary and ovarian
function. Primary amenorrhea is defined as lack of menstruation by age 15 in females with secondary sex
characteristics. Secondary amenorrhea is the absence of three or more menstrual cycles in a young woman
previously experiencing menses. For those with secondary amenorrhea, a pregnancy test should be
performed. If this is not conclusive, a progesterone challenge test may be performed. If there is withdrawal
bleeding, the cause would be anovulation. Those who do not experience withdrawal bleeding have
hypothalamic amenorrhea, and fit one criterion for the triad. 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 Zscore of 1 to 2. Osteoporosis is defined as having clinical risk factors for experiencing a fracture, along
with a Z-score <2.
Which one of the following is the most common cause of recurrent and persistent acute otitis media in
children?
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Penicillin-resistant Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Staphylococcus aureus
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella 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.

A 65-year-old asymptomatic female is found to have extensive sigmoid diverticulosis on screening

colonoscopy. She asks whether there are any dietary changes she should make.
In addition to increasing fiber intake, which one of the following would you recommend?
A. Limiting intake of dairy products
B. Limiting intake of spicy foods
C. Limiting intake of wheat flour
D. Limiting intake of nuts
E. No limitations on other intake
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.
Which one of the following should be used first for ventricular fibrillation when an initial defibrillation
attempt fails?
A. Amiodarone (Cordarone)
B. Lidocaine (Xylocaine)
C. Adenosine (Adenocard)
D. Vasopressin (Pitressin)
E. Magnesium
For persistent ventricular fibrillation (VF), in addition to electrical defibrillation and CPR, patients should
be given a vasopressor, which can be either epinephrine or vasopressin. Vasopressin may be substituted for
the first or second dose of epinephrine. Amiodarone should be considered for treatment of VF unresponsive
to shock delivery, CPR, and a vasopressor. Lidocaine is an alternative antiarrhythmic agent, but should be
used only when amiodarone is not available. Magnesium may terminate or 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.
Which one of the following is the best radiographic test for confirming the diagnosis of renal colic?
A. A KUB radiograph
B. Ultrasonography
C. CT
D. Intravenous pyelography
E. MRI
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.
A 50-year-old male has a pre-employment chest radiograph showing a pulmonary nodule. There are no
previous studies available. Which one of the following would raise the most suspicion that this is a
malignant lesion if found on the radiograph?
A. The absence of calcification
B. Location above the midline of the lung
C. A diameter of 4 mm
D. A solid appearance
Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require
evaluation. Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid
appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year. Features
of malignant nodules include a size >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 (SOR B).

A previously healthy 67-year-old male sees you for a routine health maintenance visit. During the physical
examination you discover a harsh systolic murmur that is loudest over the second right intercostal space
and radiates to the carotid arteries. The patient denies any symptoms of dyspnea, angina, syncope, or
decreased exertional tolerance. An echocardiogram shows severe aortic stenosis, with an aortic valve area
of <1 cm 2, a mean gradiant >40 mm Hg, and an ejection fraction of 60%. Which one of the following
would be most appropriate at this point?
A. Coronary angiography
B. Exercise stress testing
C. Treatment with prazosin (Minipress)
D. Referral for aortic valve replacement
E. Watchful waiting
Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with
severe disease (SOR B). 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. Peripheral blockers, such as prazosin, should be avoided because of the risk of hypotension or syncope. Coronary
angiography should be reserved for symptomatic patients who do not have evidence of severe aortic
stenosis on echocardiography performed to evaluate their symptoms, or for preoperative evaluation prior to
aortic valve replacement. Exercise stress testing is not safe with severe aortic stenosis because of the risk of
death during the test.
A 43-year-old female presents to your office for evaluation of a chronic cough that has been present for the
past 6 months. She is not a smoker, and is not aware of any exposure to environmental irritants. She does
not have any systemic complaints such as fever or weight loss, and does not have any symptoms of
heartburn or regurgitation. She is not on any regular medications. Auscultation of the lungs and a chest
radiograph show no evidence of acute disease. A trial of an inhaled bronchodilator and antihistamine
therapy does not improve the patients symptoms. Which one of the following would be the most
appropriate next step?
A. A methacholine inhalation challenge test
B. Pulmonary function testing
C. CT of the chest
D. A trial of a proton pump inhibitor
E. 24-hour pH monitoring
Gastroesophageal reflux disease (GERD) is one of the most common causes of chronic cough. Patients
with chronic cough have a high likelihood of having GERD, even in the absence of gastrointestinal
symptoms (level of evidence 3). In fact, up to 75% of patients with a cough caused by GERD may have no
gastrointestinal symptoms. The cough is thought to be triggered by microaspiration of acidic gastric
contents into the larynx and upper bronchial tree. The American College of Chest Physicians states that
patients with a chronic cough should be given a trial of antisecretory therapy (SOR B). Aggressive acid
reduction using a proton pump inhibitor twice daily before meals for 34 months is the best way to
demonstrate a causal relationship between GERD and extra-esophageal symptoms (SOR B). 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.
A 27-year-old white male construction worker suffers from severe plaque-type psoriasis that has required
systemic therapy. Which one of the following is associated with this condition?
A. A reduced overall risk of cardiovascular mortality
B. A decreased risk of skin cancer with successful treatment

C. A low likelihood of recurrence with successful treatment

D. An increased risk for the condition in the children of affected individuals
E. Low body mass index and difficulty maintaining weight
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. This is
especially true 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.
A 29-year-old gravida 2 para 1 presents for pregnancy confirmation. Her last menstrual period began 6
weeks ago. Her medical history is significant for hypothyroidism, which has been well-controlled on
levothyroxine (Synthroid), 150 g daily, for the past 2 years. Which one of the following would be the most
appropriate next step in the treatment of this patients hypothyroidism during her pregnancy?
A. Add liothyronine (Cytomel) to her current regimen
B. Decrease the levothyroxine dosage
C. Increase the levothyroxine dosage
D. Continue her current regimen
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 46 weeks gestation, and the patient eventually may require a 30%
50% increase in dosage in order to maintain her euthyroid status.
A 37-year-old recreational skier is unable to lift his right arm after falling on his right side with his arm
elevated. Radiographs of the right shoulder are negative, but diagnostic ultrasonography shows a complete
rotator cuff tear. Which one of the following is most accurate with regard to treatment?
A. Surgery is most likely to be beneficial if performed less than 6 weeks after the injury
B. Treatment with NSAIDs for 3 months is recommended before further intervention
C. Subacromial corticosteroid injections will provide functional and symptomatic relief in the majority of
patients
D. Surgical repair of rotator cuff tears to restore function is necessary only in geriatric patients
E. Therapeutic ultrasound of the shoulder will make the condition tolerable during spontaneous healing
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 (SOR B). Advanced age and limited strength are also associated with reduced
surgical benefit. NSAIDs are used for analgesia. Their benefit has not been shown to exceed that of other
simple analgesics, and the side-effect profile may be higher. 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.
A 69-year-old female presents with postmenopausal bleeding. You consider whether to begin your
evaluation with vaginal probe ultrasonography to assess the thickness of her endometrium. In evaluating
the usefulness of this test to either support or exclude a diagnosis of endometrial cancer, which one of the
following statistics is most useful?
A. Likelihood ratio
B. Number needed to treat
C. Prevalence
D. Incidence

E. Relative risk
There has been a large increase in the number of diagnostic tests available over the past 20 years. Although
tests may aid in supporting or excluding a diagnosis, they are associated with expense and the potential for
harm. In addition, the characteristics of a particular test and how the results will affect management and
outcomes must be considered. 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 510 greatly
increase the likelihood of disease, and those less than 0.10.2 greatly decrease it. In the example given, if
the patients 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, and
incidence describes the occurrence of new cases of disease in a population over a defined time period. The
relative risk is the risk of an event in the experimental group versus the control group in a clinical trial.
A 72-year-old male with a history of hypertension and a previous myocardial infarction is diagnosed with
heart failure. Echocardiography reveals systolic dysfunction, and recent laboratory tests indicated normal
renal function, with a serum creatinine level of 1.1 mg/dL (N <1.5), a sodium level of 139 mEq/L (N 136
145), and a potassium level of 3.5 mEq/L (N 3.55.0). He is currently asymptomatic. Which one of the
following medications would be the best choice for initial management in this patient?
A. Furosemide (Lasix)
B. Isosorbide dinitrate (Isordil)
C. Spironolactone (Aldactone)
D. Digoxin
E. Lisinopril (Prinivil, Zestril)
ACE inhibitors such as lisinopril are indicated for all patients with heart failure due to systolic dysfunction,
regardless of severity. ACE inhibitors have been shown to reduce both morbidity and mortality, in both
asymptomatic and symptomatic patients, in randomized, controlled trials. Unless absolutely
contraindicated, ACE inhibitors should be used in all heart failure patients. No ACE inhibitor has been
shown to be superior to another, and no study has failed to show benefit from an ACE inhibitor (SOR A).
Direct-acting vasodilators such as isosorbide dinitrate also could be used in this patient, but ACE inhibitors
have been shown to be superior in randomized, controlled trials (SOR B). -Blockers are also
recommended in heart failure patients with systolic dysfunction (SOR A), except those who have dyspnea
at rest or who are hemodynamically unstable. These agents have been shown to reduce mortality from heart
failure. 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 (SOR B). 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.
A 14-year-old female with a history of asthma is having daytime symptoms about once a week and
symptoms that awaken her at night about once a month. Her asthma does not interfere with normal activity,
and her FEV1 is >80% of predicted. Which one of the following is the most appropriate treatment plan for
this patient?
A. A short-acting inhaled -agonist as needed
B. Low-dose inhaled corticosteroids daily
C. A leukotriene receptor antagonist daily
D. Medium-dose inhaled corticosteroids daily
E. Low-dose inhaled corticosteroids plus a long-acting inhaled -agonist daily

Based on this patients 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 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 -agonist.
A 55-year-old female with diabetes mellitus, hypertension, and hyperlipidemia presents to your office for
routine follow-up. Her serum creatinine level is 1.5 mg/dL (estimated creatinine clearance 50 mL/min).
Which one of the following diabetes medications would be contraindicated in this patient?
A. Metformin (Glucophage)
B. Exenatide (Byetta)
C. Acarbose (Precose)
D. Insulin glargine (Lantus)
E. Pioglitazone (Actos)
Metformin is contraindicated in patients with chronic kidney disease. It should be stopped in females with
a creatinine level 1.4 mg/dL and in males with a creatinine level 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 <30 mL/min.
Insulin glargine can be used in patients with renal disease at any stage, but the dosage may need to be
decreased.
A 54-year-old female presents with a 2-month history of intense vulvar itching that has not improved with
topical antifungal treatment. On examination you note areas of white, thickened, excoriated skin.
Concerned about malignancy you perform punch biopsies, which reveal lichen sclerosus.The treatment of
choice for this condition is topical application of:
A. conjugated estrogens
B. fluorinated corticosteroids
C. petrolatum
D. 2% testosterone
E. fluorouracil (Efudex)
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.
Staff members of an assisted-living facility ask for your advice regarding aerobic exercise programs for
their older residents. The evidence is greatest for which one of the following benefits of physical activity in
the elderly?
A. Maintaining weight after weight loss
B. Improving quality of sleep
C. Increasing bone density
D. Reducing the risk of falls
There is strong evidence that physical activity will prevent falls in the elderly. The evidence for maintaining
weight, improving sleep, and increasing bone density is not as strong.

The U.S. Preventive Services Task Force (USPSTF) has stated that the potential cardiovascular benefits of
daily aspirin use outweigh the potential harms of gastrointestinal hemorrhage in certain populations. The
USPSTF currently recommends daily aspirin use for which one of the following populations?
A. Males 2544 years of age
B. Males over 80 years of age
C. Females 2544 years of age
D. Females over 45 years of age
E. Females 5579 years of age
The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin use for males 4579 years
of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an
increase in gastrointestinal hemorrhage, and for females 5579 years of age when the potential benefit of a
reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage
(SOR A, USPSTF A Recomendation). 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 (USPSTF I Recommendation). 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 (USPSTF D Recommendation).
You see a newly adopted 5-month-old for his first well child visit. The parents ask when the child can sit in
a safety seat in the car facing forward. You would advise that the child should face rearward until he is at
least:
A. 12 months of age AND weighs 20 lb
B. 15 months of age AND weighs 25 lb
C. 15 months of age OR weighs 25 lb
D. 18 months of age AND weighs 30 lb
E. 18 months of age OR weighs 30 lb
If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso,
and hips, but the head and neck have no support. Without support, the infants head moves rapidly forward
in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a
rear-facing position, the force of the crash is distributed evenly across the babys torso, and the back of the
child safety seat supports and protects the head and neck. For these reasons, the rear-facing position should
be used until the child is at least 12 months old and weighs at least 20 lb (9 kg). For example, a 13-monthold child who weighs 19 lb should face rearward, and a 6-month-old child who weighs 21 lb should also
face rearward.
Which one of the following is most appropriate for the treatment of fibromyalgia syndrome?
A. Metaxalone (Skelaxin)
B. Hydrocodone
C. Naproxen
D. Tizanidine (Zanaflex)
E. Amitriptyline
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. In addition, a 2008 evidence-based review for the management
of fibromyalgia syndrome performed for the European League Against Rheumatism recommends heated
pool treatment with or without exercise, tramadol for the management of pain, and certain
antidepressants,including amitriptyline. Evidence for long-term effectiveness of antidepressants in
fibromyalgia syndrome is lacking, however.

In the secondary prevention of ischemic cardiac events, which one of the following is most likely to be
beneficial in a 68-year-old female with known coronary artery disease and preserved left ventricular
function?
A. ACE inhibitors
B. Hormone therapy
C. Calcium channel blockers
D. Vitamin E
E. Oral glycoprotein IIb/IIIa receptor inhibitors
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 myocardial infarction or are at
high risk because of severe coronary artery stenosis, angina, or prior coronary surgical procedures.
Effective treatments include aspirin, -blockers after myocardial infarction, ACE inhibitors in patients at
high risk after myocardial infarction, angiotensin II receptor blockers in those with coronary artery disease,
and amiodarone in patients who have had a myocardial infarction 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 myocardial infarction.
Contrary to decades of large observational studies, multiple randomized, controlled trials show no cardiac
benefit from hormone therapy in postmenopausal women.
A chest radiograph of the driver of an automobile involved in a head-on collision shows a widened
mediastinum. This suggests:
A. myocardial contusion
B. spontaneous rupture of the esophagus
C. rupture of a bronchus
D. partial rupture of the thoracic aorta
E. acute heart failure
Deceleration-type blows to the chest can produce partial or complete transection of the aorta. A chest
radiograph 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).
The most common initial symptom of Hodgkin lymphoma is:
A. unexplained fever
B. night sweats
C. weight loss
D. painless lymphadenopathy
E. cough
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.
A 91-year-old white male presents with a 6-month history of a painless ulcer on the dorsum of the proximal
interphalangeal joint of the second toe. Examination reveals a hallux valgus and a rigid hammer toe of the
second digit. His foot has mild to moderate atrophic skin changes, and the dorsal and posterior tibial pulses
are absent. Appropriate treatment includes which one of the following?
A. Surgical correction of the hammer toe
B. Custom-made shoes to protect the hammer toe

C. Bunionectomy
D. A metatarsal pad
The treatment of foot problems in the elderly is difficult because of systemic and local infirmities, the most
limiting being the poor vascular status of the foot. 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.
Hantavirus pulmonary syndrome results from exposure to the excreta of:
A. migratory fowl
B. bats
C. parrots
D. mice
E. turtles
Hantavirus pulmonary syndrome results from exposure to rodent droppings, mainly the deer mouse in the
southwestern U.S. About 10% of deer mice are estimated to be infected with hantavirus. In other parts of
the country the virus is carried by the white-footed mouse. While other rodents are carriers of the virus,
they are less likely to live near dwellings, and populations are less dense.
A 28-year-old white female consults you with a complaint of irregular heavy menstrual periods. A general
physical examination, pelvic examination, and Papanicolaou test are normal and a pregnancy test is
negative. A CBC and chemistry profile are also normal. The next step in her workup should be:
A. endometrial aspiration
B. dilatation and curettage
C. LH and FSH assays
D. administration of estrogen
E. cyclic administration of progesterone for 3 months
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. However, the patient who is younger than 30
years of age will rarely be found to have a structural uterine defect. 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. 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.
A 45-year-old male with chronic nonmalignant back pain is on a chronic narcotic regimen. Which one of
the following behaviors is LEAST likely to be associated with pseudoaddiction, as opposed to true
addiction?
A. Requesting a specific drug
B. Aggressive complaining about needing more medication
C. Hoarding drugs during periods of reduced symptoms
D. Requesting medication exactly at prescribed times when hospitalized
E. Concurrent abuse of alcohol or illicit drugs
The use of narcotics for chronic nonmalignant pain is becoming more commonplace. Guidelines have been
developed to help direct the use of these medications when clinically appropriate. However, even when
given appropriately, the use of opioid medications for pain relief can cause both the physician and the

patient to be concerned about the possibility of addiction. Addiction is a neurobiologic, multifactorial

disease characterized by impaired control, compulsive drug use, and continued use despite harm.
Pseudoaddiction is a term used to describe patient behaviors that may occur when pain is undertreated.
Patients with unrelieved pain 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. Agreements for use of chronic opioids should include
the expectation that alcohol and illicit drugs will not be used concurrently, and doing so suggests addiction
rather than pseudoaddiction.
Which one of the following is true regarding death certificates?
A. The immediate cause of death is the final or terminal cause of death, such as cardiac arrest
B. A physician can certify a death from a natural cause but a coroner or medical examiner must certify a
death due to any other cause
C. In a case of unknown or probable cause of death, the manner of death is designated as uncertain
D. Death certificates are part of the patients medical record and, as such, are confidential and regulated by
HIPAA laws
E. In a case of death due to an accidental fall, the immediate attending physician must complete the death
certificate
It would be difficult to overstate the importance of death certificates, especially in an era of increasing
reliance on evidence-based medicine, yet physicians receive inadequate training in this important area, and
their performance on this task remains less than ideal. Death certificates are the primary tool for measuring
the mortality rate and its many ramifications in socioeconomic matters such as research funding, estate
settlement, financial matters, and other legal concerns. Most problems with death certificates stem from a
failure to complete them correctly. Notably, one study showed a 50% decrease in errors after primary care
physicians attended a 75-minute educational session. Only coroners and medical examiners can complete a
death certificate when the manner of death is not natural. The immediate cause of death is a specific
etiology, not a general concept. Uncertain is not a manner of death, but undetermined may be used by
coroners and medical examiners. The death certificate is a public document when filed.
A 10-week-old term male infant is brought to your office with a 2-day history of difficulty breathing. He
has been healthy since birth, with the exception of a 3-day episode of wheezing and rhinorrhea 3 weeks
ago. Your initial examination shows an alert infant with increased work of breathing, rhinorrhea, and
wheezing. His oxygen saturation is 93% and his temperature is 38.4C (101.1F). Which one of the
following would be most appropriate at this point?
A. Antigen testing or another rapid assay
B. A baseline chest radiograph
C. A trial of nebulized albuterol (AccuNeb)
D. Advising the parents that the child can safely be returned to day care tomorrow
The American Academy of Pediatrics guideline on the diagnosis and management of bronchiolitis
recommends against the use of laboratory or radiographic studies to make the diagnosis, although
additional testing may be appropriate if there is no improvement. Bronchiolitis can be caused by a number
of different viruses, alone or in combination, and the knowledge gained from virologic testing rarely
influences management decisions or outcomes for the vast majority of children. While the guideline does
not support routine use of bronchodilators in the management of bronchiolitis, it does allow for a trial of
bronchodilators as an option in selected cases, and continuation of the treatment if the patient shows
objective improvement in respiratory status. Bronchodilators have not been shown to affect the course of
bronchiolitis with respect to outcomes. The guideline places considerable emphasis on hygienic practices,
including the use of alcohol-based hand sanitizers before and after contact with the patient or inanimate

objects in the immediate vicinity. Education of the family about hygienic practices is recommended as well.
Returning the child to day care the next day is potentially harmful.
Which one of the following is true concerning Pagets disease of bone?
A. It is a precursor of multiple myeloma
B. Both bone formation and bone resorption are increased
C. The treatment of choice for symptomatic disease is a calcium channel blocker
D. Pagetic bone pain is difficult to relieve and resistant to medical treatment
E. Extracellular calcium homeostasis is typically abnormal
Pagets 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 Pagets 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 Pagets 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 invariably normal.
The FDA recommends that over-the-counter cough and cold products not be used in children below the age
of:
A. 1 year
B. 2 years
C. 3 years
D. 4 years
E. 5 years
In 2008 the FDA issued a public health advisory for parents and caregivers, recommending that over-thecounter 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.
In a patient with hyperuricemia who has experienced an attack of gout, which one of the following is
LEAST likely to precipitate another gout attack?
A. Red meat
B. Milk
C. Seafood
D. Nuts
E. Beans
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.
Which one of the pharmacologic effects of transdermal medications changes the LEAST with aging?
A. Liver metabolism of the drugs
B. Renal excretion of the drugs
C. Distribution within the body
D. Transdermal absorption of the drugs

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.
A patient presents with a pigmented skin lesion that could be a melanoma. Its largest dimension is 0.5 cm.
What should be the first step in management?
A. A shave biopsy
B. Excision with a 1-mm margin
C. Wide excision with a 1-cm margin
D. Excision with sentinel node dissection
The diagnosis of melanoma should be made by simple excision with clear margins. A shave biopsy should
be avoided because determining the thickness of the lesion is critical for staging. Wide excision with or
without node dissection is indicated for confirmed melanoma, depending on the findings from the initial
excisional biopsy.
Which one of the following is true regarding the treatment of generalized anxiety disorder?
A. Cognitive-behavioral therapy has been shown to be at least as effective as pharmacologic therapy
B. Buspirone (BuSpar) is as effective as SSRI therapy for patients with comorbid depression
C. Benzodiazepines are no more effective than placebo
D. Duloxetine (Cymbalta) is no more effective than placebo
E. Escitalopram (Lexapro) is no more effective than placebo
Cognitive-behavioral therapy has been shown to be at least as effective as medication for treatment of
generalized anxiety disorder (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.
A 20-month-old male presents with a history of a fever up to 38.5C (101.3F), pulling at both ears,
drainage from his right ear, and a poor appetite following several days of nasal congestion. This is his first
episode of acute illness, and he has no history of drug allergies.
The fever is confirmed on examination and the child is found to be fussy but can be distracted. He is eating
adequately and shows no signs of dehydration. Positive findings include mild nasal congestion, a purulent
discharge from the right auditory canal, and a red, bulging, immobile tympanic membrane in the left
auditory canal. Which one of the following would be first-line treatment for this patient?
A. Ceftriaxone (Rocephin)
B. Amoxicillin/clavulanate (Augmentin)
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Penicillin VK
This patient has acute bilateral otitis media, with presumed tympanic membrane perforation, and qualifies
by any criterion for treatment with antibiotics. Amoxicillin, 8090 mg/kg/day, should be the first-line
antibiotic for most children with acute otitis media (SOR B). The other medications listed are either
ineffective because of resistance (e.g., penicillin), are second-line treatments (e.g., amoxicillin/clavulanate),
or should be used in patients with a penicillin allergy or in other special situations.

The Centers for Disease Control and Prevention recommends empiric treatment of male sexual partners for
which one of the following conditions?
A. Vaginal candidiasis
B. Vaginal warts
C. Pelvic inflammatory disease
D. Bacterial vaginosis
The promise of a reduction in the incidence and prevalence of sexually transmitted diseases through partner
notification and treatment programs remains elusive, as evidence supporting this effect is scarce and
inconclusive. What is clear is that treating sexual partners does reduce reinfection of the index patient.
Programs such as contact notification, counseling and scheduling of appointments for evaluation of the
partner, and expedited partner therapy (EPT), in which sexual contacts of infected patients are provided
antibiotics delivered by the index patient without evaluation or counseling, have demonstrated only limited
effectiveness; in the case of EPT this limited benefit has been shown only with trichomoniasis. Because
currently available evidence fails to demonstrate benefit from treating the male sexual contacts of women
with vaginal candidiasis, vaginal warts, or bacterial vaginosis, the Centers for Disease Control and
Prevention (CDC) states that treating the male partner is not indicated with these infections. In the case of
pelvic inflammatory disease (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 effective against both chlamydial and gonococcal infection, regardless of the presumed etiology
of the PID.
An asymptomatic 68-year-old male sees you for a health maintenance visit. He is a former cigarette
smoker, but quit 20 years ago. According to the U.S. Preventive Services Task Force, evidence shows that
the potential benefit exceeds the risk for which one of the following screening tests in this patient?
A. A chest radiograph
B. Abdominal ultrasonography
C. Ophthalmic tonometry
D. A prostate-specific antigen level
E. An EKG
The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic
aneurysm (AAA) by ultrasonography in men aged 6575 who have ever smoked (SOR B, USPSTF B
Recommendation). The 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. There is good evidence that
abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited
facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence
of important harms from screening and early treatment, including an increased number of operations, with
associated clinically significant morbidity and mortality, and short-term psychological harms. Based on the
moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men
aged 6575 who have ever smoked outweighs the potential harm. While they may be considered for
making the diagnosis in patients who have symptoms, none of the other tests listed have evidence to
support a net benefit from their use as routine screening tools in patients like the one described here.
A 52-year-old hypertensive male has had two previous myocardial infarctions. In spite of his best efforts,
he has not achieved significant weight loss and he finds it difficult to follow a heart-healthy diet. He takes
rosuvastatin (Crestor), 20 mg/day, and his last lipid profile showed a total cholesterol level of 218 mg/dL, a
triglyceride level of 190 mg/dL, an HDL-cholesterol level of 45 mg/dL, and an LDL-cholesterol level of
118 mg/dL. Which one of the following would be the most appropriate change in management?
A. Increase the rosuvastatin dosage
B. Add atorvastatin (Lipitor)
C. Add niacin
D. Add fenofibrate (Lipofen, Tricor)

E. Add ezetimibe (Zetia)

This patients goal LDL-cholesterol level is 70 mg/dL, and he is not at the maximum dosage of a potent
statin. There is no data that shows that adding a different statin will be beneficial, and outcomes data for the
other actions is lacking. For patients not at their goal LDL-cholesterol level, the maximum dosage of a
statin should be reached before alternative therapy is chosen.
Screening for colon cancer would be recommended for which one of the following patients?
A. A 35-year-old male whose mother was diagnosed with colon cancer at age 52
B. A 40-year-old female whose mother was diagnosed with colon cancer at age 54
C. A 44-year-old female whose father had a tubular adenoma <1 cm in size removed during colonoscopy at
age 50
D. A 46-year-old male whose paternal uncle was diagnosed with colon cancer at age 51
E. A 48-year-old female whose father was diagnosed with colon cancer at age 74
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 either at age 40 or 10 years before the age at diagnosis of the youngest affected
relative, whichever comes first. The 2008 update of the guidelines on screening for CRC published by the
American College of Gastroenterology no longer recommends earlier screening for patients who have a
single first degree relative with CRC diagnosed at 60 years of age or after. Another change in this guideline
is that an increased level of screening is no longer recommended for a simple family history of adenomas in
a first degree relative.
A hemoglobin A1c of 7.0% would correspond to which one of the following mean (average) plasma
glucose levels?
A. 126 mg/dL
B. 154 mg/dL
C. 183 mg/dL
D. 212 mg/dL
E. 240 mg/dL
A hemoglobin A1c(HbA1c) of 6.0% correlates with a mean plasma glucose level of 126 mg/dL or 7.0 1c 1c
mmol/dL. A rough guide for estimating average plasma glucose levels assumes that an A1c of 6.0% equals
an average glucose level of 120 mg/dL. Each percentage point increase in 1c 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.
A 50-year-old male is brought to the emergency department with shortness of breath, chest tightness,
tremulousness, and diaphoresis. Aside from tachypnea, the physical examination is normal. Arterial blood
gases on room air show a pO2 of 98 mm Hg (N 80100), a pCO2 of 24 mm Hg (N 3545), and a pH of
7.57 (N 7.387.44). The most likely cause of the patients blood gas abnormalities is:
A. carbon monoxide poisoning
B. anxiety disorder with hyperventilation
C. an acute exacerbation of asthma
D. pulmonary embolus
E. pneumothorax
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 pulmonary embolism, pO2 and pCO2 are
decreased, while the pH is elevated, indicating the acute nature of the disorder. With the other diagnoses,
findings on the physical examination would be different than those seen in this patient. Vital signs would be

normal with carbon monoxide poisoning, and 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.
A 58-year-old male presents with recent behavior and personality changes, and you suspect dementia.
Which one of the following is most likely to present in this manner?
A. Alzheimers disease
B. Vascular dementia
C. Mixed Alzheimers disease and vascular dementia
D. Frontotemporal dementia
E. Progressive supranuclear palsy
Frontotemporal dementia is the second most common cause of early-onset dementia. It often presents with
behavioral and personality changes. Examples include disinhibition, impairment of personal conduct, loss
of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimers 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. Alzheimers 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.
A 60-year-old female receiving home hospice care was taking oral morphine, 15 mg every 2 hours, to
control pain. When this was no longer effective, she was transferred to an inpatient facility for pain control.
She required 105 mg of morphine in a 24-hour period, so she was started on intravenous morphine, 2 mg/hr
with a bolus of 2 mg, and was well controlled for 5 days. However, her pain has worsened over the past 2
days. Which one of the following is the most likely cause of this patients increased pain?
A. An inadequate initial morphine dose
B. Addiction to morphine
C. Pseudoaddiction to morphine
D. Physical dependence on morphine
E. Tolerance to morphine
This patient has become tolerant to morphine. The intravenous dose should be a third of the oral dose, so
the starting intravenous 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.
A 72-year-old white male presents with a complaint of headache, blurred vision, and severe right eye pain.
His symptoms began acutely about 1 hour ago. Examination of the eye reveals a mid-dilated, sluggish
pupil; a hazy cornea; and a red conjunctiva. Which one of the following is the most likely diagnosis?
A. Retinal detachment
B. Central retinal artery occlusion
C. Mechanical injury to the globe
D. Acute angle-closure glaucoma
This patient presents with acute angle-closure glaucoma, manifested by an acute onset of severe pain,
blurred vision, halos around lights, increased intraocular pressure, 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; increasing 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
(SOR B).
The mother of an 8-year-old female is concerned about purple warts on her daughters hands. The mother
explains that the lesions started a few months ago on the right hand along the top of most of the knuckles
and interphalangeal joints, and she has recently noticed them on the left hand. The child has no other
complaints and the mother denies any unusual behaviors. A physical examination is unremarkable except
for the slightly violaceous, flat-topped lesions the mother described. What is the most likely cause for this
patients finger lesions?
A. Dermatomyositis
B. Aggressive warts
C. Rubbing/wringing of the hands
D. Bulimia nervosa
E. Child abuse
One of the most characteristic findings in dermatomyositis is Gottrons papules, which are flat-topped,
sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal
joints.
A 20-year-old patient comes to the emergency department complaining of shortness of breath. On
examination his heart rate is 180 beats/min, and his blood pressure is 122/68 mm Hg. An EKG reveals a
narrow complex tachycardia with a regular rhythm. Which one of the following would be the most
appropriate initial treatment?
A. Amiodarone (Cordarone)
B. Diltiazem (Cardizem)
C. Adenosine (Adenocard)
D. Magnesium
E. Synchronized cardioversion
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 intravenous 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.
Which one of the following is true regarding the risk of inducing cancer with CT scanning?
A. CT of the chest is associated with a greater risk than CT of the head
B. The risk increases with age at the time of the scan
C. Males have a greater risk of ultimately developing CT-induced lung cancer than females
D. Current techniques with rapid scanners make the risk comparable to that associated with standard
radiographs of the same area
E. The risk in neonates is markedly reduced because of the efficiency of DNA repair processes at this age
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.
A patient complains of throbbing bone pain in her lower back and legs. She also has felt weaker recently.
Which one of the following tests would confirm a vitamin D deficiency?
A. 25-hydroxyvitamin D
B. 1,25-dihydroxyvitamin D

C. Ergocalciferol (vitamin D2 )
D. Cholecalciferol (vitamin D3 )
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 (SOR A). 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 (SOR
2 3B).
When obtaining informed consent from a patient, which one of the following is NOT required for a patient
to legally have decision-making capacity?
A. The absence of mental illness
B. The ability to express choice
C. The ability to understand relevant information
D. The ability to engage in reasoning
E. The ability to appreciate the significance of information and its consequences
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.
A patient is sent to you by his employer after falling down some steps and twisting his ankle and foot.
Which one of the following would be the most appropriate reason to obtain foot or ankle radiographs?
A. Notable swelling and discoloration over the anterior talofibular ligament
B. A complaint of marked pain with weight bearing as he walks into the examining room
C. Pain in the maleolar zone and bone tenderness of the posterior medial malleolus
D. The absence of passive plantar foot flexion when the calf is squeezed (Thompson test)
The Ottawa ankle and foot rules are prospectively validated decision rules that help clinicians decrease the
use of radiographs for foot and ankle injuries without increasing the rate of missed fracture. The rules apply
in the case of blunt trauma, including twisting injuries, falls, and direct blows. According to these
guidelines, an 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
emergency department, is also an indication for ankle radiographs. 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, or if
the patient is unable to bear weight both immediately after the injury and in the emergency department. A
positive Thompson sign, seen with Achilles tendon rupture, is the absence of passive plantar foot flexion
when the calf is squeezed.
A 77-year-old white male complains of urinary incontinence of more than one years duration. 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 hypertrophy 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 patients incontinence?
A. Detrusor instability
B. Urinary tract infection
C. Overflow
D. Fecal impaction

E. Recurrent bladder outlet obstruction

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 as 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 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).
A 47-year-old male is preparing for a 3-day trip to central Mexico to present the keynote address for an
international law symposium. He asks you for an antibiotic to be taken prophylactically to prevent bacterial
diarrhea. Which one of the following would you recommend?
A. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
B. Rifaximin (Xifaxan)
C. Doxycycline
D. Nitrofurantoin (Macrobid)
While prophylactic antibiotics are not generally recommended for prevention of travelers diarrhea, they
may be useful under special circumstances for certain high-risk hosts, such as the immunocompromised, or
for those embarking on critical short trips for which even a short period of diarrhea might cause undue
hardship. Rifaximin, a nonabsorbable antibiotic, has been shown to reduce the risk for travelers diarrhea
by 77%. Trimethoprim/sulfamethoxazole and doxycycline are no longer considered effective antimicrobial
agents against enteric bacterial pathogens. Increasing resistance to the fluoroquinolones, especially among
Campylobacter species, is limiting their use as prophylactic agents.
A 34-year-old female with a history of bilateral tubal ligation consults you because of excessive body and
facial hair. She has a normal body weight, no other signs of virilization, and regular menses. Which one of
the following is the most appropriate treatment for her mild hirsutism?
A. Spironolactone (Aldactone)
B. Leuprolide (Lupron)
C. Prednisone
D. Metformin (Glucophage)
Antiandrogens such as spironolactone, along with oral contraceptives, are recommended for treatment of
hirsutism in premenopausal women (SOR C). In addition to having side effects, prednisone is only
minimally helpful for reducing hirsutism by suppressing adrenal androgens. Leuprolide, although better
than placebo, has many side effects and is expensive. Metformin can be used to treat patients with
polycystic ovarian syndrome, but this patient does not meet the criteria for this diagnosis.
An 80-year-old male nursing-home resident is brought to the emergency department because of a severe,
productive cough associated with a high fever, hypoxia, and hypotension. The patient is found to have a left
lower lobe pneumonia, and admission to the intensive-care unit is advised. Which one of the following is
the most appropriate antibiotic therapy for this patient?
A. Moxifloxacin (Avelox)
B. Ceftriaxone (Rocephin) and azithromycin (Zithromax)
C. Doxycycline
D. Ceftriaxone and metronidazole (Flagyl)
E. Ceftazidime (Fortaz), imipenem/cilastatin (Primaxin), and vancomycin (Vancocin)

Empiric coverage for methicillin-resistant Staphylococcus aureus and double coverage for pseudomonal
pneumonia should be prescribed in patients with nursing homeacquired pneumonia requiring intensivecare unit admission (SOR B).
A 67-year-old white female has a DXA scan with a resulting T-score of 2.7. She has a strong family
history of breast cancer. Which one of the following would be the most appropriate treatment for this
patient?
A. A bisphosphonate
B. Raloxifene (Evista)
C. Calcitonin nasal spray (Miacalcin)
D. Teriparatide (Forteo)
E. Conjugated estrogens (Premarin)
Raloxifene is a selective estrogen receptor modulator. While it increases the risk of venous
thromboembolism, it is indicated in this patient to decrease the risk of invasive breast cancer (SOR A).
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 human parathyroid hormone 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 (SOR C).
A 50-year-old white female comes to you because she has found a breast mass. Your examination reveals a
firm, fixed, nontender, 2-cm mass. No axillary nodes are palpable, nor is there any nipple discharge. You
send her for a mammogram, and fine-needle aspiration is performed to obtain cells for cytologic
examination. The mammogram is read as suspicious and the fine-needle cytology report reads, a few
benign ductal epithelioid cells and adipose tissue. Which one of the following would be the most
appropriate next step?
A. A repeat mammogram in 3 months
B. Repeat fine-needle aspiration in 3 months
C. An excisional biopsy of the mass
D. Referral for breast irradiation
E. Referral to a surgeon for simple mastectomy
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.
A 67-year-old female comes to your office because she noticed flashing lights in her left eye 2 hours ago,
and since then has had decreased vision in the lateral aspect of that eye. On examination she has a blind
spot in the lateral visual field of her left eye. Her fundus is difficult to examine because of an early cataract.
Which one of the following is the most likely diagnosis?
A. Posterior vitreous detachment
B. Vitreous hemorrhage
C. Macular degeneration
D. Ocular migraine
E. Retinal detachment

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.
A 27-year-old white female at 12 weeks gestation comes to your office complaining of a vaginal discharge.
On speculum examination you note a purulent cervical discharge with a friable cervix. A gonorrhea culture
is negative. You make a diagnosis of Chlamydia trachomatis cervicitis. Which one of the following is the
appropriate treatment?
A. Metronidazole (Flagyl)
B. Tetracycline
C. Azithromycin (Zithromax)
D. Miconazole (Monistat) cream
Azithromycin is the drug of choice for Chlamydia trachomatis infections in pregnant patients.
Metronidazole is used to treat trichomoniasis and Gardnerella vaginitis after 12 weeks gestation. The use of
tetracycline is not appropriate in pregnant women, and miconazole is used to treat vaginal candidiasis.
A previously alert, otherwise healthy 74-year-old African-American male has a history of slowly
developing progressive memory loss and dementia associated with urinary incontinence and gait
disturbance resembling ataxia. This presentation is most consistent with:
A. normal pressure hydrocephalus
B. Alzheimers disease
C. subacute sclerosing panencephalitis
D. multiple sclerosis
In normal pressure hydrocephalus a mild impairment of memory typically develops gradually over weeks
or months, accompanied by mental and physical slowness. The condition progresses insidiously to severe
dementia. Patients also develop an unsteady gait and urinary incontinence, but there are no signs of
increased intracranial pressure. In Alzheimers disease the brain very gradually atrophies. A disturbance in
memory for recent events is usually the first symptom, along with some 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. The clinical picture is
pleomorphic, but there are usually sufficient 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.
You see a 1-year-old male for a routine well child examination. Laboratory tests reveal a hemoglobin level
of 10 g/dL (N 914), a hematocrit of 31% (N 2842), a mean corpuscular volume of 68 :m3 (N 7086), and
a mean corpuscular hemoglobin concentration of 25 g/dL (N 3036). A trial of iron therapy results in no
improvement and a serum lead level is normal. Which one of the following would be the most appropriate
test at this time?
A. Hemoglobin electrophoresis
B. Bone marrow examination
C. Vitamin B12 and folate levels
D. A TSH level
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.
Which one of the following is most accurate regarding somatization disorder?
A. Onset before age 40 is atypical
B. It is a form of malingering
C. Symptoms tend to resolve spontaneously within weeks of onset
D. Symptoms are limited to one organ system or bodily function
E. The incidence is increased among female first degree relatives of patients with the disorder
Somatization disorder is a psychological disorder characterized by the chronic presence of several
unexplained symptoms beginning before the age of 30 years. It is diagnostically grouped with conversion
disorder, hypochondriasis, and body dysmorphic disorder. By definition, the symptom complex must
include a minimum of two symptoms relating to the gastrointestinal 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.
A 42-year-old white male develops respiratory distress 12 hours after he sustained a closed head injury and
a femur fracture. A physical examination reveals a respiratory rate of 40/min. He has a pO2 of 45 mm Hg
(N 75100), a pCO2 of 25 mm Hg (N 3545), and a blood pH of 7.46 (N 2 2 7.357.45). His hematocrit is
30.0% (N 37.049.0). Of the following, the most likely diagnosis is:
A. respiratory depression due to central nervous system damage
B. heart failure
C. adult respiratory distress syndrome (ARDS)
D. hypovolemic shock
E. tension pneumothorax
Acute respiratory failure following severe injury and critical illness has received increasing attention over
the last decade. With advances in the management of hemorrhagic shock and support of circulatory and
renal function in injured patients, it has become apparent that 1%2% of significantly injured patients
develop acute respiratory failure in the post-injury period. Initially this lung injury was thought to be
related to a particular clinical situation. This is implied by such names as shock lung and traumatic wet
lung, which have been applied to acute respiratory insufficiency. It is now recognized that the pulmonary
problems that follow a variety of insults have many similarities in their clinical presentation and
physiologic and pathologic findings. This has led to the 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 alveolarcapillary 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 adult respiratory distress syndrome (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.
A 40-year-old white male presents with a 5-year history of periodic episodes of severe right-sided
headaches. During the most recent episode the headaches occurred most days during January and February
and lasted about 1 hour. The most likely diagnosis is which one of the following?
A. Migraine headache
B. Cluster headache
C. Temporal arteritis
D. Trigeminal neuralgia

Cluster headache is predominantly a male disorder. The mean age of onset is 2730 years. Attacks often
occur in cycles and are unilateral. Migraine headaches are more common in women, start at an earlier age
(second or third decade), and last longer (424 hours). Temporal arteritis occurs in patients above age 50.
Trigeminal neuralgia usually occurs in paroxysms lasting 2030 seconds.
A 24-year-old male presents with a fever of 38.9C (102.0F), generalized body aches, a sore throat, and a
cough. His symptoms started 24 hours ago. He is otherwise healthy. You suspect novel influenza A H1N1
infection, as there have been numerous cases in your community recently. A rapid influenza diagnostic test
is positive, and you recommend over-the-counter symptomatic treatment. You see him 2 days later after he
is admitted to the hospital through the emergency department with dehydration and mild respiratory
distress. A specimen is sent to the state laboratory for PCR testing. Which one of the following would be
most appropriate at this point?
A. Oseltamivir (Tamiflu)
B. Zanamivir (Relenza)
C. Amantadine (Symmetrel)
D. Rimantadine (Flumadine)
E. No antiviral treatment
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.
A 59-year-old white male is being evaluated for hypertension. His blood pressure is 150/95 mm Hg. His
medical history includes impotence, asthma, gout, first degree heart block, diet-controlled diabetes mellitus,
and depression, but he is currently taking no medications. He has a past history of alcohol abuse, but quit
drinking 10 years ago. Which one of the following would be the best choice for INITIAL therapy of his
hypertension?
A. Propranolol (Inderal)
B. Verapamil (Calan, Isoptin)
C. Clonidine (Catapres)
D. Hydrochlorothiazide/triamterene (Dyazide)
E. Enalapril (Vasotec)
Because of their favorable side-effect profile, ACE inhibitors (e.g., enalapril) may be the drugs of first
choice for the majority of unselected hypertensive patients. ACE inhibitors are not associated with
depression or sedation, and they are safe to use in patients with diabetes mellitus. Centrally-acting blockers can be associated with depression. Calcium-channel blockers, -blockers, and other sympatholytic
drugs affect cardiac conductivity.-Blockers are contraindicated in patients with asthma, and are also
associated with impotence. Thiazide diuretics raise uric acid and blood glucose levels.
A 51-year-old immigrant from Vietnam presents with a 3-week history of nocturnal fever, sweats, cough,
and weight loss. A chest radiograph reveals a right upper lobe cavitary infiltrate. A PPD produces 17 mm of
induration, and acid-fast bacilli are present on a smear of induced sputum. While awaiting formal
laboratory identification of the bacterium, which one of the following would be most appropriate?
A. Observation only
B. INH only
C. INH and ethambutol (Myambutol)
D. INH, ethambutol, and pyrazinamide
E. INH, ethambutol, rifampin (Rifadin), and pyrazinamide

Leading authorities, including experts from the American Thoracic Society, CDC, and Infectious Diseases
Society of America, mandate aggressive initial four-drug treatment when tuberculosis 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, although one regimen does not include pyrazinamide but extends coverage with the other
antibiotics. Treatment regimens can be modified once culture results are available.
An incidental 2-cm adrenal nodule is discovered on renal CT performed to evaluate hematuria in a 57-yearold female with flank pain. She has no past medical history of palpitations, headache, hirsutism, sweating,
osteoporosis, diabetes mellitus, or hypertension. A physical examination is normal, with the exception of a
blood pressure of 144/86 mm Hg. Laboratory evaluation reveals a serum sodium level of 140 mmol/L (N
135145) and a serum potassium level of 3.8 mmol/L (N 3.55.0). What is the most appropriate next step
in the evaluation of this patient?
A. Repeat CT in 12 months
B. Evaluation for adrenal hormonal secretion
C. Fine-needle aspiration of the nodule
D. MRI of the abdomen
E. Referral to a general surgeon for exploratory laparotomy
The incidental discovery of adrenal masses presents a common clinical challenge. Such masses are found
on abdominal CT in 4% of cases, and the incidence of adrenal masses increases to 7% in adults over 70
years of age. 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 g/dL after a 1-mg dose indicates
adrenal hyperfunction. Additional testing should include 24-hour fractionated metanephrines and
catecholamines to rule out pheochromocytoma. If the patient has hypertension, morning plasma aldosterone
activity and plasma renin activity should be assessed to rule out a primary aldosterone-secreting adenoma.
Nonfunctioning masses require assessment with CT attenuation, chemical shift MRI, and/or scintigraphy to
distinguish malignant masses. PET scanning is useful to verify malignant disease. Nonfunctioning benign
masses can be monitored for changes in size and for the onset of hypersecretory states, although the
appropriate interval and studies are controversial. MRI may be preferred over CT because of concerns
about excessive radiation exposure. Fine-needle aspiration of the mass can be performed to differentiate
between adrenal and non-adrenal tissue after malignancy and pheochromocytoma have been excluded.
Which one of the following has been shown to benefit from screening for asymptomatic bacteriuria?
A. Women with diabetes mellitus
B. Men with prostatic enlargement on examination
C. All adults with newly diagnosed hypertension
D. Nursing-home residents with an indwelling Foley catheter
E. Women who are pregnant
Clinical guidelines published by the U.S. Preventive Services Task Force in 2008 reaffirmed the 2004
recommendations regarding screening for asymptomatic bacteriuria in adults. The only group in which
screening is recommended is asymptomatic pregnant women at 1216 weeks gestation, or at the first
prenatal visit if it occurs later (SOR A).
In a patient with microcytic anemia, which one of the following patterns of laboratory abnormalities would
be most consistent with iron deficiency as the underlying cause?
A. Ferritin low, total iron binding capacity (TIBC) low, serum iron low
B. Ferritin low, TIBC low, serum iron high
C. Ferritin low, TIBC high, serum iron low
D. Ferritin high, TIBC low, serum iron low

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.
A 16-year-old male is brought to your office by his mother for stomachaches. On the review of systems
he also complains of headaches, occasional bedwetting, and trouble sleeping. His examination is within
normal limits. His mother says that he is often in the nurses office at school, and doesnt seem to have any
friends. When you discuss these problems with him, he admits to being teased and called names at school.
Which one of the following would be most appropriate?
A. Explain that he must try to conform to be more popular
B. Explain that these symptoms are a stress reaction and will lessen with time
C. Explore whether his school counselor has a process to address this problem
D. Order a TSH level
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 more serious problems such as
suicide, substance abuse, and victim-to-bully transformation. These are not signs or symptoms of thyroid
disease. The Olweus Bullying Prevention Program developed in Norway is a well documented, effective
program for reducing bullying among elementary and middle-school students by altering social norms and
by changing school responses to bullying incidents, including efforts to protect and support victims.
Students who have been bullied regularly are more likely to carry weapons to school, be in frequent fights,
and eventually be injured.
A 12-year-old female is brought to your office with an 8-day history of sore throat and fever, along with
migratory aching joint pain. She is otherwise healthy and has no history of travel, tick exposure, or prior
systemic illness. A physical examination is notable for exudative pharyngitis; a blanching, sharply
demarcated macular rash over her trunk; and a III/VI systolic ejection murmur. Joint and neurologic
examinations are normal. A rapid strep test is positive and her C-reactive protein level is elevated. Of the
following, the most likely diagnosis is:
A. juvenile rheumatoid arthritis
B. infective endocarditis
C. Kawasaki syndrome
D. acute rheumatic fever
E. Lyme disease
Acute rheumatic fever is very common in developing nations. It was previously rare in the U.S., but had a
resurgence in the mid-1980s. It is most common in children ages 515 years. The diagnosis is based on the
Jones criteria. Two major criteria, or one major criterion and two minor criteria, 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 erythrocyte sedimentation rate or C-reactive protein (CRP) level, 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.

A 73-year-old female presents with complaints of dyspnea and decreasing exercise tolerance over the past
few months. She says she has to prop herself up on two pillows in order to breathe better. She also
complains of palpitations, even at rest. She has long-standing hypertension, but has not taken any
antihypertensive medications for several years. She has no history of ischemic heart disease. On
examination her blood pressure is 155/92 mm Hg, her pulse rate is 108 beats/min and irregular, and her
lungs have bibasilar crackles. An EKG reveals atrial fibrillation, but no changes of acute ischemia.
Which one of the following would be most useful for determining her initial treatment?
A. A chest radiograph
B. Cardiac catheterization
C. Echocardiography
D. A TSH level
E. A D-dimer level
This patients 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. Physical findings and
chest radiographs do not distinguish systolic from diastolic heart failure. An echocardiogram is the study of
choice, as it will assess left ventricular function. In diastolic dysfunction, the left ventricular ejection
fraction is normal or slightly elevated. Diastolic failure is more common in elderly females and patients
with hypertension, and less common in patients with a previous history of coronary artery disease.
Diuretics and angiotensin receptor blockers (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.
Which one of the following is true regarding hospice?
A. Hospice benefits end if the patient lives beyond the estimated 6-month life expectancy
B. A do-not-resuscitate (DNR) order is required for a patient receiving Medicare hospice benefits
C. Patients in hospice cannot receive chemotherapy, blood transfusions, or radiation treatments
D. Patients must be referred to hospice by their physician
E. Any terminal patient with a life expectancy <6 months is eligible
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.
A 62-year-old male on hemodialysis develops a pruritic rash on his arms and chest, with erythematous,
thickened plaques and edema. He had brain imaging with a gadolinium-enhanced MRI for neurologic
symptoms 10 days ago. Which one of the following is true regarding this problem?
A. A skin biopsy is diagnostic
B. The problem is limited to the skin
C. Immediate treatment is critical
D. The disease is more common in males
E. Death from the disease is unusual
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.
A 3-year-old male is brought to the emergency department by his parents, who report seeing him swallow a
handful of adult ibuprofen tablets 20 minutes ago. Which one of the following would be the most
appropriate initial management of this patient?
A. Oral ipecac
B. Oral activated charcoal
C. Gastric lavage
D. Whole-bowel irrigation
E. Close observation
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 (SOR
C). 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 (SOR C).
A 26-year-old gravida 3 para 2 was diagnosed with gestational diabetes mellitus at 24 weeks gestation. She
was prescribed appropriate nutritional therapy and an exercise program. After 4 weeks, her fasting plasma
glucose levels remain in the range of 105110 mg/dL. Which one of the following would be the most
appropriate treatment for this patient at this time?
A. Continuation of the current regimen
B. Long-acting insulin glargine (Lantus) once daily
C. Pioglitazone (Actos) once daily
D. A combination of intermediate-acting insulin (e.g., NPH) and a short-acting insulin (e.g., lispro) twice
daily
E. Sliding-scale insulin 4 times daily using ultra-short-acting insulin
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. There is strong evidence that such treatment to maintain fasting plasma
glucose levels below 95 mg/dL and 1-hour postprandial levels below 140 mg/dL results in improved fetal
well-being and neonatal outcomes. 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.
Thiazolidinediones such as pioglitazone have not been shown to be effective or safe in pregnancy. The 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. 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.
A 45-year-old Hispanic male with schizophrenia presents with an exacerbation of his COPD. He currently
takes only ziprasidone (Geodon). He asks for a prescription for clarithromycin (Biaxin) because it has
worked well for previous exacerbations. Which one of the following effects of this drug combination
should you be alert for?
A. Stevens-Johnson syndrome
B. Prolonged QT interval
C. Seizures
D. Diarrhea
E. Hypoglycemia

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 (e.g., clarithromycin),
antiarrhythmics (class I and III), and tricyclic antidepressants. The FDA has issued a black box warning for
both first- and second-generation antipsychotic drugs due to a 1.6- to 1.7-fold increase in the risk of sudden
cardiac death and cerebrovascular accidents associated with their use in the elderly population (SOR A).
None of the other conditions listed is associated with this drug combination.
A 44-year-old female presents with a complaint of increasingly dry eyes over the past 34 months, and says
she can no longer wear contacts due to the discomfort and itching. She also apologizes for chewing gum
during the visit, explaining that it helps keep her mouth moist. On examination you note decreased tear
production, decreased saliva production, and new dental caries. She stopped taking a daily over-the-counter
allergy medication about 1 month ago. Which one of the following is the most likely diagnosis?
A. Sarcoidosis
B. Sjgrens syndrome
C. Ocular rosacea
D. Allergic conjunctivitis
E. Medication side effect
Sjgrens syndrome is one of the three most common systemic autoimmune diseases. It results from
lymphocytic infiltration of exocrine glands and leads to acinar gland degeneration, necrosis, atrophy, and
decreased function. A positive anti-SS-A or anti-SS-B antigen test or a positive salivary gland biopsy is a
criterion for classification of this diagnosis. 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 Sjgrens 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 (SOR B).
A 14-year-old female is brought to your office by her mother because of a 3-month history of irritability,
hypersomnia, decline in school performance, and lack of interest in her previous extracurricular activities.
The mother is also your patient, and you know that she has a history of depression and has recently
separated from her husband. After an appropriate workup, you diagnose depression in the daughter. For
initial therapy you recommend:
A. amitriptyline
B. methylphenidate (Ritalin)
C. divalproex sodium (Depakote)
D. cognitive-behavioral therapy
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 (SOR A). SSRIs are an adjunctive treatment reserved for
treatment of severe depression, and have limited evidence for effectiveness in children and adolescents.
Amitriptyline should not be used because of its limited effectiveness and adverse effects (SOR A).
Methylphenidate is used for treating attention deficit disorder, not depression. Divalproex sodium is used to
treat bipolar disorder.
A 55-year-old hospitalized white male with a history of rheumatic aortic and mitral valve disease has a 3day history of fever, back pain, and myalgias. No definite focus of infection is found on your initial
examination. His WBC count is 24,000/mm3(N 430010,800) with 40% polymorphonuclear leukocytes
and 40% band forms. The following day, two blood cultures have grown gram-positive cocci in clusters.
Until the specific organism sensitivity is known, the most appropriate antibiotic treatment would be:

A. ciprofloxacin (Cipro)
B. nafcillin
C. streptomycin and penicillin
D. ceftriaxone (Rocephin)
E. vancomycin and gentamicin
This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the organism are
known, treatment should include intravenous antibiotic coverage for Enterococcus, Streptococcus, and
methicillin-sensitive and methicillin-resistant Staphylococcus. A patient who does not have a prosthetic
valve should be started on vancomycin and gentamicin, with monitoring of serum levels. Enterococcus and
methicillin-resistant Staphylococcus 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.
A 40-year-old white female lawyer sees you for the first time. When providing a history, she describes
several problems, including anxiety, sleep disorders, fatigue, persistent depressed mood, and decreased
libido. These symptoms have been present for several years and are worse prior to menses, although they
also occur to some degree during menses and throughout the month. Her menstrual periods are regular for
the most part. The most likely diagnosis at this time is:
A. premenstrual syndrome
B. dysthymia
C. dementia
D. menopause
E. anorexia nervosa
Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with
premenstrual syndrome (PMS), and must be ruled out before initiating therapy. Symptoms are cyclic in true
PMS. 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.
A mother brings her 2-month-old infant to the emergency department because of profuse vomiting and
severe diarrhea. The infant is dehydrated, has a cardiac arrhythmia, appears to have ambiguous genitalia,
and is in distress. This presentation suggests a diagnosis of:
A. acute gastroenteritis
B. hypertrophic pyloric stenosis
C. congenital adrenal hyperplasia
D. congenital intestinal malrotation
E. Turners syndrome
Congenital adrenal hyperplasia is a family of diseases caused by an inherited deficiency of any of the
enzymes necessary for the biosynthesis of cortisol. In patients with the salt-losing variant, symptoms begin
shortly after birth with failure to regain birth weight, progressive weight loss, and dehydration. Vomiting is
prominent, and anorexia is also present. Disturbances in cardiac rate and rhythm may occur, along with
cyanosis and dyspnea. In the male, various degrees of hypospadias may be seen, with or without a bifid
scrotum or cryptorchidism.
A 62-year-old African-American female undergoes a workup for pruritus. Laboratory findings include a
hematocrit of 55.0% (N 36.046.0) and a hemoglobin level of 18.5 g/dL (N 12.016.0). Which one of the
following additional findings would help establish the diagnosis of polycythemia vera?
A. A platelet count >400,000/mm3
B. An O2 saturation <90%
C. A WBC count <4500/mm (N 430010,800)3

D. An elevated uric acid level

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
ofsplenomegaly. Minor criteria includeelevated 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.
Over the last 6 months a developmentally normal 12-year-old white female has experienced intermittent
abdominal pain, which has made her quite irritable. She also complains of joint pain and general malaise.
She has lost 5 kg (11 lb) and has developed an anal fissure. Which one of the following is the most likely
cause of these symptoms?
A. Celiac disease (gluten enteropathy)
B. Irritable bowel syndrome
C. Hepatitis A
D. Crohns disease
E. Giardiasis
The most common age of onset for inflammatory bowel disease is during adolescence and young
adulthood, with a second peak at 5080 years of age. The manifestations of Crohns disease are somewhat
dependent on the site of involvement, but systemic signs and symptoms are more common than with
ulcerative colitis. Perianal disease is also common in Crohns disease. Irritable colon and other functional
bowel disorders may mimic symptoms of Crohns disease, but objective findings of weight loss and anal
lesions are extremely uncommon. This is also true for viral hepatitis and giardiasis. In addition, the
historical and epidemiologic findings in this case are not consistent with either of these infections. Celiac
disease and giardiasis can produce Crohns-like symptoms of diarrhea and weight loss, but are not
associated with anal fissures.
A 67-year-old female has started receiving home hospice care. Her attending physician can bill through
which one of the following?
A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D
E. The attending physician cannot bill Medicare
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 (Medicare
Advantage Plans) is offered by private companies, and combines Part A and Part B coverage. 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.
Which one of the following is considered first-line therapy for nausea and vomiting of pregnancy?
A. Ginger
B. Blue cohosh
C. Cranberry
D. Vitamin B6

E. Fenugreek
A number of alternative therapies have been used for problems related to pregnancy, although vigorous
studies are not always possible. For 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. Cranberry products can be useful for preventing urinary tract
infections, and could be recommended for patients if this is a concern. Blue cohosh is used by many
midwives as a partus preparator, but there are concerns about its safety. Fenugreek has been used to
increase milk production in breastfeeding mothers, but no rigorous trials have been performed.
A 45-year-old female presents to your office because she has had a lump on her neck for the past 2 weeks.
She has no recent or current respiratory symptoms, fever, weight loss, or other constitutional symptoms.
She has a history of well-controlled hypertension, but is otherwise healthy. On examination you note a
nontender, 2-cm, soft node in the anterior cervical chain. The remainder of the examination is
unremarkable. Which one of the following would be most appropriate at this point?
A. Immediate biopsy
B. Treatment with antibiotics, then a biopsy if the problem does not resolve
C. Monitoring clinically for 46 weeks, then a biopsy if the node persists or enlarges
D. Serial ultrasonography to monitor for changes in the node
There is limited evidence to guide clinicians in the management of an isolated, enlarged cervical lymph
node, even though this is a common occurrence. Evaluation and management is guided by the presence or
absence of inflammation, the duration and size of the node, and associated patient symptoms. In addition,
the presence of risk factors for malignancy should be taken into account. Immediate biopsy is warranted if
the patient does not have inflammatory symptoms and the lymph node is >3 cm, if the node is in the
supraclavicular area, or if the patient has coexistent constitutional symptoms such as night sweats or weight
loss. Immediate evaluation is also indicated if the 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 46 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.
A 45-year-old male is seen in the emergency department with a 2-hour history of substernal chest pain. An
EKG shows an ST-segment elevation of 0.3 mV in leads V4V6. In addition to evaluation for reperfusion
therapy, which one of the following would be appropriate?
A. Enteric aspirin, 81 mg
B. Intravenous metoprolol (Lopressor)
C. Oral clopidogrel (Plavix)
D. Warfarin (Coumadin), after blood is drawn to establish his baseline INR
E. Delaying treatment pending results of two sets of cardiac enzyme measurements
This patient has an ST-segment elevation myocardial infarction (STEMI). STEMI is defined as an STsegment elevation of greater than 0.1 mV in at least two contiguous precordial or adjacent limb leads. The
most important goal is to begin fibrinolysis less than 30 minutes after the first contact with the health
system. The patient should be given oral clopidogrel, and should also chew 162325 mg of aspirin. Enteric
aspirin has a delayed effect. Intravenous -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.
A 36-year-old female sees you for a 6-week postpartum visit. Her pregnancy was complicated by
gestational diabetes mellitus. Her BMI at this visit is 33.0 kg/m2 and she has a family historyof diabetes
mellitus. This patients greatest risk factor for developing type 2 diabetes mellitus is her:

A. age
B. obesity
C. history of a completed pregnancy
D. history of gestational diabetes
E. family history of diabetes
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. This patients age is not a risk
factor. 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 (SOR C). 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.
You see a 68-year-old mechanic for a routine evaluation. He has a 2-year history of hypertension. His
weight is normal and he adheres to his medication regimen. His current medications are metoprolol
(Lopressor), 100 mg twice daily; olmesartan (Benicar), 40 mg/day; and hydrochlorothiazide, 25 mg/day.
His serum glucose levels have always been normal, but his lipid levels are elevated. A physical examination
is unremarkable except for an enlarged prostate and a blood pressure of 150/94 mm Hg. Laboratory studies
show a serum creatinine level of 1.6 mg/dL (N 0.61.5) and a serum potassium level of 4.9 mmol/L (N 3.5
5.0). The patients record shows blood pressures ranging from 145/80 mm Hg to 148/96 mm Hg over the
past year. Which one of the following would be most appropriate at this point?
A. Continue his current management with no changes
B. Substitute furosemide (Lasix) for hydrochlorothiazide
C. Add clonidine (Catapres)
D. Add spironolactone (Aldactone)
E. Add hydralazine (Apresoline)
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.
Actinic keratoses of the skin may progress to:
A. nodular basal cell cancer
B. pigmented basal cell cancer
C. squamous cell cancer
D. Merkel cell cancer
E. malignant melanoma
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.
A 52-year-old male presents with a small nodule in his palm just proximal to the fourth
metacarpophalangeal joint. It has grown larger since it first appeared, and he now has mild flexion of the
finger, which he is unable to straighten. He reports that his father had similar problems with his fingers. On
examination you note pitting of the skin over the nodule. The most likely diagnosis is:
A. degenerative joint disease
B. trigger finger
C. Dupuytrens contracture
D. a ganglion

E. flexor tenosynovitis
Dupuytrens contracture is characterized by changes in the palmar fascia, with progressive thickening and
nodule formation 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 Dupuytrens contracture.
Which one of the following is NOT considered a first-line treatment for head lice?
A. Lindane 1%
B. Malathion 0.5% (Ovide)
C. Permethrin 1% (Nix)
D. Pyrethrins 0.33%/pipernyl butoxide 4% (RID)
Lindanes efficacy has waned over the years and it is inconsistently ovicidal. Because of its neurotoxicity,
lindane carries a black box warning and is specifically recommended only as second-line treatment by the
FDA. Pyrethroid resistance is widespread, but permethrin is still considered to be a first-line treatment
because of its favorable safety profile. The efficacy of malathion is attributed to its triple action with
isopropyl alcohol and terpineol, likely making this a resistance-breaking formulation. The probability of
simultaneously developing resistance to all three substances is small. Malathion is both ovicidal and
pediculicidal.
Which one of the following is a frequent cause of cross-reactive food-allergy symptoms in latex-allergic
individuals?
A. Avocadoes
B. Goats milk
C. Pecans
D. Pastrami
E. Peppermint
The majority of patients who are latex-allergic are believed to develop IgE antibodies that cross-react with
some proteins in plant-derived foods. 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. Although many fruits and vegetables have been implicated, fruits most commonly
linked to this problem are bananas, avocadoes, and kiwi.
A 42-year-old female is found to have a thyroid nodule during her annual physical examination. Her TSH
level is normal. Ultrasonography of her thyroid gland shows a solitary nodule measuring 1.2 cm. Which
one of the following would be most appropriate at this point?
A. A radionuclide thyroid scan
B. A fine-needle aspiration biopsy of the nodule
C. Partial thyroidectomy
D. Total thyroidectomy
E. Reassurance
All patients who are found to have a thyroid nodule on a physical examination 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 (SOR B).
A 19-year-old female high-school student is brought to your office by a friend who is concerned about the
patient having cut her wrists. The patient denies that she was trying to kill herself, and states that she did
this because she just got so angry at her boyfriend when she caught him sending a text message to
another woman. She denies having a depressed mood or anhedonia, and blames her fluctuating mood on
everyone who keeps abandoning her, making her feel like shes nothing. She admits that she has
difficulty controlling her anger. Her sleep quality and pattern appear normal, as does her appetite. She
denies hallucinations or delusions. The wounds on her wrists appear superficial and there is evidence of
previous cutting behavior on her forearms. Her vital signs are stable. Which one of the following would be
most beneficial for this patient?
A. Clonazepam (Klonopin)
B. Fluoxetine (Prozac)
C. Quetiapine (Seroquel)
D. Inpatient psychiatric admission
E. Psychotherapy
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. It is estimated to be
present in 1% of the general population and involves equal numbers of men and women; women seek care
more often, however, leading to a disproportionate number of women being identified by medical
providers. 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 is
considered the mainstay of therapy, especially in a relatively stable patient such as the one described.
Treatment with donepezil (Aricept) is associated with an increased risk for:
A. pulmonary embolism
B. liver failure
C. bradycardia requiring pacemaker implantation
D. cataract development requiring surgery
E. confusion requiring institutionalization
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.
An 8-year-old female is brought to your office with a 3-day history of bilateral knee pain. She has had no
associated upper respiratory symptoms. On examination she is afebrile. Her knees have full range of
motion and no effusion, but she has a purpuric papular rash on both lower extremities. Which one of the
following is the most likely cause of her symptoms?

A. Henoch-Schnlein purpura
B. Rocky Mountain spotted fever
C. Juvenile rheumatoid arthritis
D. Lyme disease
E. Rheumatic fever
The combination of arthritis with a typical palpable purpuric rash is consistent with a diagnosis of HenochSchnlein 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 bulls-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.
Which one of the following hospitalized patients is the most appropriate candidate for thromboembolism
prophylaxis with enoxaparin (Lovenox)?
A. An ambulatory 22-year-old obese male admitted for an appendectomy
B. A 48-year-old male with atrial fibrillation on chronic therapeutic anticoagulation, admitted for cellulitis
C. A 48-year-old male with end-stage liver disease and coagulopathy
D. A 52-year-old female on chronic estrogen therapy, admitted with severe thrombocytopenia
E. A 67-year-old female with hemiparesis, admitted for community-acquired pneumonia
Venous thromboembolism is a frequent cause of preventable death and illness in hospitalized patients.
Approximately 10%15% of high-risk patients who do not receive prophylaxis develop venous thrombosis.
Pulmonary embolism is thought to be associated with 5%10% of deaths in hospitalized patients.
Anticoagulant prophylaxis significantly reduces the risk of pulmonary embolism and should be used in all
high-risk patients. 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 67year-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.
A 25-year-old white male who has a poorly controlled major seizure disorder and a 6-week history of
recurrent fever, anorexia, and persistent, productive coughing visits your office. On physical examination
he is noted to have a temperature of 38.3C (101.0F), a respiratory rate of 16/min, gingival hyperplasia,
and a fetid odor to his breath. Auscultation of the lungs reveals rales in the mid-portion of the right lung
posteriorly. Which one of the following is most likely to be found on a chest radiograph?
A. Sarcoidosis
B. Miliary calcifications
C. A lung abscess
D. A right hilar mass
E. A right pleural effusion
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.
Which one of the following should be given intravenously in the initial treatment of status epilepticus?
A. Propofol (Diprivan)
B. Phenobarbital
C. Lorazepam (Ativan)
D. Midazolam (Versed)
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, 0.10.15 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.
According to JNC 7, the risk of cardiovascular disease begins to increase when the systolic blood pressure
exceeds a threshold of:
A. 150 mm Hg
B. 140 mm Hg
C. 130 mm Hg
D. 125 mm Hg
E. 115 mm Hg
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.
Which one of the following insulin regimens most closely mimics the normal pattern of pancreatic insulin
release in a nondiabetic person?
A. 70/30 NPH/regular insulin (Humulin 70/30) twice daily
B. NPH insulin twice daily plus an insulin sliding-scale protocol using regular insulin
C. Insulin glargine (Lantus) daily plus an insulin sliding-scale protocol using regular insulin
D. Insulin detemir (Levamir) daily plus rapid-acting insulin with meals
E. Rapid-acting insulin before each meal
Basal insulin provides a relatively constant level of insulin for 24 hours, with an onset of action in 1 hour
and no peak. NPH gives approximately 12 hours of coverage with a peak around 68 hours. Regular insulin
has an onset of action of about 30 minutes and lasts about 58 hours, with a peak at about 24 hours. New
rapid-acting analogue insulins have an onset of action within 515 minutes, peak within 3075 minutes,
and last only about 23 hours after administration. Thus, a 70/30 insulin mix (typically 70% NPH and 30%
regular) provides coverage for 12 hours, but the peaks of insulin release do not closely mimic natural
patterns. NPH given twice daily along with an insulin sliding-scale protocol using regular insulin is only
slightly closer than a 70/30 twice-daily regimen. Rapid insulin alone does not provide any basal insulin,
and the patient would therefore not have insulin available during the night.
An anxious and agitated 18-year-old white male presents to your office with a 2-hour history of severe
muscle spasms in the neck and back. He was seen 2 days ago in a local emergency department with

symptoms of gastroenteritis, treated with intravenous fluids, and sent home with a prescription for
prochlorperazine (Compazine) suppositories. The best therapy for this problem is intravenous
administration of:
A. atropine
B. diphenhydramine (Benadryl)
C. haloperidol
D. succinylcholine (Anectine)
E. carbamazepine (Tegretol)
While rarely life threatening, an 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.
In a patient with a severe anaphylactic reaction to peanuts, the most appropriate route for epinephrine is:
A. intramuscular
B. intravenous
C. oral
D. subcutaneous
E. sublingual
Intramuscular epinephrine is the recommended drug for anaphylactic reactions (SOR A). Epinephrine is
absorbed more rapidly intramuscularly than subcutaneously.
A 19-year-old college student comes to your office with significant pain in his right great toe that is making
it difficult for him to walk. He has never had this problem before. When you examine him you find
increased swelling with marked erythema and seropurulent drainage and ulceration of the medial nail fold.
The toe is very tender to touch, particularly when pressure is applied to the tip of the toe. The most
appropriate initial management would be:
A. oral antibiotics that cover common skin flora, for 57 days
B. soaking the toe in warm, soapy water for 1020 minutes twice daily, followed by application of a
topical antibiotic, with a return visit in 35 days
C. elevation of the nail with a wisp of cotton
D. partial avulsion of the medial nail plate and phenolization of the matrix at this visit
E. partial avulsion of both the medial and lateral nail plates at this visit
This ingrown nail meets the criteria for moderate severity: increased swelling, seropurulent drainage,
infection, and ulceration of the nail fold. In these cases, antibiotics before or after phenolization of the
matrix do not decrease healing time, postoperative morbidity, or recurrence rates (SOR B). A conservative
approach, elevating the nail edge with a wisp of cotton or a gutter splint, is reasonable in patients with a
mild to moderate ingrown toenail who do not have significant pain, substantial erythema, or purulent
drainage. Either immediate partial nail avulsion followed by phenolization, or direct surgical excision of the
nail matrix is effective for the treatment of ingrown nails (SOR B). Pretreatment with soaking and
antibiotics has not been demonstrated to add therapeutic benefit or to speed resolution. 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. Bilateral partial matricectomy
maintains the functional role of the nail plate (although it narrows the nail plate) and should be considered
in patients with a severe ingrown toenail or to manage recurrences.
A 59-year-old male who is morbidly obese suffers a cardiac arrest. Intravenous access cannot be obtained.
Which one of the following is true regarding intraosseous drug administration in this patient?
A. The patients age and size are a contraindication to intraosseous administration
B. The time needed to establish intraosseous access is too great

C. Many drugs cannot be administered intraosseously

D. Endotracheal administration is preferred
E. There are no contraindications to intraosseous administration in this patient
The current American Heart Association 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 intravenously can be administered intraosseously. Many drugs administered via an
endotracheal tube are poorly absorbed, and drug levels vary widely.
Ultrasonography shows a complete placenta previa in a 23-year-old primigravida at 20 weeks gestation.
She has not experienced any vaginal bleeding. Which one of the following would be the most appropriate
management for this patient?
A. Schedule a cesarean section at 38 weeks gestation
B. Perform a digital examination to assess for cervical dilation
C. Administer corticosteroids to promote fetal lung maturity
D. Order MRI to rule out placenta accreta
E. Repeat the ultrasonography at 28 weeks gestation
Placenta previa is a relatively common incidental finding on second trimester ultrasonography.
Approximately 4% of ultrasound studies at 2024 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
ultrasonography in the third trimester (SOR A). Because many placenta previas resolve close to term, a
decision regarding mode of delivery should not be made until after ultrasonography is performed at 36
weeks gestation. Digital cervical examinations should not be performed in patients with known placenta
previa because of the risk of precipitating bleeding. Corticosteroids are indicated at 2434 weeks gestation
if the patient has bleeding, given the higher risk of premature birth. In patients with a history of previous
cesarean delivery who have a placenta previa at the site of the previous incision, a color-flow Doppler study
should be performed to evaluate for a potential placenta accreta. In such cases, MRI may be helpful to
confirm the diagnosis.
Which one of the following classes of diabetes medications acts primarily by stimulating pancreatic insulin
secretion?
A. Biguanides, such as metformin (Glucophage)
B. Thiazolidinediones, such as pioglitazone (Actos)
C. DPP-4 inhibitors, such as sitagliptin (Januvia)
D. Sulfonylureas, such as glipizide (Glucotrol)
E. Amylin analogs, such as pramlintide (Symlin)
Biguanides and thiazolidinediones are insulin sensitizers that decrease hepatic glucose production and
increase insulin sensitivity. Sulfonylureas and meglitinides stimulate pancreatic insulin secretion, while
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 -cell production. Amylin analogs act
with insulin to delay gastric emptying and they also inhibit glucagon release.
A 30-year-old male presents with a 3-week history of severe, burning pain in his right shoulder. He recalls
no mechanism of injury. An examination reveals weakness to resistance of the biceps and triceps, and with
external rotation of the shoulder. Full range of motion of the neck and shoulder does not worsen the pain.
Which one of the following would be most likely to identify the cause of this patients problem?
A. Electromyography and nerve conduction studies
B. MRI of the neck
C. MR arthrography (MRA) of the shoulder
D. CT of the brain

E. Ultrasonography of the upper extremity

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.
A 30-year-old African-American female is being evaluated because of absent menses for the last 6 months.
Menarche was at age 12. Her menstrual periods have frequently been irregular, and are accompanied only
occasionally by dysmenorrhea. She had her first child 4 years ago, but has not been able to become
pregnant since. A physical examination and pelvic examination are unremarkable. A serum pregnancy test
is negative, prolactin levels are normal, and LH and FSH levels are both three times normal on two
occasions. These findings are consistent with:
A. hypothalamic amenorrhea
B. ovarian failure
C. pituitary microadenoma
D. polycystic ovary syndrome
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.
A 30-year-old female presents to your office for an initial visit. She reports a long history of asthma that
currently awakens her three times per month, necessitating the use of an albuterol inhaler (Proventil,
Ventolin). According to current guidelines, which one of the following would be optimal treatment?
A. Continued use of a short-acting -agonist only as needed
B. Adding a long-acting -agonist
C. Adding a leukotriene receptor antagonist
D. Adding a low-dose inhaled corticosteroid
E. Adding theophylline
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.
A 26-month-old child presents with a 2-day history of 68 loose stools per day and a low-grade fever.
When evaluating the child to determine whether he is dehydrated, which one of the following would NOT
be useful?
A. Skin turgor
B. Capillary refill time
C. Respiratory rate and pattern
D. The BUN/creatinine ratio
E. The serum bicarbonate level
The most useful findings for identifying dehydration are prolonged capillary refill time, abnormal skin
turgor, and abnormal respiratory pattern (SOR C). Capillary refill time is not affected by fever and should
be less than 2 seconds. Skin recoil is normally instantaneous, but recoil time increases linearly with the

degree of dehydration. The respiratory pattern should be compared with age-specific normal values, but
will be increased and sometimes labored, depending on the degree of dehydration. 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. In
combination with other clinical indicators, a low serum bicarbonate level (<17 mmol/L) is helpful in
identifying children who are dehydrated, and a level <13 mmol/L is associated with an increased risk of
failure of outpatient rehydration efforts.
A 70-year-old Asian male presents with hematochezia. He has stable vital signs. Lower endoscopy is
performed, but is unsuccessful due to active bleeding. Which one of the following would be most
appropriate at this point?
A. Abdominal CT
B. A barium enema
C. A technetium-99m blood pool scan
D. Exploratory laparotomy
E. A small-bowel radiograph
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.
A patient presenting with severe carbon monoxide poisoning should be treated with:
A. inhaled helium
B. supplemental oxygen
C. intravenous calcium gluconate
D. intravenous iron
E. intravenous magnesium
Patients with carbon monoxide poisoning should be treated immediately with normobaric oxygen, which
speeds up the excretion of carbon monoxide.
Which one of the following situations is most likely to result in immunity from court-awarded damages for
personal injuries occurring as a result of reasonable and ordinary emergency care?
A. Evaluating a football injury as a volunteer team physician at a local high-school game
B. Stabilizing an injured victim at the scene of an automobile accident until EMS arrives
C. Providing emergency care to your office nurse after he collapses while on the job
D. Responding to the collapse of one of your patients in the hospital parking lot
E. Treating an asthma attack while staffing the first-aid shelter at an outdoor rock concert
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.
A patient who underwent coronary bypass grafting several months ago has been intolerant of all
medications for cholesterol lowering. However, on the recommendation of a friend, he began taking red
yeast rice that he purchased at a natural healing store. His cholesterol level has improved with this product
and he has tolerated it so far. You should consider monitoring which one of the following in this patient,
based on the active ingredient in red yeast rice?
A. WBC count
B. Platelet count
C. Prothrombin time
D. Liver enzymes
E. Kidney function tests
Red yeast rice (Monascus purpureus) is a widely available dietary supplement that has been used as an
herbal medication in China for centuries. In recent years it has been used for alternative management of
hyperlipidemia in the U.S. 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.
A 40-year-old nurse presents with a 1-year history of rhinitis, and a more recent onset of episodic wheezing
and dyspnea. Her symptoms seem to improve when she is on vacation. She does not smoke, although she
says that her husband does. Her FEV1 improves 20% with inhaled -agonists. Which one of the following
is the most likely diagnosis?
A. Occupational asthma
B. Sarcoidosis
C. COPD
D. Anxiety
E. Vocal cord dysfunction
Occupational asthma merits special consideration in all cases of new adult asthma or recurrence of
childhood asthma after a significant asymptomatic period (SOR C). 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 -agonist use makes COPD less likely, in addition to the fact
that the patient is a nonsmoker. Cystic fibrosis 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.
A previously healthy 60-year-old male is diagnosed with multiple myeloma after a workup for an incidental
finding on routine laboratory work. He has no identified organ or tissue damage and is asymptomatic.
Which one of the following would be appropriate treatment of this patients condition?
A. No treatment
B. Chemotherapy

C. Autologous stem cell transplantation

D. Radiation
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 (SOR A) and may increase the likelihood of developing acute leukemia. The standard treatment
for symptomatic patients under age 65 is autologous stem cell transplantation. Patients over 65 who are
healthy enough to undergo transplantation would also be appropriate candidates. Patients who are not
candidates for autologous stem cell transplantation generally receive melphalan and prednisolone with or
without thalidomide. Radiotherapy can be used to relieve metastatic bone pain or spinal cord compression.
A 35-year-old male presents with a 4-month history of pain in the lower lumbar region without radiation.
He works in retail sales, and the pain and stiffness prevent him from working. He estimates the pain to be 7
on a 10-point scale. He has been under the care of a chiropractor and has experienced some relief with
spinal manipulation. His history is negative for red flags indicating a serious cause for his pain.
The only positive findings on a physical examination are diffuse mild tenderness over the lumbar region
and mild limitation of lumbar mobility on forward and lateral flexion/extension maneuvers. Appropriate
laboratory tests and imaging studies are all within normal limits. In addition to appropriate analgesics,
which one of the following modalities has the best evidence of long-term benefit in this situation?
A. Transdermal electric nerve stimulation (TENS)
B. Epidural corticosteroid injections
C. SSRIs
D. Multidisciplinary rehabilitation
This patient has nonspecific chronic back pain, most likely a lumbar strain or sprain. In addition to
analgesics (e.g., acetaminophen or NSAIDs) (SOR A) and spinal manipulation (SOR B), a
multidisciplinary rehabilitation program is the best choice for management (SOR A). 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. Back school, TENS, and SSRIs
have been found to have negative or conflicting evidence of effectiveness (SOR C). There is no evidence to
support the use of epidural corticosteroid injections in patients without radicular signs or symptoms (SOR
C).
A 55-year-old male presents to your office for evaluation of increasing dyspnea with exertion over the past
2 weeks. He has smoked 2 packs of cigarettes per day since the age of 20. He has had a chronic cough for
years, along with daily sputum production. He was given an albuterol inhaler for wheezing in the past,
which he uses intermittently. On examination he has a severe decrease in breath sounds, no evidence of
jugular venous distention, no cardiac murmur, and no peripheral edema. A chest film shows hyperinflation,
but no infiltrates or pleural effusion. Office spirometry shows that his FEV1 is only 55% of the predicted
value. You consider using inhaled corticosteroids as part of the treatment regimen for this patient. This has
been shown to:
A. increase cataract formation
B. increase the incidence of fracture
C. increase the risk of pneumonia
D. slow the progression of the disease
E. improve overall mortality from the disease
COPD has several symptoms, including poor exercise tolerance, chronic cough, sputum production,
dyspnea, and signs of right-sided heart failure. The most common etiology is cigarette smoking. A patient
with any combination of two of these findings, such as a 70-pack-year history of smoking, decreased breath
sounds, or a history of COPD, likely has airflow obstruction, defined as an FEV1 60% of the predicted
value. In stable COPD, treatment is reserved for patients who have symptoms and airflow obstruction.
Treatment options for monotherapy are all similar in effectiveness and include long-acting inhaled

anticholinergics, long-acting -agonists, and inhaled corticosteroids. 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. There appears to be no increase in cataract formation or rate of
fracture. These agents do have side effects, including candidal infection of the oropharynx, hoarseness, and
an increased risk of developing pneumonia.
Which one of the following patients is unlikely to benefit from vaccination against hepatitis A?
A. A missionary traveling to Mexico
B. A man who has sex with men
C. A methamphetamine addict
D. A patient with chronic hepatitis
E. A 40-year old recent immigrant from India
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.
For a healthy 1-month-old, daily vitamin D intake should be:
A. 50 IU
B. 100 IU
C. 200 IU
D. 400 IU
E. 800 IU
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. The current recommendation replaces the previous
recommendation of a minimum daily intake of 200 IU/day of vitamin D supplementation beginning in the
first 2 months after birth and continuing through adolescence. These revised guidelines for vitamin D intake
for healthy infants, children, and adolescents are based on evidence from new clinical trials and the
historical precedent of safely giving 400 IU of vitamin D per day in the pediatric and adolescent
population. New evidence supports a potential role for vitamin D in maintaining innate immunity and
preventing diseases such as diabetes mellitus and cancer.
A 68-year-old male was seen in a local urgent-care clinic 6 days ago for upper respiratory symptoms and
was started on cefuroxime (Ceftin). He presents to your office with a 2-day history of 45 watery stools per
day with no blood or mucus. He is afebrile and has a normal abdominal and rectal examination. A stool
guaiac test is negative, and a stool sample is sent for further testing. What is the best initial management for
this patient?
A. Stop the cefuroxime
B. Start ciprofloxacin (Cipro)
C. Start metronidazole (Flagyl)
D. Start loperamide (Imodium)
E. Recommend probiotics until he completes the course of cefuroxime
This patient is at high risk for Clostridium difficileassociated diarrhea, based on his age and his recent
broad-spectrum antibiotic use. The initial management is to stop the antibiotics. Treatment 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.

A 74-year-old female presents with a several-month history of gradually increasing dyspnea on exertion,
swelling in her feet and lower legs, and having to sleep sitting up due to increased shortness of breath while
lying flat. She has been healthy otherwise, with no known heart disease or hypertension, and she has no
significant family history of heart disease. An echocardiogram shows an ejection fraction of 20% and a
thin-walled, diffusely enlarged left ventricle. Which one of the following is the most likely diagnosis?
A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular cardiomyopathy
E. Athletes heart
This patients symptoms and echocardiographic findings indicate a dilated cardiomyopathy. In patients with
hypertrophic cardiomyopathy the echocardiogram 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.
Which one of the following is true regarding treatment of pressure ulcers?
A. Multiple controlled trials have shown that nutritional supplements hasten ulcer healing
B. Keeping the head of the bed elevated to 45 during the day promotes healing by minimizing shearing
forces
C. Systemic antibiotics are most helpful when used intermittently to reduce bacterial counts
D. Topical antibiotics should not be used for more than 2 weeks at a time
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 (SOR C).
The Get Up and Go Test evaluates for which one of the following?
A. Risk of falling
B. Effects of peripheral neuropathy
C. Kinetic tremor
D. Neurocardiogenic syncope
E. Central causes of vertigo
The Get Up and Go Test is the most frequently recommended screening test for mobility. It takes less
than a minute to perform and involves asking the patient to rise from a chair, walk 10 feet, turn, return to
the chair, and sit down. 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 physical therapy 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.
A 20-year-old male presents with a complaint of pain in his right testis. The onset of pain has been gradual
and has been associated with dysuria and urinary frequency. The patient has no medical problems and is
sexually active. On examination he has some swelling and mild tenderness of the testis. The area posterior
to the testis is swollen and very tender. He has a normal cremasteric reflex, and the pain improves with
elevation of the testicle. Which one of the following would be the most appropriate management of this
patient?
A. Surgical evaluation

B. Doppler ultrasonography
C. Ceftriaxone (Rocephin) and doxycycline
D. Levofloxacin (Levaquin)
E. Ciprofloxacin (Cipro)
This patient has epididymitis. In males 1435 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 (SOR C). 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 (SOR C). If there is concern about testicular torsion, urgent
surgical evaluation and ultrasonography 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.
An elevation of serum alkaline phosphatase combined with an elevation of 5'-nucleotidase is most
suggestive of conditions affecting:
A. bone
B. the liver
C. the placenta
D. the small intestine
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 (SOR C).
A 60-year-old right-handed white male arrives in the emergency department with symptoms and signs
consistent with a stroke. His past medical history is significant for tobacco abuse and chronic treated
hypertension. He is alert and afebrile. His pulse rate is 100 beats/min, respirations 20/min, and blood
pressure 190/95 mm Hg. He has a moderate right-sided hemiparesis and is aphasic. There are no other
significant physical findings. While appropriate tests are being ordered, immediate management in the
emergency department should include which one of the following?
A. Monitoring oxygenation status with pulse oximetry
B. Prompt lowering of systolic blood pressure to <140 mm Hg
C. Beginning an intravenous heparin infusion
D. Restricting fluid intake to 75 cc/hr
E. Giving parenteral corticosteroids
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 4872 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.

Which one of the following is the most common secondary cause of nephrotic syndrome in adults?
A. Diabetes mellitus
B. Systemic lupus erythematosus
C. Hepatitis
D. NSAIDs
E. Multiple myeloma
Although 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.
A 19-year-old college student comes to your office with her mother. The mother reports that her daughter
has frequently been observed engaging in binge eating followed by induced vomiting. She has also
admitted to using laxatives to prevent weight gain. Which one of the following laboratory abnormalities is
most likely to be found in this patient?
A. Hypokalemia
B. Hypoglycemia
C. Hyponatremia
D. Hypercalcemia
E. Hypermagnesemia
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.
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 102F. Which one of the following additional findings 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
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.
While playing basketball, a 29-year-old male falls on his outstretched hand with his wrist fully extended.
He sees you the following day because of diffuse wrist pain and decreased range of motion. The point of
maximal tenderness is on the dorsal aspect of the wrist between the extensor pollicis brevis and extensor
pollicis longus tendons. There is no visible deformity. Radiographs show no fracture. Which one of the
following is the most appropriate initial treatment of this patient?
A. A wrist extension splint
B. An ulnar gutter splint
C. A thumb spica splint
D. A short arm cast
E. Physical therapy

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 12 weeks.
A 42-year-old male seeks your advice regarding smoking cessation. You recommend a smoking cessation
class, as well as varenicline (Chantix). You caution him that the most common side effect is:
A. dermatitis
B. diarrhea
C. edema
D. hirsutism
E. nausea
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.
Occlusion of the circumflex artery is most likely to cause EKG changes in:
A. V1 and V2
B. V3 and V4
C. II, III, and AVF
D. I and AVL
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.
Which one of the following is true concerning postpartum depression?
A. It has no effect on cognitive development of the child
B. It is directly related to the desired gender of the infant
C. It is usually transient, lasting about 10 days
D. Thyroid function should always be assessed in women with postpartum depression
Thyroid function must be evaluated in women with postpartum depression since both hyperthyroidism and
hypothyroidism are more common post partum. 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.
A 6-month-old white male is brought to your office because he has blisters in his diaper area. On
examination, you find large bullae filled with cloudy yellow fluid. Some of the blisters have ruptured and
the bases are covered with a thin crust. Which one of the following is most appropriate in the management
of this condition?
A. Rinsing diapers with a vinegar solution
B. A topical antifungal agent
C. Penicillin
D. Trimethoprim/sulfamethoxazole (Bactrim, Septra)

Bullous impetigo is a localized skin infection characterized by large bullae; it is caused by phage group II
Staphylococcus aureus. Cultures of fluid from an intact blister will reveal the causative agent. The lesions
are caused by exfolatin, a local toxin produced by the S. aureus, and develop on intact skin. Complications
are rare, but cellulitis occurs in <10% of cases. Strains of Staphylococcus associated with impetigo in the
U.S. have little or no nephritogenic potential. 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.
Patients with which rheumatologic condition have the highest relative risk of internal malignancy compared
to the general population?
A. Systemic scleroderma
B. Systemic lupus erythematosus
C. Sjgrens syndrome
D. Rheumatoid arthritis
E. Dermatomyositis
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-Hodgkins lymphoma.Among
patients with polymyositis, 15% developed cancer. 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 Sjgrens syndrome, the risk of non-Hodgkins lymphoma
is 44 times higher than in the general population, with an individual lifetime risk of 6%10%.
A 36-year-old white male complains of episodic pain in the rectum over the past several years. The pain
occurs every 36 weeks and is sharp, cramp-like, and severe. It lasts from 1 to 15 minutes. He has no other
gastrointestinal complaints. A physical examination, including a digital rectal examination and anoscopy, is
normal. The most likely diagnosis is:
A. fecal impaction
B. coccygodynia
C. anal fissure
D. proctalgia fugax
E. sacral nerve neuralgia
Symptoms consistent with proctalgia fugax occur in 13%19% of the general population. These consist of
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. All the other
diagnoses listed would be evident from the physical examination, except for sacral nerve neuralgia, which
would not be intermittent for years and would be longer lasting.
The most common cause of acute interstitial nephritis is:
A. hypertension
B. pyelonephritis
C. collagen vascular disease
D. dehydration
E. hypersensitivity to medications
Approximately 85% of cases of acute interstitial nephritis result from a drug-related hypersensitivity
reaction; other cases are due to mechanisms such as an immunologic response to infection or an idiopathic
immune syndrome. Hypertension and dehydration do not cause interstitial nephritis. Medications that most
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 of the problem
within 710 days in the majority of cases, and most patients have a good recovery.
A 24-year-old female has noted excessive hair loss over the past 2 months, with a marked increase in hairs
removed when she brushes her hair. She delivered a healthy baby 5 months ago. She is on no medications,
and is otherwise healthy. Examination of her scalp reveals diffuse hair thinning without scarring. An
evaluation for thyroid dysfunction and iron deficiency is negative. Which one of the following is the most
likely cause of her hair loss?
A. Telogen effluvium
B. Anagen effluvium
C. Alopecia areata
D. Female-pattern hair loss
E. Discoid lupus erythematosus
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. The normal ratio of anagen to telogen
hairs is 90:10. 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, which 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.
A 60-year-old Chinese female asks you about being tested for osteoporosis. She is postmenopausal and has
never used hormone therapy. She does not consume dairy products because she has lactose intolerance. She
is on no medications, is otherwise healthy, and has no history of falls or fractures. Her mother had
osteoporosis and vertebral compression fractures. Her BMI is 20 kg/m2. Which one of the following tests
would be best to determine whether this patient has osteoporosis?
A. A central DXA scan of the lumbar spine and hips
B. A forearm DXA scan
C. Quantitative CT of the lumbar spine
D. Quantitative calcaneal ultrasonography
E. Measurement of biochemical markers of bone turnover in the urine
This patient has several risk factors for osteoporosis: Asian ethnicity, low body weight, positive family
history, ostmenopausal 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.
A 56-year-old female has a 35-pack-year smoking history. She is concerned that she may have COPD,
although she has no history of chronic cough, chest pain, or other pulmonary symptoms. Her family history
is remarkable for a mother with COPD who was a smoker, but there is no family history of 1-antitrypsin
disease. Which one of the following would you recommend with regard to screening spirometry?
A. Screening, based on her age
B. Screening, based on her family history

C. Screening, based on her smoking history

D. No screening, based on lack of benefit
COPD is the fourth leading cause of death in the United States. The 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 U.S. Preventive Services Task Force recently concluded that
there is moderate certainty that screening asymptomatic patients for COPD using spirometry has little or
no benefit and is not recommended. This recommendation applies to otherwise healthy individuals without
a family history of 1-antitrypsin disease.
An 8-year-old white male presents with a 4-day history of erythematous cheeks, giving him a slappedcheek appearance. Examination of the
extremities reveals a mildly pruritic,
reticulated, erythematous, maculopapular rash
(see Figure 1). He is afebrile and no other
constitutional symptoms are present. The most
likely etiologic agent is:
A. human parvovirus
B. adenovirus
C. cytomegalovirus
D. coxsackievirus
All of these viruses can cause an erythematous
exanthem; however, this description is classic
for fifth disease, or erythema infectiosum. It
was the fifth exanthem to be identified after
measles, scarlet fever, rubella, and Filatov-Dukes disease (atypical scarlet fever). Roseola infantum is
known as sixth disease. 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. The first
is a facial flushing, described as a slapped cheek appearance. In the next stage, the exanthem can spread
concurrently to the trunk and proximal extremities as a diffuse macular erythematous rash. Finally, central
clearing of this rash creates a lacy, reticulated appearance, as seen in Figure 1. This rash tends to be on the
extensor surfaces and spares the palms and soles. It resolves in 13 weeks but can recur with heat, stress,
and exposure to sunlight.
A 35-year-old right-handed softball player injures his left wrist when sliding into second base. When he
sees you the next day his description of the injury indicates that he hyperextended his wrist while sliding,
and the pain was later accompanied by swelling. Your examination is remarkable only for mild swelling
and tenderness of the dorsal wrist, distal to the ulnar styloid. A radiograph of the wrist is shown in Figure 2.
Which one of the following best describes this injury?

A. Triquetral fracture
B. Scaphoid (navicular) fracture
C. Lunate fracture
D. Lunate dislocation
E. Wrist sprain
Triquetral fractures typically occur with hyperextension of the wrist. Dorsal avulsion fractures are more
common than fractures of the body of the bone. Tenderness is characteristically noted on the 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. Most studies indicate that this carpal bone has the second or third highest fracture
rate after the navicular. Avulsion fractures respond well to 4 weeks of splinting and protection.
Clinical and radiologic signs do not match those expected in navicular or scaphoid fractures. Navicular
fractures may initially have normal radiologic findings. Immobilization and follow-up radiographs are
required. Tenderness in the snuffbox area is expected, but dorsal tenderness and swelling are not
characteristic. The radiographs do not show a lunate fracture or dislocation. A wrist sprain is a diagnosis of
exclusion and should not be considered too early.
Which one of the following medications is most effective for treating the arrhythmia shown in Figure 3?
A. Atropine
B. Bretylium tosylate (Bretylol)
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl)
E. Adenosine (Adenocard)
Adenosine, an expensive intravenous drug, is highly effective in terminating many resultant
supraventricular arrhythmias. Although it can cause hypotension or transient atrial fibrillation, 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.
The condition shown in Figure 4 occurred in a 31-year-old sexually active male. Which one of the
following is true regarding this problem?

A. Diagnosis by biopsy and viral typing is

recommended
B. Acetowhite staining is indicated to accurately map
margins prior to treatment
C. Treatment with 5% fluorouracil cream (Efudex) is
effective and safe
D. Treatment has a favorable impact on the incidence
of cervical and genital cancer
E. HPV testing is indicated for this patients sexual
partners
Genital warts are typically caused by human
papillomavirus (HPV) types 5 and 11, 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.
Which one of the following interpretations of Figure 5 is most accurate?
A. Surgical menopause is on the
increase
B. Menopause is occurring at an
earlier age
C. The mean age for reaching
menopause is 50
D. One hundred percent of this
sample reached menopause by age 60
E. Menopause is the result of relative
estrogen deficiency
The most efficient method of
gathering epidemiologic data is to
study a representative sample rather
than the entire population subject to
the event. The measurements
obtained are still affected by sampling
variation, however, due to the effect
of chance. 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. Although 18 years is the earliest age of menopause
represented on this particular graph, a comparative conclusion cannot be drawn in the absence of
corresponding comparative data. 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.

A cement plant worker presents to your office with the recurrent acute skin
eruption on his legs shown in Figure 7. It extends proximally from the dorsum
of the feet to just below the knees. This is the third eruption in 2 years.This
patient most likely has:
A. tinea with a secondary id reaction
B. rhus dermatitis
C. methicillin-resistant Staphylococcus aureus (MRSA) cellulitis
D. contact dermatitis related to his occupation
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.
At a routine annual visit, a 31-year-old inner-city elementary school
teacher asks you about a lesion on the nail of her ring finger, shown in
Figure 8. On examination, you note that her other nails all have a slight
linear depression or groove. Which one of the following is the most likely
cause of this problem?
A. A paronychial fungal infection
B. Psoriasis
C. Iron deficiency
D. Lead exposure
E. A traumatic/metabolic event
Fingernails and toenails are often overlooked as clues to systemic illness.
Like hair shafts, they 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 Beaus
lines. No treatment is required. The other options listed involve the nails,
but cause different and characteristic types of nail changes.
Which one of the following drugs inhibits platelet function for the life of the platelet?
A. Aspirin
B. Ibuprofen
C. Dipyridamole (Persantine)
D. Ticlopidine (Ticlid)
E. Warfarin (Coumadin)
A number of drugs inhibit platelet function, but aspirin is the only effective drug that interferes with platelet
aggregation for the life of the platelet. It does this by permanently acetylating the platelet enzyme
cyclooxygenase, thus inhibiting prostaglandin synthesis. This phenomenon is clinically helpful when an
antithrombotic effect is desired, but it may require that necessary surgical procedures be delayed. 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.

An otherwise healthy 10-year-old female presents with a papulovesicular eruption on one leg.It extends
from the lateral buttock, down the posterolateral thigh, to the lateral calf. It is mildly painful. The patients
immunizations are up to date, including varicella and MMR. Her family has a pet cat at home, and another
child at her school was sent home with a rash earlier in the week. Which one of the following is the most
likely diagnosis?
A. Contact dermatitis
B. Herpes zoster dermatitis
C. Tinea corporis
D. Scabies
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.
According to the U.S. Preventive Services Task Force, which one of the following is true regarding prostate
cancer screening?
A. Most men between the ages of 50 and 75 should be screened for prostate cancer
B. Screening for prostate cancer is inappropriate at any age
C. The harms of screening for prostate cancer after the age of 75 outweigh the benefits
D. A digital rectal examination has greater sensitivity than prostate-specific antigen (PSA) testing for
detecting prostate cancer
E. Health outcomes are improved by monitoring PSA velocity and doubling time
The U.S. Preventive Services Task Force (USPSTF) concluded with moderate certainty that the harm from
screening for prostate cancer in men 75 or older outweighs the benefits. Potential harms include urinary
incontinence, erectile dysfunction, bowel dysfunction, and death, and the USPSTF found no direct evidence
of benefits from screening. The USPSTF also concluded that current evidence is insufficient to assess the
benefits versus harms of screening in men younger than age 75. Most major U.S. medical organizations,
including the American Academy of Family Physicians, recommend individualizing decisions after
discussions with the patient, and agree that the best candidates for screening are men age 50 or older with a
life expectancy [1]10 years. Prostate-specific antigen (PSA) is more sensitive than the digital rectal
examination. Utilizing PSA velocity and doubling time has not been shown to improve health outcomes.
A 30-year-old female with dysfunctional uterine bleeding asks about treatment options. An examination is
normal and blood testing is negative. She is unmarried and is undecided about having children. Which one
of the following would be the most appropriate treatment for this patient?
A. A levonorgestrel-releasing intrauterine device
B. Endometrial ablation
C. Hysterectomy
D. Oral progestin during the luteal phase
Few treatments for dysfunctional uterine bleeding have been studied. NSAIDs, oral contraceptive pills, and
danazol have not been shown to have sufficient evidence of effect. 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 releasing IUD is
most effective and preserves fertility.
You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September, and he
tells you that he has severe symptoms every autumn that impair his academic performance. He has a
strongly positive family history of atopic dermatitis. Which one of the following medications is considered
optimal treatment for this condition?
A. Intranasal glucocorticoids
B. Intranasal cromolyn sodium
C. Intranasal decongestants

D. Intranasal antihistamines
Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the
treatment of 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. Overall, they
are not as effective as topical glucocorticoids.
You are treating a 53-year-old female for a deep-vein thrombosis in her left leg. The use of compression
stockings for this problem has been shown to:
A. increase the risk of pulmonary embolism
B. increase the level of pain
C. increase complications if used prior to completion of a course of anticoagulation therapy
D. decrease the risk of post-thrombotic syndrome
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. A Cochrane review identified three
randomized, controlled trials examining the use of compression therapy in patients diagnosed with a new
DVT. 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 (confidence interval of 0.200.48). A separate
trial cited in the Cochrane review documented no increased incidence of pulmonary embolism, and a
reduction in pain and swelling in the treatment group. Compression stockings should be applied when
anticoagulation therapy is started, not when it has been completed. The studies did not examine the rates of
recurrent DVT.
Which one of the following is true concerning the use of dexamethasone to treat acute laryngotracheitis
(croup)?
A. A single dose is adequate for treatment
B. It commonly leads to a secondary bacterial infection due to immunosuppression
C. It increases the need for hospitalization
D. It is indicated only for patients with severe croup
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.
In the development of clinical guidelines, which one of the following is rated as the strongest and highestquality evidence?
A. Evidence from randomized, placebo-controlled studies
B. Evidence from nonrandomized, double-blind, placebo-controlled studies
C. Evidence from nonrandomized, double-blind, crossover, placebo-washoutcontrolled studies
D. Evidence obtained from well-designed cohort or case-control analytical studies from more than one
center or research group
E. Evidence based on reports of expert committees or opinions of respected authorities in the appropriate
specialty area

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).
A 55-year-old male who had a recent episode of atrial fibrillation that converted in the emergency
department is asymptomatic and currently in sinus rhythm. He is in good health otherwise and has no
history of hypertension, diabetes mellitus, heart failure, transient ischemic attack, or stroke. Which one of
the following would be best for preventing a stroke in this patient?
A. Aspirin
B. Clopidogrel (Plavix), 75 mg daily
C. Warfarin (Coumadin), with a goal INR of 1.52.5
D. Warfarin, with a goal INR of 2.03.0
E. Warfarin, with a goal INR of 2.53.5
The absolute rate of stroke depends on age and comorbid conditions. The stroke risk index CHADS , used
to quantify risk of stroke for patients who have atrial fibrillation and to aid in the selection of
antithrombotic therapy, is a mnemonic for individual stroke risk factors: C (congestive heart failure), H
(hypertension), A (age 75), D (diabetes mellitus), and S (secondary prevention for prior ischemic stroke or
transient attackmost experts include patients with a systemic embolic event). Each of these clinical
parameters is assigned one point, except for secondary prevention, which is assigned 2 points. Patients are
considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk
with a 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.
Which one of the following serum proteins is typically DECREASED in a hospitalized patient with sepsis?
A. Complement C3
B. Ferritin
C. C-reactive protein (CRP)
D. Albumin
E. Fibrinogen
The acute phase response refers to the multiple physiologic changes that occur with tissue injury. 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.
A 25-year-old female is concerned about recurrent psychological and physical symptoms that occur during
the luteal phase of her menstrual cycle and resolve by the end of menstruation. She wants help managing
these symptoms, but does not want to take additional estrogen or progesterone.
Which one of the following management strategies is supported by the best clinical evidence?
A. Cognitive-behavioral therapy
B. Spironolactone during the luteal phase
C. Bright light therapy during the luteal phase
D. Evening primrose oil started 24 days prior to the luteal phase
E. Black cohosh

Randomized, controlled trials found that luteal-phase spironolactone improved psychological and physical
symptoms of premenstrual syndrome over 26 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.
A 55-year-old male is brought to the emergency department with a complaint of pain in the right eye and
reduced vision of about 10 minutes duration. His eye was injured while he was hitting a metal stake with a
sledge hammer. He was not wearing safety goggles. On examination you note a subconjunctival
hemorrhage completely surrounding the cornea. The iris is irregular. Which one of the following is
contraindicated prior to emergency transfer to an ophthalmologist?
A. Administering an analgesic
B. Attempting tonometry
C. A visual acuity test
D. Use of an eye shield
E. Administering an antiemetic
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. Relief of pain with an analgesic is appropriate
before transfer. Because of a risk of extruding intraocular fluid, tonometry should not be attempted if globe
rupture is suspected. 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.
A 23-year-old gravida 1 para 0 at 36 weeks gestation presents to the office complaining of ankle swelling
and headache for the past 2 days. She denies any abdominal pain or visual disturbances. On examination
you note a fundal height of 35 cm, a fetal heart rate of 140 beats/min, 2+ lower extremity edema, and a
blood pressure of 144/92 mm Hg. A urine dipstick shows 1+ proteinuria. A cervical examination reveals 2
cm dilation, 90% effacement, 1 station, and vertex presentation. Which one of the following is the most
appropriate next step in the management of this patient?
A. Laboratory evaluation, fetal testing, and 24-hour urine for total protein
B. Ultrasonography to check for fetal intrauterine growth restriction
C. Initiation of antihypertensive treatment
D. Immediate induction of labor
E. Immediate cesarean delivery
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. Ultrasonography should be done to
assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
Delivery is the definitive treatment for preeclampsia. The timing of delivery is determined by the
gestational age of the fetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred
over cesarean delivery, if possible, in patients with preeclampsia. It is not necessary to start this patient on
antihypertensive therapy at this point. An obstetric consultation should be considered for patients with
preeclampsia.
Which one of the following injection sites for insulin administration is best for preventing hypoglycemia in
a 14-year-old male with diabetes mellitus who wishes to participate in track and field running events?
A. Arm
B. Abdomen

C. Hip
D. Calf
E. Thigh
The use of a nonexercised 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.
Which one of the following is the best diagnostic test for vitamin D deficiency?
A. Ionized calcium
B. Serum phosphorus
C. 24-hour urine for calcium
D. 1,25-hydroxyvitamin D
E. 25-hydroxyvitamin D
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 <20 ng/mL (50
nmol/L).
A 69-year-old male presents with a 2-week history of fever, fatigue, weight loss, and mild diarrhea. He is
found to have a mildly tender mass in the left lower quadrant of the abdomen. The most likely diagnosis is:
A. Crohns disease
B. ulcerative colitis
C. celiac disease
D. diverticulitis
E. lymphoma
Diverticulitis commonly affects the left lower quadrant in the elderly and may present as an abscess.
Crohns 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.
A 35-year-old white gravida 2 para 1 sees you for her initial prenatal visit. Since delivering her first child
10 years ago, she has developed type 2 diabetes mellitus. She has kept her disease under excellent control
by taking metformin (Glucophage). A recent hemoglobin A1c level was 6.5%. You should now treat her
diabetes with:
A. metformin
B. acarbose (Precose)
C. pioglitazone (Actos)
D. human insulin
The safety of most oral hypoglycemics in pregnancy has not been established with regard to their
teratogenic potential. However, all oral 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.

A 4-year-old male is brought to your office for evaluation of fever, coryza, and cough. On examination, the
child appears mildly ill but in no respiratory distress. His temperature is 37.4C (99.3F) and other vital
signs are within the normal range. An HEENT examination is significant only for light yellow rhinorrhea
and reddened nasal mucous membranes. Lung auscultation reveals good air flow with a few coarse upper
airway sounds. While performing the examination you note multiple red welts and superficial abrasions
scattered on the chest and upper back. When you question the parents, they tell you the marks are where
the sickness is leaving his body, and were produced by rubbing the skin with a coin. This traditional
healing custom is practiced principally by people from which geographic region?
A. Sub-Saharan Africa
B. Southeast Asia
C. The Middle East
D. Caribbean islands
E. Andean South America
Coin rubbing is a traditional healing custom practiced primarily in east Asian countries such as Cambodia,
Korea, China, and Vietnam. The belief is that ones illness must be drawn out of the body, and the red
marks produced by rubbing the skin with a coin are evidence of the bodys release of the illness. These
marks may be confused with abuse, trauma from some other source, or an unusual manifestation of the
illness itself.
A 12-year-old white male asthmatic has an acute episode of wheezing. You diagnose an acute asthma attack
and prescribe an inhaled 2-adrenergic agonist. After 2 hours of treatment, he continues to experience
wheezing and shortness of breath. Which one of the following is the most appropriate addition to acute
outpatient management?
A. Oral theophylline (Theo-Dur)
B. Oral corticosteroids
C. An oral -adrenergic agonist
D. Inhaled cromolyn (Intal)
E. Inhaled corticosteroids
The treatment of choice for occasional acute symptoms of asthma is an inhaled 2-adrenergic agonist such
as albuterol, terbutaline, or pirbuterol. If symptoms do not respond to -agonists, they should be treated
with a short course of systemic 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 2-selective agonists are less effective and have a slower onset of action than the same drugs
given by inhalation.
An 18-year-old male comes to your office because of the recent onset of recurrent, unpredictable episodes
of palpitations, sweating, dyspnea, gastrointestinal distress, dizziness, and paresthesias. His physical
examination is unremarkable except for moderate obesity. Laboratory findings, including a CBC, blood
chemistry profile, and thyroid-stimulating hormone (TSH) level, reveal no abnormalities. The most likely
diagnosis is:
A. mitral valve prolapse
B. paroxysmal supraventricular tachycardia
C. pheochromocytoma
D. generalized anxiety disorder
E. panic disorder

Panic disorder typically presents with the symptoms described, in late adolescence or early adulthood. The
attacks are sporadic and last 1060 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.
Which one of the following is most associated with falls in older adults?
A. Diphenhydramine (Benadryl)
B. Atorvastatin (Lipitor)
C. Metformin (Glucophage)
D. Memantine (Namenda)
E. Theophylline (Theo-24)
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 one of the anticholinergic
medications associated with falls in older adults. The other drugs listed are not in the higher-risk groups of
medications.
A 78-year-old white male is scheduled to undergo CT with contrast. His current diagnoses include type 2
diabetes mellitus, heart failure, anemia of chronic disease, and renal insufficiency. Evidence supports the
use of which one of the following to reduce the risk of contrast-induced nephropathy in this patient?
A. Intravenous furosemide
B. Ascorbic acid
C. Calcium antagonists
D. Isotonic bicarbonate infusion
E. High osmolar contrast media
Prospective randomized trials examining the risk for contrast-induced nephropathy have identified
significant differences between contrast agents due to their physiochemical properties. Low-osmolar or isoosmolar 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 8
procedure, preferably with isotonic saline or isotonic sodium bicarbonate solution. There is limited
evidence that any pharmacologic intervention will prevent contrast-induced nephropathy.
A 70-year-old white female complains of two episodes of urinary incontinence. On both occasions she was
unable to reach a bathroom in time to prevent loss of urine. The first episode occurred when she was in her
car and the second while she was in a shopping mall. She is reluctant to go out because of this problem.
The most likely cause of her problem is:
A. overflow incontinence
B. stress incontinence
C. urge incontinence
D. functional incontinence
At least 10 million Americans suffer from urinary incontinence. 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. This patient has mild urge incontinence. The first approach to this problem should be

behavioral. In a mild case such as this, a cure can be expected, with success rates of 30%90% in published
studies. For more severe cases, various pharmacologic agents, including anticholinergics, are useful.
Failure of these modalities should lead to urodynamic testing and consideration of surgery.
A 40-year-old obese African-American male presents with a history of excessive daytime drowsiness. He
readily falls asleep when reading or watching television. He admits to nearly crashing his car twice in the
past month because he briefly fell asleep behind the wheel. Most frightening to the patient have been
episodes characterized by sudden loss of muscle tone, lasting about 1 minute, associated with laughing. An
overnight sleep study shows decreased sleep latency and no evidence of obstructive sleep apnea.
Appropriate treatment includes which one of the following?
A. Methylphenidate (Ritalin)
B. Zolpidem (Ambien) at bedtime
C. Carbidopa/levodopa (Sinemet)
D. Weight reduction
E. Avoidance of daytime napping
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.
A 42-year-old female presents to the emergency department with pleuritic chest pain. Her probability of
pulmonary embolism is determined to be low. Which one of the following should be ordered to further
evaluate this patient?
A. Brain natriuretic peptide (BNP)
B. CT pulmonary angiography
C. ELISA-based D-dimer
D. A cardiac troponin level
E. A ventilation-perfusion lung scan
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.
A 34-year-old white male is brought to the emergency department following an automobile accident in
which he was the only occupant of the vehicle. He lost control of the vehicle and hit a utility pole. He was
knocked unconscious initially, but he is now awake and combative. You note a strong smell of alcohol. He
has a frontal hematoma approximately 3 cm in diameter and an actively bleeding 4-cm laceration of the
occiput. He will not permit you to examine him further and he prepares to leave the emergency department.
You should:
A. detain him in the emergency department
B. make him sign out against medical advice
C. tell him that he cannot return if he leaves
D. tell him that if he leaves he can return later
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 cannot be 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.
A 17-year-old soccer player presents for a preparticipation examination. His family history is significant for
the sudden death of his 12-year-old sister while playing basketball, and for his mother and maternal
grandmother having recurrent syncopal episodes. His medical history and examination are completely
normal. Prior to approving his participation in sports, which one of the following is recommended?
A. A resting EKG
B. A stress EKG
C. An echocardiogram
D. Pulmonary function testing
E. No further evaluation
A family history of sudden death and recurrent syncope is highly suspicious for genetic long-QT syndrome.
It is best diagnosed with a resting EKG that shows a QTc >460 msec in females and >440 msec in males.
This syndrome especially places young people at risk for sudden death. Management may include blockers, an implantable cardioverter-defibrillator, and no participation in competitive sports.
Which one of the following dietary supplements has the best evidence of efficacy in the treatment of
osteoarthritis of the knee?
A. Methylsulfonylmethane (MSM)
B. Glucosamine sulfate
C. Harpagophytum procumbens (devils claw)
D. Curcuma longa (turmeric)
E. Zingiber officinale (ginger)
Glucosamine sulfate may be used to reduce symptoms and possibly slow disease progression in patients
with osteoarthritis of the knee (SOR B). Methylsulfonylmethane, devils claw, turmeric, and ginger are not
recommended because of insufficient evidence of their effectiveness.
A 24-year-old female has a history of mood swings over the past several months, which have created
marital and financial problems, in addition to jeopardizing her career as a television news reporter. You
have made a diagnosis of bipolar disorder, and she has finally accepted the need for treatment. However,
she insists that you choose a drug that wont make me fat. Which one of the following would be best for
addressing her concerns?
A. Aripiprazole (Abilify)
B. Olanzapine (Zyprexa)
C. Quetiapine (Seroquel)
D. Risperidone (Risperdal)
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.
A 75-year-old white female presents with back pain of several months duration, which is worsened by
movement. A physical examination is unremarkable except for mild pallor. She takes furosemide (Lasix)
for hypertension. Hemoglobin 10.0 g/dL (N 12.016.0), Serum creatinine 2.0 mg/dL (N 0.61.5), BUN 40
mg/dL (N 825), Serum uric acid 8.0 mg/dL (N 3.07.0), Serum calcium 12.0 mg/dL (N 8.510.5), Total
serum protein 9.8 g/dL (N 6.08.4), Globulin 6.1 g/dL (N 2.33.5), Albumin 3.7 g/dL (N 3.55.0), Serum
IgG 3700 mg/dL (N 6391349), Urine positive for Bence-Jones protein. Which one of the following would
be most appropriate at this point?
A. Repeat the physical examination and laboratory evaluation every 6 months

B. Discontinue the diuretic and repeat the laboratory evaluation in 1 month

C. Obtain a bone scan
D. Obtain a bone marrow examination
E. Begin therapy with tamoxifen (Soltamox), 20 mg daily
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.
A 20-year-old nonsmoker presents to your office with a sudden onset of chest pain. You order a chest
radiograph, which shows a small (<15%) pneumothorax. He is in no respiratory distress and vital signs are
normal. Pulse oximetry shows a saturation of 98% on room air. which one of the following would be most
appropriate initially?
A. CT of the affected lung
B. Analgesics and a follow-up visit in 48 hours
C. Chest tube insertion
D. Hospital admission and a repeat chest film in 24 hours
Practice guidelines state that a patient without apparent lung disease who develops a spontaneous small
pneumothorax (<15% of lung volume) can be managed as an outpatient with analgesics and follow-up
within 72 hours. 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.
In which one of the following patients can a diagnosis of osteoporosis be made?
A. A 58-year-old female who fractured her wrist when she slipped and fell on her outstretched hand onto a
carpeted floor
B. A 62-year-old female who sustained a pelvic fracture in a motor vehicle accident
C. A 52-year-old female with a T-score of +2.5 on bone mineral density (BMD) testing of her hip
D. A 67-year-old female with a T-score of 1.7 on BMD testing of her spine
E. A 72-year-old female with a T-score of 2.0 on BMD testing of her spine
Osteoporosis is defined as a fragility or low-impact fracture, or as a spine or hip bone mineral density
(BMD) 2.5 standard deviations 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.
At a routine visit, a 40-year-old female asks about beginning an exercise regimen. She has a family history
of heart disease and hypertension. She currently has no medical problems, but she is sedentary. Which one
of the following would be the most appropriate recommendation for this patient?
A. Fast walking for 30 minutes on 5 or more days per week
B. Jogging for 30 minutes every other day
C. Weight training once weekly
D. An exercise stress test prior to beginning exercise
E. A baseline EKG and rhythm strip
This patient would benefit from exercise to prevent or delay the onset of heart disease and hypertension,
and to manage her weight. Exercise stress testing is not specifically indicated for this patient. Current

recommendations are for healthy adults to engage in 30 minutes of accumulated moderate-intensity

physical activity on 5 or more days per week.
A 56-year-old male with a history of nephrolithiasis presents with a complaint of right flank pain. Further
evaluation reveals a right ureteral calculus 4 mm in diameter. Laboratory tests reveal a serum calcium level
of 12.1 mg/dL (N 8.510.5), a normal albumin level, and normal kidney and liver function tests. The
patient takes no chronic medications. Which one of the following is most likely to reveal the cause of this
patients elevated calcium?
A. A 24-hour urine calcium level
B. A repeat serum calcium level in 46 weeks
C. A serum 25-hydroxyvitamin D level
D. A serum calcitonin level
E. A serum intact parathyroid hormone level
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 46 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.
You are caring for a 70-year-old male with widespread metastatic prostate cancer. Surgery, radiation, and
hormonal therapy have failed to stop the cancer, and the goal of his care is now symptom relief. He is being
cared for through a local hospice. Over the past few days he has been experiencing respiratory distress. His
oxygen saturation is 94% on room air and his lungs are clear to auscultation. His respiratory rate is 16/min.
Which one of the following would be best at this point?
A. Morphine
B. Oxygen
C. Albuterol (Proventil, Ventolin)
D. Haloperidol
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.
A 72-year-old white female is admitted to the hospital with her first episode of acute heart failure. She has a
history of hypertension treated with a thiazide diuretic. An echocardiogram reveals no evidence of valvular
disease and no segmental wall motion abnormalities. Left ventricular hypertrophy is described, and the
ejection fraction is 55%. Her pulse rate is 72beats/min. The most likely cause of her heart failure is:
A. systolic dysfunction
B. diastolic dysfunction
C. hypertrophic cardiomyopathy
D. high-output failure
Diastolic dysfunction is now recognized as an important cause of heart failure. It is due to left ventricular
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, left ventricular hypertrophy, and a normal ejection fraction (50%55%).
A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If the usual
incidence of this complication were 1% per year, how many patients with this disease would have to be
treated with this medication for 1 year to prevent one occurrence of this complication?

A. 20
B. 50
C. 100
D. 200
E. 500
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 to
benefit one patient. To calculate this number, the percentage 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).
You would recommend pneumococcal vaccine for which one of the following?
A. A 20-year-old male who smokes 1 pack of cigarettes daily
B. A 52-year-old male with type 2 diabetes mellitus who received pneumococcal vaccine 6 years ago
C. A 60-year-old male who is a long-term resident of a nursing home because of a previous stroke, and
who received pneumococcal vaccine at age 54
D. A 62-year-old male with chronic renal failure who received pneumococcal vaccine at age 50 and age 55
E. A 71-year-old male with no medical problems who received pneumococcal vaccine at age 65
In October 2008 the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease
Control and Prevention recommended adding cigarette smoking to the list of high-risk conditions that are
indications for the 23-valent pneumococcal polysaccharide vaccine. 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. The patient with chronic renal failure in this question has already received two immunizations.
The diabetic patient and the nursing-home resident have both received one immunization and should not
receive a second dose until age 65. The 71-year-old has already been immunized after age 65, and a repeat
immunization is not recommended.
A 64-year-old white male presents to the emergency department with a 48-hour history of left lower
quadrant pain. After a thorough history and a physical examination you conclude that the patient has
diverticulitis. The patient is allergic to metronidazole (Flagyl). You recommend a clear-liquid diet, a followup visit with his primary care physician in 48 hours, and treatment with:
A. amoxicillin
B. amoxicillin/clavulanate (Augmentin)
C. ciprofloxacin (Cipro)
D. doxycycline
E. azithromycin (Zithromax)
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.
An 86-year-old mildly demented male nursing-home resident rarely leaves the facility. He has frequent
fecal incontinence that is disturbing to both him and his family. He has diet-controlled diabetes mellitus and
hypertension, and a history of transurethral resection of the prostate (TURP) for benign prostatic
hypertrophy. An examination is remarkable only for an empty rectum and no focal neurologic findings.
Which one of the following is the most likely cause of this patients fecal incontinence?
A. Decreased rectal sensation secondary to diabetes mellitus
B. Decreased rectal storage capacity
C. Internal sphincter weakness
D. Puborectalis weakness
E. Overflow

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.
A 13-year-old male presents with a 3-week history of left lower thigh and knee pain. There is no history of
a specific injury, and his past medical history is negative. He has had no fevers, night sweats, or weight
loss, and the pain does not awaken him at night. He tried out for the basketball team but had to quit because
of the pain, which was worse when he tried to run. Which one of the following physical examination
findings would be pathognomonic for slipped capital femoral epiphysis?
A. Excessive forward passive motion of the tibia with the knee flexed
B. Lateral displacement of the patella with active knee flexion
C. Limited internal rotation of the flexed hip
D. Reduced hip abduction with the hip flexed
E. Inability to extend the hip past the neutral position
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.
A 74-year-old male presents with a 4-day history of diarrhea that he had initially thought was a 24-hour
virus. He states that the onset of his illness included nausea, one episode of vomiting, and profuse
diarrhea. He has felt feverish and has been having abdominal cramps. He does not recall eating anything
unusual and has not traveled recently. On examination he appears uncomfortable, but in no real distress.
His oral temperature is 37.1C (98.8F), blood pressure 134/82 mm Hg, and pulse rate 100 beats/min. He
has lost 4 kg (9 lb) since his last visit 2 months earlier. His abdomen is soft, with hyperactive bowel sounds
and mild diffuse tenderness on palpation. A CBC and basic metabolic profile are normal. Which one of the
following is the most likely cause of this patient's illness?
A. Norwalk-like virus (Norovirus)
B. Shigella
C. Campylobacter
D. Escherichia coli O157:H7
E. Staphyloccocus aureus
Campylobacter jejuni is one of the most common causes of bacterial foodborne illnesses, estimated to
affect 1 million Americans annually. Undercooked or improperly handled chicken is most often implicated
as the source; surveys have demonstrated that between 20% and 100% of all retail chicken sold in the
United States is contaminated. The infection is generally isolated and sporadic, occurs more frequently at
the extremes of age, is most common during the summer months, and affects males disproportionately.
Symptoms typically begin 25 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 2448 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.
A 50-year-old female with significant findings of rheumatoid arthritis presents for a preoperative evaluation
for planned replacement of the metacarpophalangeal joints of her right hand under general anesthesia. She
generally enjoys good health and has had ongoing medical care for her illness. Of the following, which one
would be most important for preoperative assessment of this patients surgical risk?
A. Resting pulse rate
B. Resting oxygen saturation
C. Erythrocyte sedimentation rate
D. Rheumatoid factor titer
E. Cervical spine imaging
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 patients 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. Although
rheumatoid arthritis may influence oxygen saturation and the erythrocyte sedimentation rate, these tests
would not alert the surgical team to the possibility of significant operative morbidity and mortality. Resting
pulse rate and rheumatoid factor are unlikely to be significant factors in this preoperative scenario.
A 68-year-old white male with diabetes mellitus is hospitalized after suffering a right middle cerebral artery
stroke. A nurse in the intensive-care unit calls to advise you that his blood pressure is 200/110 mm Hg. You
should:
A. continue monitoring the patient
B. administer labetalol (Trandate)
C. administer nicardipine (Cardene)
D. administer nitroprusside (Nitropress)
E. administer nitroglycerin
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 <220 mm Hg or a
diastolic blood pressure <120 mm Hg. The elevated blood pressure is thought to be a protective mechanism
that increases cerebral perfusion, and lowering the blood pressure may increase morbidity.
A 59-year-old white female has a blood pressure consistently at or above 140/90 mm Hg. Her only other
significant medical problem is diabetes mellitus, which is controlled by diet. Which one of the following is
the most clearly established advantage of angiotensin receptor blockers (ARBs) when compared with ACE
inhibitors in patients such as this?
A. Reduced risk of persistent cough
B. Reduced risk of headache
C. Reduced risk of heart failure
D. Improved control of blood pressure
E. Improved lipid profile
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, was thought to be ACE-inhibitor specific. However, it is rare and there is not yet good evidence
that ARBs are safer. There have been case reports of angioedema associated with ARB use. The incidence
of headache is similar for the two drug classes. ARBs have not been proven superior to ACE inhibitors in
blood pressure control, effects on lipid profiles, or prevention of heart failure, and there is substantially
more data on ACE inhibitors for the prevention of heart failure and proteinuria.

Which one of the following is the most likely cause of chronic unilateral nasal obstruction in an adult?
A. Nasal septal deviation
B. Foreign-body impaction
C. Allergic rhinitis
D. Adenoidal hypertrophy
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 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.
Which one of the following is most consistent with a diagnosis of iron deficiency anemia?
A. Low iron-binding capacity
B. An elevated methylmalonic acid level
C. Increased serum ferritin
D. Reticulocytosis about 1 week after administration of iron
In iron deficiency anemia, serum iron is low but iron-binding capacity is high. Serum ferritin is one-tenth of
normal. Bone marrow iron stores are depleted. Oral replacement, which is safer than parenteral
administration and more acceptable to patients, should 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.
Which one of the following is the best INITIAL management for hypercalcemic crisis?
A. Intravenous furosemide
B. Intravenous pamidronate (Aredia)
C. Intravenous plicamycin (Mithramycin)
D. Intravenous saline
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 1415 mg/dL. Because patients often have a fluid deficiency of 45 liters, delivering
1000 mL of normal saline during the first hour, followed by 250300 mL/hour, may decrease the
hypercalcemia to less than critical levels (<13 mg/dL). If the clinical status is not satisfactory after
hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide.
Intravenous 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.
A healthy 24-year-old male presents with a sore throat of 2 days duration. He reports mild congestion and
a dry cough. On examination, his temperature is 37.2C (99.0F). His pharynx is red without exudates, and
there are no anterior cervical nodes. His tympanic membranes are normal, and his chest is clear. You would
do which one of the following?
A. Treat with analgesics and supportive care
B. Treat with azithromycin (Zithromax)
C. Perform a throat culture and begin treatment with penicillin
D. Perform a rapid strep test

The Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts to
develop evidence-based guidelines for evaluating and treating adults with acute respiratory disease.
According to these guidelines, the most reliable clinical predictors of streptococcal pharyngitis are the
Centor criteria. These include tonsillar exudates, tender anterior cervical lymphadenopathy, absence of
cough, and history of fever. The presence of three or four of these criteria has a positive predictive value of
40%60%, and the absence of three or four of these criteria has a negative predictive value of 80%.
Patients with four positive criteria should be treated with antibiotics, those with three positive criteria
should be tested and treated if positive, and those with 01 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.
A 28-year-old male is seen for follow-up of acute low back pain. He has a past history of substance abuse.
Ibuprofen and acetaminophen have helped some, but he is experiencing muscle spasms. It is best to avoid
which one of the following when treating this patients problem?
A. Chlorzoxazone (Parafon Forte DSC)
B. Metaxalone (Skelaxin)
C. Cyclobenzaprine (Flexeril)
D. Methocarbamol (Robaxin)
E. Carisoprodol (Soma)
There is limited data regarding the effectiveness of muscle relaxants in musculoskeletal conditions, but
strong evidence regarding their toxicity. Because the evidence for comparable effectiveness is weak, drug
selection should be based on patient preference, side-effect profile, drug interactions, and abuse potential.
Carisoprodol is metabolized to meprobamate, which is a class III controlled substance. It has been shown to
produce both physical and psychologic dependence.
You test a patients muscles and find that his maximum performance consists of the ability to move with
gravity neutralized. This qualifies as which grade of muscle strength, on a scale of 5?
A. 0
B. 1
C. 2
D. 3
E. 4
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, while 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.
A 40-year-old male with acute pancreatitis has an alanine transaminase (ALT) level that is five times
normal. Which one of the following is the most likely diagnosis?
A. Gallstone pancreatitis
B. Pancreatic necrosis
C. Pancreatic pseudocyst
D. Hepatitis C
E. Alcohol-induced pancreatitis
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 C-reactive protein are associated with pancreatic
necrosis. Hepatitis C is identified by antibody detection or polymerase chain reaction testing. Other
markers are investigational.

You are asked to see a mentally challenged 45-year-old male from a nearby group home who has groin
pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles.
These findings are consistent with:
A. a variant form of Down syndrome
B. Aspergers syndrome
C. Klinefelters syndrome
D. homocystinuria
E. Fragile X syndrome
Fragile X syndrome accounts for more cases of mental retardation in males than any other genetic disorder
except Down syndrome; about one in 40006000 males is affected. Down syndrome, Klinefelters
syndrome, and homocystinuria do not present with the described findings. Aspergers syndrome is a variant
of autism in people of normal to high intelligence. Patients with Klinefelters syndrome usually have small
testicles.
According to the U.S. Preventive Services Task Force, multivitamin supplements in the geriatric age group:
A. are not recommended for prevention of any disorder
B. should be prescribed to reduce elevated homocysteine levels
C. decrease coronary atherosclerosis
D. decrease the incidence of lung cancer
E. decrease the incidence of colon cancer
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.
Which one of the following antihypertensive drugs is most likely to cause ankle edema?
A. Hydrochlorothiazide
B. Amlodopine (Norvasc)
C. Lisinopril (Prinivil, Zestril)
D. Losartan (Cozar)
E. Atenolol (Tenormin)
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.
A 27-year-old Korean female consults you regarding several painful ulcers she has developed in the vaginal
area. Your examination reveals multiple 0.5-cm to 1.5-cm oval ulcers with sharply defined borders and a
yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her
mouth, her past history is unremarkable. You obtain blood for a CBC and serology. A Tzanck smear and
culture of her ulcer is negative for herpes simplex virus. Two days later she returns to discuss her laboratory
findings. She draws your attention to a pustule with an erythematous margin at the site where the
venipuncture was done. At this time the most likely diagnosis is:
A. Reiters syndrome
B. Behets syndrome
C. syphilis
D. mucocutaneous lymph node syndrome (Kawasaki disease)
E. AIDS

The original description of Behets syndrome included recurring genital and oral ulcerations and relapsing
uveitis. It is more common in Japan, Korea, and the Eastern Mediterranean area, and affects primarily
young adults. The cause is unknown. Two-thirds of patients will develop ocular involvement that may
progress to blindness. Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic
manifestations. This disease is also associated with cutaneous hypersensitivity; 60%70% of patients will
develop a sterile pustule with an erythematous margin within 48 hours of an aseptic needle prick. Reiters
syndrome is not associated with genital ulcers. The ulcers of syphilis are characteristically painless.
Mucocutaneous lymph node syndrome (Kawasaki disease) primarily affects children under 6 years of age.
While AIDS causes distinctive skin lesions, genital ulcers are not a common manifestation of this disease.
A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on
asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation
causes pain over the lateral 5th metatarsal. The pain is also reproduced when he jumps on the affected leg.
When you ask about his shoes he tells you he bought them several years ago. Which one of the following is
the most likely diagnosis?
A. Ligamentous sprain of the arch
B. Stress fracture
C. Plantar fasciitis
D. Osteoarthritis of the metatarsal joint
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.
A 55-year-old male is brought to the emergency department because of confusion and seizures. He has a
history of hypertension and obstructive sleep apnea due to obesity. He is not conscious and no other history
is available. An examination shows no focal neurologic findings, but a general examination is limited
because of his size. Breath sounds are diminished, and heart sounds are difficult to hear. He has venous
insufficiency changes on his lower extremities, with brawny-type edema. Laboratory testing reveals a
sodium level of 116 mmol/L (N 135145), but normal renal and liver functions. A chest radiograph shows
mild cardiomegaly. A BNP level is pending, but immediate treatment is felt to be indicated. Which one of
the following is the treatment of choice for this patient?
A. Valsartan (Diovan)
B. Furosemide
C. Vasopressin (Pitressin)
D. Hypertonic saline
E. Conivaptan (Vaprisol)
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
12 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.
A 29-year-old gravida 1 para 0 at 8 weeks gestation is concerned about Down syndrome. She had a sibling
with Down syndrome, and she and her spouse want to know what antenatal tests are available to them.
Which one of the following has the best detection rate for Down syndrome in the first trimester of
pregnancy?

A. Serum -hCG and pregnancy-associated plasma protein A (PAPP-A), with nuchal translucency
(combined screening)
B. Maternal serum levels of inhibin A, -fetoprotein, unconjugated estriol, and -hCG (quadruple
screening)
C. Ultrasonography
D. Chorionic villus sampling
E. Amniocentesis
In todays environment, there are multiple screening tools and tests to detect fetal aneuploidy. All pregnant
women, regardless of age, should be offered the opportunity to undergo some form or combination of
screening to detect fetal abnormalities (SOR B). Chorionic villus sampling can be offered at 1013 weeks
gestation, and has a 97.8% detection rate for Down syndromethe best detection rate of studies offered in
the first trimester (SOR C). Combined screening can be offered at 1114 weeks gestation, and has a
78.7%89% detection rate (SOR A). Although amniocentesis has the best detection rate of the options
listed (99.4%), it cannot be offered until 1618 weeks gestation (SOR C). Quadruple screening is done at
1520 weeks gestation, and has a 67%81% detection rate (SOR A); ultrasonography at 1822 weeks
gestation has a 35%79% detection rate (SOR C).
A 72-year-old male presents to your clinic in atrial fibrillation with a rate of 132 beats/min. He has
hypertension, but no history of heart failure or structural heart disease. He is otherwise healthy and active.
The best INITIAL approach to his atrial fibrillation would be:
A. rhythm control with antiarrythmics and warfarin (Coumadin) only if he cannot be consistently
maintained in sinus rhythm
B. rhythm control with antiarrythmics and warfarin regardless of maintenance of sinus rhythm
C. ventricular rate control with digoxin, and warfarin for anticoagulation
D. ventricular rate control with digoxin, and aspirin for anticoagulation
E. ventricular rate control with a calcium channel blocker or -blocker, and warfarin for anticoagulation
Randomized, controlled trials have indicated that in most patients with atrial fibrillation, rate control is the
best initial management. Patients who were stratified to the rhythm control arm of these trials did not have
lower morbidity or mortality and were more likely to suffer from adverse drug effects and increased
hospitalizations. The most efficacious drugs for rate control are calcium channel blockers and -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 -blocker or calcium channel blocker, or for patients with significant left ventricular
systolic dysfunction. In patients 65 years of age 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.
A 7-year-old Hispanic female has a 3-day history of a fever of 40.0C (104.0F), muscle aches, vomiting,
anorexia, and headache. Over the past 12 hours she has developed a painless maculopapular rash that
includes her palms and soles but spares her face, lips, and mouth. She has recently returned from a week at
summer camp in Texas. Her pulse rate is 140 beats/min, and her blood pressure is 80/50 mm Hg in the right
arm while lying down. Which one of the following is the most likely diagnosis?
A. Mucocutaneous lymph node syndrome
B. Leptospirosis
C. Rocky Mountain spotted fever
D. Scarlet fever
E. Toxic shock syndrome
While all of the diagnoses listed are in the differential, the most likely is Rocky Mountain spotted fever
(RMSF) (SOR C). It occurs throughout the United States, but is primarily found in the South Atlantic and
south central states. It is most common in the summer and with exposure to tall vegetation (e.g., while

camping, hiking, or gardening), and is transmitted by ticks. The diagnosis is based on clinical criteria that
include fever, hypotension, rash, myalgia, vomiting, and headache (sometimes severe). The rash associated
with RMSF usually appears 24 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 <2 years old), but symptoms include changes in the lips and oral
cavity, such as strawberry tongue, redness and cracking of the lips, and erythema of the oropharyngeal
mucosa. Leptospirosis is usually accompanied by severe cutaneous hyperesthesia. The patient with 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.
A 48-year-old male who weighs 159 kg (351 lb) is admitted to the hospital with a left leg deepvein
thrombosis and pulmonary embolism. Treatment is begun with enoxaparin (Lovenox). Which one of the
following would be most appropriate for monitoring the adequacy of anticoagulation in this patient?
A. Anti-factor Xa levels
B. Activated partial thromboplastin time (aPTT)
C. Daily INRs
D. Daily factor VIII levels
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. The INR is used to monitor warfarin therapy, and the activated partial thromboplastin
time (aPTT) is used to monitor therapy with unfractionated heparin. Factor VIII levels are not used to
monitor anticoagulation therapy.
Under current guidelines, hospice programs are most likely to serve patients dying from:
A. heart failure
B. COPD
C. severe dementia
D. multiple strokes
E. cancer
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. Diseases such as 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.
A healthy 48-year-old bookkeeper who works in a medical office has a positive PPD on routine yearly
screening. Which one of the following would be most appropriate at this point?
A. A chest radiograph
B. A repeat PPD
C. Treatment with isoniazid and one other antituberculous drug for 12 months
D. Anergy testing
Clinical evaluation and a chest radiograph are recommended in asymptomatic patients with a positive PPD
(SOR C). A two-step PPD is performed on those at high risk whose initial test is negative. 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. Patients with a negative PPD who are still at high risk

for TB, especially HIV-positive patients, could be evaluated for anergy, but it is not recommended at this
time.
Which one of the following decreases the absorption of orally administered calcium supplements?
A. Taking calcium carbonate with meals
B. Taking calcium citrate with meals
C. Vitamin D supplementation
D. Proton pump inhibitors
Long-term histamine H -blocker or proton pump inhibitor 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.
A 16-year-old high-school football player plants his left foot to make a cut and feels his left leg give way.
He feels a pop in the knee, followed by acute pain. He is evaluated on the field, and examination with the
knee flexed 20 reveals that the tibia can be displaced farther anteriorly than with the uninvolved knee.
Which one of the following conditions is most likely?
A. Patellar tendon rupture
B. Posterior cruciate ligament tear
C. Anterior cruciate ligament tear
D. Tibial plateau fracture
E. Patellar dislocation
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. Approximately 50% of patients with this injury develop osteoarthritis in 1020
years. 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. The other conditions listed are also sports-related
knee injuries, but have different mechanisms of injury or physical findings. Patients with patellar tendon
rupture are unable to fully extend their knee and examination shows a palpable defect in the patellar
ligament and a high-riding patella. While the mechanism of injury in patients with posterior cruciate
ligament tears may be similar to that of ACL injury, the examination would show posterior rather than
anterior displacement of the tibia when the knee is flexed at 90 (the posterior drawer sign). The
mechanism of injury of tibial plateau fractures in a healthy young male generally involves a highenergy
collision causing a valgus force with axial loading. Patients with patellar dislocations have symptoms
similar to those of an ACL injury, including an audible crack or pop and the feeling of the knee giving way
after a twisting motion. Immediately following the injury, however, examination would show an obvious
deformity, but the patella may spontaneously relocate prior to the on-field exam. There would be no
instability on the Lachman maneuver.
The best available evidence supports which one of the following guidelines for discussing serious illnesses?
A. Physicians should delay having a detailed discussion with the patient about the expected prognosis of
cancer until staging is completed
B. For patients who are ambivalent about knowing their prognosis, the discussion should focus on optimal
potential outcomes and providing hope, even if this is unrealistic
C. Physicians should delay discussions about palliative care until curative measures have failed
D. Physicians should respect the familys wishes regarding how much information to share with the patient

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 patients 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, symptomdirected
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 physicians assessment of the patients level of understanding about the disease and how much patients
themselves want to know.
A 50-year-old male presents with a 1-day history of fever and chest pain. The chest pain is worse when he
is in a supine position and with deep inspiration, and improves when he leans forward. He has no shortness
of breath and has never had this problem before. His vital signs are normal except for a temperature of
37.8C (100.0F). He has no other medical problems or allergies, and takes no medications. An EKG
reveals widespread ST-segment elevation, upright T waves, and PR-segment depression. His troponin level
is normal. An echocardiogram is pending. Which one of the following would be the most appropriate
treatment for this patient?
A. Aspirin
B. Prednisone
C. Heparin
D. Enoxaparin (Lovenox)
This patient demonstrates classic clinical features of acute pericarditis. Although the EKG findings appear
specific for the early stages of pericarditis, myocardial infarction would also be included in the differential
diagnosis. However, unlike with acute pericarditis, the EKG in myocardial infarction typically
demonstrates ST elevation that is localized and convex, often has Q waves, and rarely shows PR-segment
depression. A friction rub can be heard in up to 85% of patients with acute pericarditis. An echocardiogram
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.
An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight
irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right
crural fold. The area fluoresces coral-red under a Woods light. Which one of the following would be the
most appropriate treatment at this time?
A. Amoxicillin
B. Erythromycin
C. Ketoconazole
D. Nystatin (Mycostatin)
E. Triamcinolone (Kenalog)
The characteristics of this lesion, including coral-red fluorescence under a Woods light, suggests
Corynebacterium infection, which is associated with erythrasma. Tinea cruris caused by Microsporum
infection fluoresces green, while intertrigo and tinea cruris caused by Epidermophyton or Trichophyton
infections do not fluoresce. Erythromycin, either systemic or topical, is the treatment of choice.
An otherwise healthy 40-year-old male comes to your office for follow-up of elevated liver enzymes on an
insurance examination. He is 173 cm (68 in) tall and weighs 113 kg (250 lb) (BMI 37.7 kg/m2). He says he
drinks about two beers per week. Findings are normal on a physical examination, except for a slightly
enlarged liver. AST and ALT levels are twice the upper limits of normal. Which one of the following would
be the most appropriate next step?
A. A liver biopsy

B. Ultrasonography of the liver

C. Colonoscopy
D. Testing for viral hepatitis
E. Repeat AST and ALT levels in 3 months
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.
A 68-year-old African-American male with a history of hypertension and heart failure continues to have
shortness of breath and fatigue after walking only one block. He has normal breath sounds, no murmur, and
no edema on examination. His current medications include furosemide (Lasix), 20 mg/day, and metoprolol
extended-release (Toprol-XL), 50 mg/day. He previously took lisinopril (Prinivil, Zestril), but it was
discontinued because of angioedema. A recent echocardiogram showed an ejection fraction of 35%. Which
one of the following would be most likely to improve both symptoms and survival in this patient?
A. Valsartan (Diovan)
B. Metolazone (Zaroxolyn)
C. Digoxin
D. Verapamil (Calan, Isoptin)
E. Isosorbide/hydralazine (BiDil)
In patients with systolic heart failure, the usual management includes an ACE inhibitor and a -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 AfricanAmericans, a combination of direct-acting vasodilators such as isorbide and hydralazine is
preferred.Verapamil has a negative inotropic effect and should not be used.
A 70-year-old white female comes to your office for an initial visit. She has taken levothyroxine
(Synthroid), 0.3 mg/day, for the last 20 years. Although a recent screening TSH was fully suppressed at
<0.1 U/mL, she claims that she has felt awful when previous physicians have attempted to lower her
levothyroxine dosage. You explain that a serious potential complication of her current thyroid medication
is:
A. adrenal insufficiency
B. carcinoma of the ovary
C. carcinoma of the thyroid
D. hip fracture
E. renal failure
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.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and
solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination, you
note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8C (100.2F),
respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his height is 170
cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous membranes are dry.
You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are
normal. You promptly consult a gastroenterologist, who performs upper endoscopy, which reveals

numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa. As you continue
to investigate, you take a more detailed history. Which one of the following is most likely to be related to
the patients problem?
A. Intravenous drug use
B. A family history of esophageal cancer
C. Chest pain relieved by nitroglycerin
D. Recent travel to Russia
A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have
HIV infection. Intravenous drug use 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.
A 4-year-old male presents with a 3-day history of sores on his right leg. The sores began as small red
papules but have progressed in size and now are crusting and weeping. Otherwise he is in good health and
is up to date with immunizations. On examination he has three lesions on the right anterior lower leg that
are 0.51.5 cm in diameter, with red bases and honey-colored crusts. There is no regional lymphangitis or
lymphadenitis. Which one of the following is the preferred first-line therapy?
A. Oral erythromycin (Erythrocin)
B. Oral penicillin V
C. Topical hexachlorophene (pHisoHex)
D. Topical mupirocin (Bactroban)
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.
A 25-year-old female at 31 weeks gestation presents to the labor wing with painful uterine contractions
every 3 minutes. On examination her cervix is 3 cm dilated and 50% effaced. Her membranes are intact and
fetal heart monitoring is reassuring. She is treated with tocolysis,betamethasone, antibiotics, and
intravenous hydration, and cultured for group B Streptococcus. The neonatal intensive care unit is notified,
but the contractions ease and eventually stop. After 2 days of observation, her cervix is unchanged and she
is discharged home. One week later, the patient presents with contractions for the last 8 hours. Her cervical
findings are unchanged. Her group B Streptococcus culture was negative. Which one of the following
would be the most appropriate next step in the management of this patient?
A. Repeat tocolysis, betamethasone, antibiotics, and intravenous hydration
B. Betamethasone, antibiotics, and intravenous hydration only
C. Antibiotics and intravenous hydration only
D. Tocolysis only
E. Expectant management
The purpose of obstetric management of preterm labor before 34 weeks gestation is to allow time to
administer corticosteroids. 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. They do not add any benefit otherwise, even though subclinical amnionitis may be a causative
factor in many cases of preterm labor. 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 intensive-care unit involvement should be part of expectant management
of preterm labor cases.
You have decided that in addition to the counseling she has been receiving for depression, a 12-year-old
female in your practice might benefit from an antidepressant medication. Which one of the following has
shown the most favorable risk-to-benefit ratio in children and adolescents?
A. Fluoxetine (Prozac)
B. Lithium
C. Amitriptyline
D. Venlafaxine (Effexor)
E. St. Johns wort
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 817 years old. There is
limited or no evidence to support the use of lithium, venlafaxine, or St. Johns 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.
Fibromyalgia is characterized by tender trigger points:
A. along the medial border of each scapula
B. bilaterally at the anatomic snuffbox
C. at the insertion of the Achilles tendon into the posterior heel
D. at the second and third web spaces on the plantar surface of the foot
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.
A 47-year-old female presents to your office with a complaint of hair loss. On examination she has a
localized 2-cm round area of complete hair loss on the top of her scalp. Further studies do not reveal an
underlying metabolic or infectious disorder. Which one of the following is the most appropriate initial
treatment?
A. Topical minoxidil (Rogaine)
B. Topical immunotherapy
C. Intralesional triamcinolone (Kenalog)
D. Oral finasteride (Proscar)
E. Oral spironolactone (Aldactone)
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 612 months, although
areas of regrowth may be pigmented differently. Recovery is less likely if the condition persists for longer
than a year, worsens, or begins before puberty. The initial treatment of choice for patients older than 10
years of age, in cases where alopecia areata affects less than 50% of the scalp, is intralesional corticosteroid
injections. Minoxidil is an alternative for children younger than 10 years of age or for patients in whom
alopecia areata affects more than 50% of the scalp. While topical immunotherapy is the most effective
treatment for chronic severe alopecia areata, it has the potential for severe side effects and should not be
used as a first-line agent. Finasteride inhibits 5 -reductase type 2, resulting in a decrease in
dihydrotestosterone levels, and is used in the treatment of androgenic alopecia (male-pattern baldness).
Similarly, spironolactone is sometimes used for androgenic alopecia because it is an aldosterone antagonist
with antiandrogenic effects.

The preferred antibiotic treatment for community-acquired pneumonia in a young adult in the ambulatory
setting is:
A. trimethoprim/sulfamethoxazole (Bactrim, Septra)
B. cephalexin (Keflex)
C. azithromycin (Zithromax)
D. penicillin V
E. ciprofloxacin (Cipro)
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.
Which one of the following is a risk factor for intermittent claudication?
A. Hyperthyroidism
B. Hypercalcemia
C. Diabetes mellitus
D. Hypogonadism
E. Elevated angiotensin-converting enzyme
Diabetes mellitus and cigarette 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.
The most common presenting symptom of obstructive sleep apnea is:
A. excessive daytime sleepiness
B. snoring
C. morning headache
D. gastroesophageal reflux
E. enuresis
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.
Which one of the following is recommended in the treatment of all four stages of COPD, from mild
through very severe?
A. Scheduled oral mucolytics
B. Scheduled inhaled corticosteroids such as fluticasone (Flovent HFA)
C. Scheduled long-acting inhaled bronchodilators such as salmeterol (Serevent)
D. Scheduled long-acting anticholinergics such as tiotropium (Spiriva)
E. Short-acting inhaled 2 -agonists such as albuterol (Ventolin HFA), as needed for dyspnea
Short-acting bronchodilators such as albuterol and ipratropium are recommended on an as-needed basis for
treatment of breathlessness in stage I (mild) COPD. They are also recommended for as-needed use 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.

A 50-year-old female complains of a 6-month history of the insidious onset of right shoulder pain and
decreased range of motion. She does not respond to consistent use of prescription strength antiinflammatory medication. Radiographs are negative. Treatment of this patients condition should include:
A. physical therapy with home exercises
B. early surgical referral
C. a short course of oral methylprednisolone
D. corticosteroid injection of the acromioclavicular joint
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.
In a patient with symptoms of thyrotoxicosis and elevated free thyroxine (T4 ), the presence of thyroid TSH
receptor site antibodies would indicate which one of the following as the cause of thyroid gland
enlargement?
A. Toxic multinodular goiter
B. Toxic adenoma
C. Hashimotos (lymphadenoid) thyroiditis
D. Subacute (giant cell) thyroiditis
E. Graves disease
When there is a question about the etiology of goiter and thyrotoxicosis, the presence of thyroid TSH
receptor immunoglobulins would indicate the presence of Graves disease, which is considered an
autoimmune disease. The prevalence of specific forms of TSH receptor site antibodies can distinguish
Graves disease from Hashimotos disease. Both are autoimmune diseases, but in Graves disease there is a
predominance of TSH receptor antibodies. In Hashimotos disease TSH receptorblocking antibodies are
more predominant. These immunoglobulins tend to disappear during therapy.
In assessing the nutritional status of an infant it is useful to know that birth weight is expected to be
regained within:
A. 5 days
B. 14 days
C. 21 days
D. 28 days
A helpful guideline for assessing normal growth in the very young infant is that birth weight should be
regained within 14 days.
The advance directive specifications contained in an individuals living will become effective:
A. at the time it is signed and witnessed
B. when it is confirmed by the individuals health care surrogate
C. at the time of admission to a health care facility such as a hospital
D. when the patient develops a terminal illness
E. when the individual becomes unable to communicate health care wishes
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.

A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain
around his right hip. Today he has a temperature of 37.6C (99.7F), cries when bearing weight on his right
leg, and will not allow the leg to be moved in any direction. A radiograph of the hip is normal. Which one
of the following would be most appropriate at this time?
A. A CBC and an erythrocyte sedimentation rate
B. A serum antinuclear antibody level
C. Ultrasonography of the hip
D. MRI of the hip
E. In-office aspiration of the hip
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). Studies have shown that septic arthritis should be considered highly likely in a
child who has a fever over 38.7C (101.7F), refuses to bear weight on the leg, has a WBC count >12,000
cells/mm , and has an ESR >40 mm/hr. If several or all of these conditions exist, aspiration 3 of the hip
guided by ultrasonography 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.
A 55-year-old male is found to have three hyperplastic polyps on a routine screening colonoscopy. He has
no personal or family history of colon cancer. This patients next colonoscopy should be in:
A. 1 year
B. 3 years
C. 5 years
D. 10 years
Colonoscopy is the gold standard for screening for colon cancer. Because of differences in recommended
screening intervals, the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal
Cancer issued recommendations for follow-up in 2006 to bring some uniformity to the guidelines. 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 one or two small adenomas (<1 cm,
with no- or low-grade dysplasia) are considered at low risk and can be followed up in 510 years,
depending on family history, previous colonoscopy findings, and patient and physician preference. Patients
with three or more small adenomas, or one adenoma >1 cm in size 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 26 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.
The parents of a 7-year-old male ask you to evaluate him because of increasing concerns about his temper
tantrums over the past 9 months. He often becomes angry and hostile, argues with them constantly, and
refuses to follow rules or directions. A major source of difficulty is his refusal to quit playing with his toys
when he is asked to come to the dinner table. After the child ignored repeated attempts to get him to come
to the table a few nights ago, the father became frustrated and told him he had lost his television privileges.
In response, the child became aggressive and destructive, breaking his toys and sweeping his dinner plate
and glass of milk onto the floor. The parents describe many similar scenarios at bedtime, bath time, and
when he is getting dressed. They believe that their son is deliberately behaving this way to annoy them.
This history is most consistent with:
A. attention-deficit/hyperactivity disorder
B. bipolar disorder
C. conduct disorder
D. oppositional defiant disorder
E. normal childhood individualization

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.
In patients with type 2 diabetes mellitus, intensive glycemic control has not been shown to be beneficial for
which one of the following diabetic complications?
A. Peripheral neuropathy
B. Foot infections
C. Cardiovascular disease
D. Proliferative retinopathy
E. Nephropathy
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 mellitus. In fact, there is data to suggest 1c
that intensive glycemic control (hemoglobin A <6.5) may be detrimental in certain populations, such as the
elderly and those with cardiovascular disease.
A 52-year-old male requests everything youve got to help him stop smoking. You review common
barriers to quitting and the benefits of cessation with him, and develop a plan that includes follow-up. He
chooses to start varenicline (Chantix) to assist with his efforts, and asks about also using nicotine
replacement. Which one of the following would be accurate advice?
A. Combining these medications has not proven to be beneficial
B. The addition of transdermal nicotine, but not nicotine gum, has proven benefits
C. The combination is highly efficacious
D. Nicotine replacement doses need to be doubled in a patient taking varenicline
E. The combination of nicotine and varenicline is potentially lethal
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, this medication 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.
Which one of the following is more likely to occur with glipizide (Glucotrol) than with metformin
(Glucophage)?
A. Lactic acidosis
B. Hypoglycemia
C. Weight loss
D. Gastrointestinal distress
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. 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-maintaining or even a
weight loss effect. Gastrointestinal distress is a common side effect of metformin, particularly early in
therapy.
Typically, a high-grade squamous intraepithelial lesion (HSIL) of the cervix is treated with ablation or
excision. In which one of the following can treatment be deferred?
A. Adolescents
B. Patients attempting to conceive
C. Patients with a history of three previous normal Papanicolaou smears
D. Patients with a negative DNA test for HPV
E. Patients over the age of 70
Patients attempting to conceive are 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 three normal Papanicolaou (Pap) smears in
succession are candidates for lengthened screening intervals according to some recommendations.
However, once a problem is found, they should be managed the same as other cases. A negative test for
HPV can be used to assess the 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.
A 14-year-old female is brought to your office by her parents because of concerns regarding her low food
intake, excessive exercise, and weight loss. Her weight is less than 75% of ideal for her height. Which one
of the following sets of additional findings would indicate that the patient suffers from severe anorexia
nervosa?
A. Hypertension, tachycardia, and hyperthermia
B. Hypertension, tachycardia, and hypothermia
C. Hypotension, tachycardia, and hypothermia
D. Hypotension, bradycardia, and hyperthermia
E. Hypotension, bradycardia, and hypothermia
Characteristic vital signs in patients with severe anorexia nervosa include hypotension, bradycardia, and
hypothermia. Criteria for hospital admission include a heart rate <40 beats/min, blood pressure <80/50 mm
Hg, and temperature <36C (97F). Increased cardiac vagal hyperactivity is thought to cause the
bradycardia.
A 55-year-old female has severe symptoms of gastroesophageal reflux disease. Upper endoscopy with a
biopsy shows severe esophagitis and Barretts esophagus. Which one of the following is true regarding this
patient?
A. The severity of her symptoms is due to the presence of Barretts esophagus
B. Follow-up screening endoscopy will reduce her risk of death from esophageal cancer
C. Her risk of developing esophageal adenocarcinoma is >90%
D. Her risk of developing esophageal adenocarcinoma is <1%
The actual risk of adenocarcinoma from Barretts esophagus is less than 1%. Endoscopy does nothing to
reduce the risk of death. Patients with Barretts esophagus can have minimal symptoms.

A 45-year-old male presents with a complaint of recent headaches. He has had four headaches this week,
and his description indicates that they are moderate to severe, bilateral, frontal, and nonthrobbing. There is
no associated aura. He has had similar episodes of recurring headachesin the past. Based on this limited
history, which one of the following headache types can be eliminated from the differential diagnosis?
A. Tension-type headache
B. Sinus headache
C. Migraine headache
D. Cluster headache
E. Headache of intracranial neoplasm
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.
In which one of the following scenarios is a physician most likely to be protected by a Good Samaritan
statute?
A. Assisting flight attendants with the care of a fellow passenger who develops respiratory distress while in
flight over the United States
B. Attending to an unconscious player while acting as an unpaid volunteer physician at a high-school
football game
C. Attending to a bicyclist with heat exhaustion while volunteering at a first-aid station during a fundraising ride
D. Attending to the family member of a patient who slips and falls in the waiting room at the physicians
office
E. Attending to a nurses aide who collapses while the physician is staffing the hospital emergency
department
Generally, Good Samaritan laws apply to situations in which the physician does not have a preexisting duty
to provide care to the patient. A physician who volunteers as a standby health care provider 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. 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 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a
fungal infection in five toenails. She says the condition is painful and limits her ability to complete her
morning walks. She asks for treatment that will allow her to resume her daily walks as soon as possible.
Her only other medical problem is allergic rhinitis which is well controlled.
A. Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks
B. Oral terbinafine (Lamisil) daily for 12 weeks
C. Topical terbinafine (Lamisil AT) daily for 12 weeks
D. Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks
E. Toenail removal
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.

A 24-year-old female had been healthy with no significant medical illnesses until about 3 months ago,
when she was diagnosed with schizophrenia and treatment was initiated. She is now concerned because she
has gained 10 lb since beginning treatment. A comprehensive metabolic panel is normal, with the exception
of a fasting blood glucose level of 156 mg/dL. Which one of the following medications would be most
likely to cause these findings?
A. Clonazepam (Klonopin)
B. Thioridazine
C. Chlorpromazine
D. Aripiprazole (Abilify)
E. Olanzapine (Zyprexa)
Second-generation, or atypical, antipsychotics are associated with weight gain, elevated triglycerides, and
type 2 diabetes mellitus. 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.
A 40-year-old male with a 20-pack-year history of smoking is concerned about lung cancer. He denies any
constitutional symptoms, or breathing or weight changes. You encourage him to quit smoking and order
which one of the following?
A. No testing
B. A chest radiograph
C. Low-dose CT of the chest
D. Sputum cytology
This patient is at risk for lung cancer, even with no symptoms. He should be encouraged to stop smoking,
especially if he has concerns that may help motivate him to quit. No study has demonstrated that screening
with any of the tests listed improves survival, and no major organization endorses lung cancer screening.
A 40-year-old white female presents with pain on inspiration and dyspnea since this morning. She has no
chronic medical problems, takes no medications, has not traveled, and has no history of trauma. On
examination the patient is afebrile, has a heart rate of 90 beats/min and a respiratory rate of 20/min, and her
lungs are clear to auscultation. The pain is worse in the supine position. Which one of the following would
you do initially?
A. Order a CBC with differential
B. Order a chest film and EKG
C. Prescribe ibuprofen
D. Prescribe omeprazole (Prilosec)
E. Prescribe a bronchodilator
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, pulmonary embolism, pneumothorax, and myocardial
infarction, and a chest film 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.
An anxious 62-year-old white male comes to the emergency department complaining of extreme shortness
of breath and a cough producing blood-tinged sputum. The patient denies chest pain and fever. On
examination he is afebrile and has expiratory wheezes and a few rales throughout the chest. The heart is

normal except for a rapid rate and an S3 gallop. A chest radiograph reveals a right pleural effusion with
enlargement of the cardiac silhouette and redistribution of blood flow to the upper lobes. Which one of the
following tests would be best for confirming the diagnosis?
A. Troponin I
B. BNP
C. D-dimer
D. CT angiography of the chest
E. Arterial blood gases
This patient has heart failure with a bronchospastic component. The S3 gallop occurs with a dilated left
ventricle and a right-sided pleural effusion, which are common in heart failure. A BNP level is useful in
differentiating cardiac and 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.
A study finds that the positive predictive value of a new test for breast cancer is 75%, which means:
A. if 100 patients with known breast cancer have the test, 75 (75%) will have a positive test result
B. if 100 patients with no breast cancer have the test, 75 (75%) will have a negative test
C. 75% of patients who test positive actually have breast cancer
D. 75% of patients who test negative do not have breast cancer
Positive predictive value refers to the percentage of patients with a positive test for a disease who actually
have the disease. The negative predictive value of a test is the proportion of patients with negative test
results who do not have the disorder. The percentage of patients with a disorder who have a positive test for
that disorder is a tests sensitivity. The percentage of patients without a disorder who have a negative test
for that disorder is a tests specificity.
A 49-year-old white female comes to your office complaining of painful, cold finger tips which turn white
when she is hanging out her laundry. While there is no approved treatment for this condition at this time,
which one of the following drugs has been shown to be useful?
A. Propranolol (Inderal)
B. Nifedipine (Procardia)
C. Ergotamine/caffeine (Cafergot)
D. Methysergide (Sansert)
At present there is no approved treatment for Raynauds disease. However, patients with this disorder
reportedly experience subjective symptomatic improvement with calcium channel antagonists, with
nifedipine being the calcium channel blocker of choice. -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 Raynauds
disease.
A 54-year-old male comes to your office with a 2-day history of swelling, erythema, and pain in his right
first metatarsophalangeal joint. This is the third time this year he has had this problem. He has treated
previous episodes with over-the-counter pain medicines, ice packs, and elevation. Your evaluation suggests
gout as the diagnosis. Which one of the following treatments for gout is most likely to worsen his current
symptoms?
A. Allopurinol (Zyloprim)
B. Colchicine (Colcrys)
C. Elastic compression bandages
D. Indomethacin
E. Prednisone

All of the treatments listed are commonly used in the management of gout with good success. 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 patients 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.
A 30-year-old female who had a deep venous thrombosis in her left leg during pregnancy has an uneventful
delivery. During the pregnancy she was treated with low molecular weight heparin. Just after delivery her
left leg is pain free and is not swollen. She plans to resume normal activities soon. Which one of the
following would be most appropriate with regard to anticoagulation?
A. Discontinuing treatment, with no further evaluation
B. Discontinuing treatment if venous Doppler ultrasonography is negative for thrombus
C. Continuing low molecular weight heparin for 6 more weeks
D. Switching to low-dose unfractionated heparin for 6 weeks
E. Switching to aspirin for 6 weeks
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.
An overweight 11-year-old male with acanthosis nigricans is found to have a fasting plasma glucose level
of 175 mg/dL on two occasions. Over the next 6 months, despite reasonable adherence to a diet and
exercise regimen, he has preprandial and bedtime finger-stick blood glucose levels that average 180 mg/dL.
His hemoglobin A1c is 9.0%. Which one of the following oral agents would be most appropriate at this
time?
A. Metformin (Glucophage)
B. Glyburide (DiaBeta)
C. Sitagliptin (Januvia)
D. Pioglitazone (Actos)
E. Acarbose (Precose)
Metformin and insulin are the only agents approved for treatment of type 2 diabetes mellitus in children.
A 32-year-old female experiences an episode of unresponsiveness associated with jerking movements of
her arms and legs. Which one of the following presentations would make a diagnosis of true seizure more
likely?
A. Post-event confusion
B. Eye closure during the event
C. A history of fibromyalgia
D. A history of chronic back pain
E. A normal serum prolactin level after the event
Up to 20% of patients diagnosed with epilepsy actually have pseudoseizures. Eye closure throughout the
event is uncommon in true seizures, and 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.

A patient dying of cancer is suffering from pain in spite of his narcotic regimen. You increase his dosage of
morphine, knowing it will probably hasten his death. Which ethical principle are you following?
A. Distributive justice
B. Double effect
C. Death with dignity
D. Futility
E. Autonomy
The concept of double effect dates back to the Middle Ages. It 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 doctors 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 patients ability to
direct his or her own care,which is n ot an issue in this case.
You are a member of a committee at your local hospital that has been asked to develop measures to reduce
the incidence of postoperative methicillin-resistant Staphylococcus aureus (MRSA) infections. Which one
of the following would be most effective for preventing these infections?
A. Give preoperative antibiotics to all surgical patients to eradicate bacteria
B. Screen all admitted patients for MRSA and use antibiotics pre- and postoperatively in positive cases
C. Culture the nares of all hospital employees upon hiring and on a routine basis thereafter
D. Institute an intensive program of good hand washing for all employees
Nosocomial infections are a significant factor in morbidity and cost in the health care field.
Methicillinresistant Staphylococcus aureus (MRSA) has rapidly increased in frequency, first being found
only at tertiary centers, then local hospitals, and now in the outpatient setting. In 2004, an estimated 1.5%
of U.S. residents carried MRSA in the anterior nares of the nose. Of those who are found to be colonized,
either at the time of hospitalization or later by a routine culture, 25% will develop a MRSA infection.
However, a recent study showed that of 93 patients who became infected with the organism, 57% were not
colonized at the time of infection. The study also attempted to screen all patients for MRSA on admission,
but found that even though 337 previously unknown carriers were found (in addition to those already
known to harbor the organism), there was not a significant decrease in the rate of MRSA infections during
the study. Although MRSA infections can be seriouss, they comprise only 8% of nosocomial infections in
the hospital, and concentrating prevention efforts only on MRSA has little effect on that 8%, and no effect
on the 92% of infections caused by other organisms. Iatrogenic complications arise from trying to treat
MRSA carriers, including both drug reactions and the development of other resistant organisms. Costs
related to attempts at prophylaxis also go up. Culturing all hospital employees has not been proven to be of
value, as employees can pick up the organism after screening, and also can spontaneously eradicate the
organism without treatment. The best way to prevent complications and postoperative infections is to
aggressively advocate universal and frequent hand washing and room cleaning, and use good isolation
techniques and methods of preventing infection, such as strict catheter and intravenous tubing protocols.
A 25-year-old male who came to your office for a pre-employment physical examination is found to have
2+ protein on a dipstick urine test. You repeat the examination three times within the next month and results
are still positive. Results of a 24-hour urine collection show protein excretion of <2 g/day and normal
creatinine clearance. As part of his further evaluation you obtain split urine collections with a 16-hour
daytime specimen containing an increased concentration of protein, and an 8-hour overnight specimen that
is normal. Additional appropriate evaluation for this mans problem at this time includes which one of the
following?
A. Serum and urine protein electrophoresis
B. Antinuclear antibody
C. Serum albumin and lipid levels
D. Renal ultrasonography

E. No specific additional testing

Persons younger than 30 years of age who excrete less than 2 g of protein per day and who have a normal
creatinine clearance should be tested for 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.
A 50-year-old male is brought to the emergency department because of a syncopal episode.Prior to the
episode, he felt bad for 30 minutes, then developed nausea followed by vomiting. During a second bout of
vomiting he blacked out and fell to the floor. His wife did not observe any seizure activity, and he was
unconscious only for a few seconds. His history is otherwise negative, his past medical history is
unremarkable, and he currently takes no medications. A physical examination is normal. Which one of the
following would be the most helpful next step?
A. CT of the head
B. Carotid ultrasonography
C. A CBC and complete metabolic profile
D. Echocardiography
E. An EKG
The workup of patients with syncope begins with a history and a physical examination to identify those at
risk for a poor outcome. Patients who have a prodrome of 5 seconds or less may have a cardiac arrhythmia.
Patients with longer prodromes, nausea, or vomiting 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.
A 38-year-old female with seasonal allergies presents with a 10-day history of sinus pain and purulent nasal
drainage, along with temperature elevations up to 102F (39C). She has been taking nonprescription
loratidine (Claritin), but says it provides little relief. She asks you to prescribe an antibiotic. Which one of
the following would be most appropriate at this point?
A. Continuation of symptomatic treatment only
B. In-office nasal irrigation2
C. Amoxicillin
D. Azithromycin (Zithromax)
E. Imaging of the sinuses
The American Academy of Otolaryngology published guidelines for the diagnosis and management of
rhinosinusitis in adults in 2007. They cite reasonable evidence for initiating antibiotic treatment in patients
with symptoms persisting for 710 days that are not improving or worsening (SOR B). Amoxicillin should
be the first-line agent, with azithromycin or trimethroprim/sulfamethoxazole recommended 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.
A 27-year-old male was roughhousing with his children when he was accidentally struck in the left eye. He
immediately felt pain in the eye, and over the next hour noted increased tearing,pain with blinking,
increasing headache, and a foreign-body sensation. You see the patient the next day, and examination with

flourescein dye and a cobalt-blue filtered light reveals a corneal abrasion. Appropriate management
includes which one of the following?
A. An eye patch for 2448 hours
B. Mydriasis with a short-acting agent, such as tropicamide ophthalmic (Mydriacyl)
C. A topical anesthetic instilled every 4 hours if no foreign body or infection is found
D. Topical corticosteroid drops
E. Referral to an ophthalmologist if the edge of the abrasion is white or gray
A white or gray appearance at the edge of a corneal abrasion may indicate infection, and referral to an
ophthalmologist is indicated. Mydriatic agents and eye patching are ineffective for corneal abrasions and
are not recommended (SOR A). Progression to recurrent corneal erosion may occur years after a corneal
abrasion. Symptoms mimic the initial corneal abrasion, and tearing on awakening is common. Topical
anesthetics should be administered only in the office; if a patient uses the medication at home, it can delay
healing and mask complications.
When a screening test identifies a cancer earlier, thereby increasing the time between diagnosis and death
without prolonging life, this is called:
A. length-time bias
B. lead-time bias
C. a false-positive screening test
D. increasing the positive predictive value of the screening test
E. attributable risk
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.
A 42-year-old white female presents to your office as a new patient. She states that she has an 8-year
history of abdominal cramps and diarrhea. Her symptoms have not responded to the usual treatments for
irritable bowel syndrome. She has no rectal bleeding, anemia, weight loss, or fever, and no family history
of colon cancer. Her medical history and a review of symptoms is otherwise negative, and a physical
examination is normal. Which one of the following would be the most appropriate next step in evaluating
this patient?
A. A CBC
B. A TSH level
C. A complete metabolic panel
D. Serologic testing for celiac sprue
E. Stool testing for ova and parasites
In patients who have symptoms of irritable bowel syndrome (IBS), the differential diagnosis includes celiac
sprue, microscopic and collagenous colitis, atypical Crohns disease for patients with diarrhea-predominant
IBS, and chronic constipation (without pain) for those with constipation-predominant IBS. If there are no
warning signs, laboratory testing is warranted only if indicated by the history.
During a comprehensive health evaluation a 65-year-old African-American male reports mild, very
tolerable symptoms of benign prostatic hyperplasia, rated as a score of 7 on the American Urological
Association Symptom Index. He has never smoked, and his medical history is otherwise unremarkable.
Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is

normal and his prostate-specific antigen level is 1.8ng/mL. Based on current evidence, which one of the
following treatment options is most appropriate at this time?
A. Observation, with repeat evaluation in 1 year
B. Saw palmetto
C. An -receptor antagonist
D. A 5--reductase inhibitor
E. Urologic referral for transurethral resection of the prostate
Watchful waiting with annual follow-up is appropriate for men with mild benign prostatic hyperplasia
(BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the
treatment of choice, if indicated (SOR C). PSA levels >2.0 ng/mL for men in their 60s correlate with a
prostatic volume >40 mL. This patients PSA falls below this level. In men with a prostatic volume >40
mL, 5 -reductase inhibitors should be considered for treatment (SOR A). -Blockers provide symptomatic
relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms
(SOR A). 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 American Urological Association 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.
A 47-year-old female presents with progressive difficulty hearing. She is employed as an office worker, has
no significant past medical history, and takes no medications. Physical examination shows no gross
abnormalities of her outer ears. The external ear canals are free of cerumen, and the tympanic membranes
move well to insufflation. Webers test and the Rinne test have results that are compatible with a conductive
hearing loss. Which one of the following is the most likely cause of this patients hearing loss?
A. Noise-induced hearing loss
B. Menieres disease
C. Otosclerosis
D. Acoustic neuroma
E. Perilymphatic fistula
Otosclerosis typically presents between the third and fifth decades, 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. Menieres 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.
Risk factors for venous thromboembolism include which one of the following?
A. Anemia
B. The use of oral hypoglycemic agents
C. Being underweight
D. Young age
E. Spinal cord injury
There are many risk factors for thromboembolism, including polycythemia vera, oral contraceptive use,
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.
Women should be tested for human papillomavirus (HPV) DNA:

A. every year, when a Papanicolaou (Pap) test is performed

B. every 2 years, when a Pap test is performed
C. prior to receiving HPV vaccine (Gardasil)
D. when a Pap smear shows ASC-US
E. when genital warts are noted
Human papillomavirus (HPV) DNA testing is useful for determining whether colposcopy is needed in
patients whose Papanicolaou (Pap) test shows aytpical squamous cells of undetermined significance
(ASCUS). Women with a negative result for high-risk HPV can be safely followed without colposcopy.
Some recent studies suggest that screening HPV DNA testing for women in their thirties may be useful,
most likely as a replacement for Pap smears; however, this is in the preliminary stages of study. Younger
women would not benefit from screening for HPV DNA because it would identify the very large number of
young women who have a transient infection. The addition of HPV DNA testing to Pap smears at currently
recommended intervals would not change management. The presence or absence of HPV DNA does not
alter the indications for HPV vaccine, because patients with or without HPV are candidates for vaccination.
The vaccine protects against HPV strains that the patient may not have contracted. Genital warts are caused
by HPV, usually a low-risk strain, so testing for HPV in patients with this problem does not provide useful
information.
A 41-year-old male trips on a curb while running, sustaining an inversion ankle injury. According to the
Ottawa ankle rules, which one of the following would be an indication for radiographic evaluation?
A. Tenderness at the anterior talofibular ligament
B. Point tenderness over the cuboid
C. Inability to take four steps either immediately after the injury or while in your office
D. Bony tenderness at the anterior aspect of the distal tibia
E. Point tenderness over the base of the fourth metatarsal
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; or localized tenderness at the posterior
edge or tip of either malleolus.
An anxious 30-year-old white female comes to the emergency department with shortness of breath,
circumoral paresthesia, and carpopedal spasms. Which one of the following sets of blood gas values is most
consistent with this clinical picture?
A. pH 7.25 (N 7.357.45), pCO2 25 mm Hg (N 3545), pO2 100 mm Hg (N 80100)
B. pH 7.25, pCO2 50 mm Hg, pO2 80 mm Hg
C. pH 7.50, pCO2 25 mm Hg, pO2 100 mm Hg
D. pH 7.55, pCO2 50 mm Hg, pO2 80 mm Hg
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.
A 72-year-old female is admitted to the hospital after having surgery for a hip fracture. Her previous
medical history is significant for hypertension and type 2 diabetes mellitus. Two days after admission the
orthopedic surgeon consults with you because the patient has had several hours of fever to 39C (102F);
tachycardia, with a pulse rate of 120 beats/min; and systolic blood pressures of 9197 mm Hg (baseline
120140 mm Hg with medication). When you examine the patient she says she feels weak and chilled but
she is alert. Her oxygen saturation is excellent on room air, and a physical examination is normal except for
the sinus tachycardia and low blood pressure. A urinary catheter is in place, but there has been little output

over the last 4 hours. Her renal function was normal prior to her hospitalization. A chest radiograph is
normal. Her electrolyte levels are normal, but laboratory tests reveal the following abnormal results: WBCs
2500/mm3 (N 500010,000), BUN 50 mg/dL (N 1015), Creatinine 2.3 mg/dL (N 0.61.0), Bicarbonate 18
mmol/L (N 2230), Urinalysis: Specific gravity >1.030 (N 1.0031.040), WBCs >100/hpf, RBCs 10
20/hpf, Epithelial cells 35/hpf, Casts few hyaline. In addition to antibiotics, which one of the following
would be the most appropriate management of this patients problem?
A. High-rate intravenous normal saline
B. Intravenous furosemide, 40 mg every 6 hours
C. Intravenous dopamine, 24 g/kg/min
D. Intravenous sodium bicarbonate
E. Urgent nephrology consultation for dialysis
This patient appears to be 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 intravenous 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 patients fluid status should be monitored carefully. Metabolic acidosis
will likely reverse with appropriate hydration, and sodium bicarbonate should be reserved for severe
acidosis (<1015 mmol/L) or for those with chronic kidney disease. Low-dose dopamine has been proven
to be ineffective in acute renal failure, and this patient does not have an indication for dialysis. Intravenous
furosemide is contraindicated.
A 30-year-old female comes to your office because she is concerned about irregular menses (fewer than
9/year), acne, and hirsutism. Her BMI is 36.0 kg/m2. She has no other medical problems and would like to
have a baby. Her fasting blood glucose level is 140 mg/dL. Which one of the following would be the most
appropriate treatment for this patients condition and concerns?
A. Lifestyle modification only
B. Lifestyle modification and pioglitazone (Actos)
C. Lifestyle modification and metformin (Glucophage)
D. Lifestyle modification and an oral contraceptive
E. Lifestyle modification and oral testosterone
This patient has classic features of polycystic ovary syndrome (PCOS). The diagnosis is based on the
presence of two of the following: oligomenorrhea or amenorrhea, clinical or biochemical
hyperandrogenism, or polycystic ovaries visible on ultrasonography. Lifestyle modifications are necessary,
but medications are also needed. First-line agents for the treatment of hirsutism in patients with PCOS
include spironolactone, metformin, and eflornithine (SOR A). Firstline agents for ovulation induction and
treatment of infertility in patients with PCOS include metformin and clomiphene, alone or in combination
with rosiglitazone (SOR A). Metformin can also improve menstrual irregularities in patients with PCOS
(SOR A), and is probably the first-line agent for obese patients to promote weight reduction (SOR B). In
addition, metformin improves insulin resistance (diagnosed by elevated fasting blood glucose) in patients
with PCOS, as do rosiglitazone and pioglitazone. Pioglitazone would not be appropriate for this patient
because it causes weight gain. Oral contraceptives would improve the patients menstrual irregularities and
hirsutism, but she wishes to become pregnant. Testosterone would worsen the hyperandrogenism and
would not treat the PCOS.
Which one of the following drugs would be the most appropriate empiric therapy for nursing home
acquired pneumonia in a patient with no other underlying disease?
A. Cefazolin
B. Erythromycin
C. Ampicillin
D. Tobramycin (Nebcin)
E. Levofloxacin (Levaquin)

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
Grams 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.
A severely depressed 77-year-old male is hospitalized after an intentional drug overdose. He was found by
chance when his housekeeper returned to retrieve something she had left behind. The patient has been
severely depressed since he suffered a myocardial infarction 1 year ago, and the recent death of his wife has
increased his despondency. He had left a note apologizing to his family and his physician, who has treated
him with multiple medications for depression over the past year. He has been treated with SSRIs, SNRIs,
and atypical antipsychotics in high doses and in various combinations without significant improvement.
Which one of the following would be most likely to improve this patients depression at this point?
A. Cognitive-behavioral therapy
B. Psychoanalysis
C. Electroconvulsive therapy
D. Goal-directed psychotherapy
E. Limbic stimulation
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 patients age, his failure to respond to medications, and the need for rapid improvement to
decrease the risk of further suicide attempts.
A 55-year-old obese male with hypertension and daytime somnolence is found to have severe obstructive
sleep apnea, with an apnea-hypopnea index of 32 on an overnight polysomnogram. Which one of the
following is considered to be first-line therapy for this patient's condition?
A. Continuous positive airway pressure (CPAP)
B. An oral dental appliance
C. Uvulopalatopharyngoplasty
D. Sleep positioning therapy
E. Tracheostomy
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.
A 72-year-old male is brought by ambulance to the emergency department with weakness and numbness of
his left side that began earlier this morning. While in the emergency department he becomes comatose with
infrequent, gasping breaths and is quickly intubated and placed on a ventilator. A full evaluation shows an
acute ischemic right-sided stroke. His wife states that she wishes to have the ventilator stopped, as she
believes this would be consistent with her husbands wishes in this circumstance. She understands that this
would precipitate the patients death. The wife presents a legally valid advance directive confirming her as
the patients healthcare proxy. Which one of the following responses to the wifes request is most ethically
appropriate?
A. Withdraw the ventilator as requested
B. Contact the hospital ethics committee to initiate the legal requirements to process the wifes request
C. Inform the wife that all life-sustaining care should be given until the patients condition has been
determined to be irreversible
D. Inform the wife that intubation may have been avoided in the emergency department, but once lifesustaining care has been initiated it should not be withdrawn
E. Promptly contact hospital security or the local law enforcement agency to report the wifes request

Competent adult patients have the right to refuse any medical intervention, even if forgoing this treatment
may result in their death. Legally and ethically it does not matter whether the patient requests that care be
withheld before it is started or that it be withdrawn once it is begun. All states currently allow competent
patients to legally designate a health-care proxy to make these decisions for them if they become unable to
communicate or are no longer competent to decide for themselves. The patient in this example has
instituted such a legal advance directive and his proxys 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 patients 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.
Which one of the following is most likely to be of benefit in patients with essential tremor of the hand?
A. Isoniazid
B. Diazepam (Valium)
C. Topiramate (Topamax)
D. Clonidine (Catapres)
E. Gabapentin (Neurontin)
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, -blockers other than propranolol, calcium channel blockers, clonidine, gabapentin, and
isoniazid.
A 24-year-old African-American male presents with a history of several weeks of dyspnea, cough
productive of bloody streaks, and malaise. His examination is normal except for bilateral facial nerve palsy.
A CBC and urinalysis are normal. A chest radiograph reveals bilateral lymph node enlargement. This
presentation is most consistent with:
A. polyarteritis nodosa
B. Goodpastures syndrome
C. sarcoidosis
D. pulmonary embolus
Sarcoidosis, a disease of unknown etiology, affects young to middle-age adults (predominantly 2029 years
ld). In the U.S. it is more common in African-Americans. It is asymptomatic in 30%50% of patients, and
is often diagnosed on a routine chest film. About one-third of cases will present 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. Facial nerve
palsy is seen in <5% of patients, and usually occurs late in the process. 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. Polyarteritis nodosa
may involve the lungs. Although pneumonic episodes may be associated with hemoptysis in a small
percentage of patients, the chest radiograph is more likely to reveal granulomatous lesions rather than
patchy infiltrates. Goodpastures syndrome is characterized by pulmonary hemorrhage, glomerulonephritis,
and antiglomerular basement membrane antibodies. Hemoptysis, pulmonary alveolar infiltrates, dyspnea,
and iron-deficiency anemia are frequent presenting features. Within days or weeks, the pulmonary findings
are generally followed by hematuria, proteinuria, and the rapid loss of renal function. Pulmonary embolus
is an acute event, and would present with dyspnea and possibly hemoptysis, but not hilar lymphadenopathy.
An elderly male patient takes aspirin, 81 mg daily, for prevention of a heart attack. He also takes herbal
supplements. Which one of the following supplements can have a negative interaction with aspirin?

A. Kava
B. Yohimbine
C. Saw palmetto
D. Echinacea
E. Ginkgo biloba
Herbal and dietary supplements can affect the absorption, metabolism, and disposition of other drugs.
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 and has
been associated with case reports of spontaneous bleeding. 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.
An 8-year-old male presents to your office 2 days after returning from a trip to Mexico with his family. He
developed watery, nonbloody diarrhea on the day of departure. He has mild abdominal cramping, but no
fever or vomiting. His mother had similar symptoms, which were milder and resolved with over-thecounter treatments. Which one of the following would be most appropriate to treat this patients condition?
A. Metronidazole (Flagyl)
B. Ciprofloxacin (Cipro)
C. Azithromycin (Zithromax)
D. Mebendazole
E. Metoclopramide (Reglan)
Travelers diarrhea commonly occurs in travelers to Mexico and developing countries. It is usually caused
by bacterial organisms such as Escherichia 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.
Fluoroquinolones are effective in adults, but should not be used in an 8-year-old. Azithromycin isgenerally
effective and safe in children. Metronidazole, mebendazole, and metoclopramide would not be likely to
successfully treat bacterial travelers diarrhera.
Secondary causes of osteoporosis in males include which one of the following?
A. Weekly consumption of 36 alcoholic drinks
B. Male hormone supplementation
C. Vitamin D excess
D. Obesity
E. Corticosteroid use
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.
The preferred site for an emergency airway is:
A. the thyrohyoid membrane
B. the cricothyroid membrane
C. immediately below the cricoid cartilage
D. through the first and second tracheal rings
E. at the level of the thyroid isthmus
Fortunately, emergency tracheotomy is not often necessary, but should one be necessary the best site for the
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. The thyrohyoid membrane lies well above the vocal cords, making this

an impractical site. The area directly below the cricoid cartilagewhich includes the second, third, and
fourth tracheal rings, as well as the thyroid isthmusis the preferred tracheotomy site under controlled
circumstances, but excessive bleeding and difficulty finding the trachea may significantly impede the
procedure in an emergency.
A 60-year-old male complains of multiple episodes of lightheadedness over the past 3 months, saying he
felt as if he might pass out while sitting at his desk. His past medical history and a physical examination
are unremarkable. An EKG shows right bundle branch block and left anterior hemiblock. Which one of the
following would be the most appropriate next step?
A. Echocardiography
B. Cardiac event monitoring
C. Hospital admission for pacemaker insertion
D. Immediate initiation of aspirin and metoprolol (Lopressor)
This patients EKG demonstrates a right bundle branch block, as well as a left anterior hemiblock. This
trifascicular block puts the patient at risk for tachyarrhythmias and bradyarrhythmias. Given the patients
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.
A 45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now has anterior neck
tenderness and swelling, with pain radiating up to her ears. An examination reveals a tender goiter. Which
one of the following would support a diagnosis of subacute granulomatous thyroiditis?
A. Pretibial myxedema
B. Exophthalmos
C. A thyroid bruit
D. Low radioactive iodine uptake (<5%)
Subacute granulomatous thyroiditis is the most common cause of thyroid pain. Free T is elevated early 4 in
the disease, as it is in Graves disease; however, later in the disease T becomes depressed and then returns
to normal as the disease resolves. Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be
found in Graves disease, but not in subacute granulomatous thyroiditis. Patients with subacute
granulomatous thyroiditis will have a low radioactive iodine uptake (RAIU) at 24 hours, but patients with
Graves disease will have an elevated RAIU (SOR C).
You are examining a patient with a chronically painful shoulder. You forward flex the arm to 90 with the
elbow bent to 90. You then internally rotate the arm, which causes pain in the shoulder. This finding
suggests:
A. glenohumeral instability
B. anterior shoulder dislocation
C. impingement/rotator cuff disorder
D. acromioclavicular joint osteoarthritis
E. acromioclavicular joint separation
The maneuver described is Hawkins impingement test. Pain with this maneuver may signify subacromial
impingement, including a rotator cuff tendinopathy or tear.
A 26-year-old female presents with symptoms of anhedonia and anxiousness. Your evaluation leads to a
diagnosis of major depressive disorder. The patient consents to medical treatment and counseling, but she is
engaged to be married in 2 months and is concerned that antidepressants may lower her libido even further.
Which one of the following would be best for reducing the likelihood of sexual dysfunction?
A. Bupropion (Wellbutrin)

B. Paroxetine (Paxil)
C. Fluoxetine (Prozac)
D. Sertraline (Zoloft)
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.
In a patient with hypertriglyceridemia, the National Cholesterol Education Program recommends that a
reasonable goal for non-HDL cholesterol is no more than:
A. 30 mg/dL above the LDL-cholesterol level
B. 40 mg/dL above the LDL-cholesterol level
C. 50 mg/dL above the LDL-cholesterol level
D. 60 mg/dL above the LDL-cholesterol level
E. 90 mg/dL above the LDL-cholesterol level
The National Cholesterol Education Programs Adult Treatment Panel III recommends a goal non
HDLcholesterol level of no more than 30 mg/dL greater than the LDL-cholesterol level. This is based on a
normal very low density lipoprotein cholesterol level being defined as that present when triglycerides are
<150 mg/dL. This value typically is 30 mg/dL. Conversely, when triglyceride levels are >150 mg/dL, very
low density lipoprotein is usually >30 mg/dL.
A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea, cough, and
poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a
chest examination reveals tachypnea and rales. A chest film shows hyperinflation and diffuse interstitial
infiltrates. A WBC count reveals eosinophilia. What is the most likely etiologic agent?
A. Staphylococcus species
B. Chlamydia trachomatis
C. Respiratory syncytial virus
D. Parainfluenza virus
Chlamydial pneumonia is usually seen in infants 316 weeks of age, and they frequently have been sick for
several weeks. The infant appears nontoxic and is 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.
Staphylococcal pneumonia has a sudden onset. The infant appears very ill and has a fever. At the time of
onset there may be an expiratory wheeze simulating bronchiolitis. Signs of abdominal distress, tachypnea,
dyspnea, and localized or diffuse bronchopneumonia or lobar disease may be present. The WBC count
shows a prominent leukocytosis. Respiratory syncytial infections start with rhinorrhea and pharyngitis,
followed in 13 days by cough and wheezing. Auscultation reveals diffuse rhonchi, fine rales, and wheezes.
The chest film is often normal. If the illness progresses, cough and wheezing increase, air hunger and
intercostal retractions develop, and evidence of hyperexpansion of the chest is seen. In some infants, the
course of the illness may be similar to that of pneumonia. Rash or conjunctivitis may occur occasionally,
and fever is an inconsistent sign. The WBC count is normal or elevated, and the differential may be normal
or shifted either to the right or left. Chlamydial infections may be differentiated from respiratory syncytial
infections by a history of conjunctivitis and a subacute onset. Coughing is prominent, but wheezing is not.
There may also be eosinophilia. Fever is usually absent. Parainfluenza virus infection presents with typical
cold symptoms. Eight percent of infections affect the upper respiratory tract. In children hospitalized for
severe respiratory illness, parainfluenza viruses account for about 50% of the cases of laryngotracheitis and
about 15% each of the cases of bronchitis, bronchiolitis, and pneumonia.
A 52-year-old female presents to the emergency department with a complaint of chest pain. The symptoms
began 2 hours ago while she was shopping. She describes the pain as a tightness on the left side of her chest

that radiates to her left shoulder. She has some shortness of breath with the pain, but no nausea or
diaphoresis. Her past medical history is significant for panic disorder.Her vital signs and a physical
examination are within normal limits.Which one of the following would be the most appropriate next step
in the management of this patient?
A. Admit to a monitored bed for further evaluation
B. Obtain a CBC, a blood chemistry profile, liver function tests, and an EKG
C. Administer a short-acting benzodiazepine and observe for 60 minutes
D. Consult with a cardiologist for immediate heart catheterization
E. Obtain a troponin I measurement and an EKG
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.
The most common identifiable cause of skin and soft-tissue infections presenting to metropolitan
emergency departments is:
A. Staphylococcus epidermidis
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. methicillin-resistant Staphylococcus aureus (MRSA)
E. Bacillus cereus
Recent clinical experience has shown that methicillin-resistant Staphylococcus aureus (MRSA) is the most
common identifiable cause of skin and soft-tissue infections among patients presenting to emergency
departments in 11 U.S. cities. The other responses should be considered in evaluating these infections, but
they are not as common as MRSA infections.
A 16-year-old male accompanied by his mother presents to your outpatient clinic with concerns about his
short stature and boyish looks. He is a sophomore in high school but is frequently mistaken for someone
much younger. Radiographs reveal a bone age of 14.7 years. Which one of the following would suggest the
need for further evaluation?
A. A family history of delayed growth
B. Height below the fifth percentile for age
C. Weight below the fifth percentile for age
D. Prepubescent testicular size
Most cases of short stature are due to constitutional growth delay, a term which implies that the child is
normal but delayed in his development. A hallmark of this condition is being below the fifth percentile for
height for most of childhood. Usually these children are thin and have a family history of delayed
development. Bone age would be expected to be at least 2.5 standard deviations below the mean for
agematched peers of the same chronologic age. However, most experts agree that if no signs of puberty are
seen by 14 years of age (no breast development in girls, no testicular enlargement in boys), then further
workup for a more serious condition should be sought. Other indications for evaluation would be no
menarche in a girl by 16 years of age and underdeveloped genitalia in a boy 5 years after his first pubertal
changes.
A 60-year-old African-American male is found to have type 2 diabetes mellitus. Which one of the
following should be ordered before initiating treatment with metformin (Glucophage)?
A. Serum electrolytes
B. A serum creatinine level

C. A CBC
D. A lipid panel
E. A thyroid panel
Metformin is contraindicated in patients with renal dysfunction, because it is associated with an increased
incidene of lactic acidosis.
Which one of the following nutritional interventions should be recommended to accelerate pressure ulcer
healing in the elderly?
A. Supplemental arginine
B. Oral vitamin C and zinc
C. High-dose multivitamins
D. Adequate protein intake
Very few nutritional interventions have been shown to accelerate pressure ulcer healing in the elderly.
Maintaining a protein intake of at least 1.21.5 g/kg/day is recommended, 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.
According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), in which situation
would a physician be allowed to disclose personal information without the patients written authorization?
A. The patient makes a verbal request to release information
B. The patients spouse requests information
C. The adult children of the patient request written information
D. A lawyer who claims to represent the patient requests information
E. Another physician involved in the patients care requests information
HIPAA legislation states that a patients 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:
(1) coordination of care between providers and those involved in the patients case (i.e., caretakers, nurses,
consulting physicians); (2) arranging payment for medical services rendered; and (3) health-care operations
such as evaluating a provider or systems 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 patients best interest. In such situations
it is advisable to ask the patients permission to do so if possible, and the information should be related on a
need-to-know basis.
The use of a corticosteroid inhaler in patients with stable chronic obstructive lung disease has been shown
to:
A. increase the risk for osteoporotic fracture
B. increase the risk for pneumonia
C. produce no change in patients perceptions of quality of life
D. reduce overall mortality
COPD is the fourth leading cause of death in the United States. Stopping smoking and the use of
continuous oxygen, when necessary, are the main interventions that have been shown to lessen overall
mortality in this illness. The use of corticosteroid inhalers for COPD has received mixed reviews. Studies
show an increase in the incidence of pneumonia, which is directly related to the dosage. There are also
concerns about the potential for an increase in fractures; however, a meta-analysis of multiple studies has
not shown this to be the case. There has been no improvement in overall mortality with the use of the
corticosteroid inhalers; nevertheless, on questionnaires patients indicate an improvement in quality of life
and fewer bronchitis exacerbations.

Which one of the following is known to cause hyperthyroidism?

A. Propranolol (Inderal)
B. Amiodarone (Cordarone)
C. Methimazole (Tapazole)
D. Propylthiouracil
E. Methotrexate (Rheumatrex, Trexall)
Amiodarone is 37% iodine and is the most common source of iodine excess in the United States.
Excessive iodine intake from dietary sources, radiographic contrast media, or amiodarone increases the
production and 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. -Blockers such as propranolol
may be useful in controlling the symptoms of hyperthyroidism. Methimazole and propylthiouracil interfere
with organification of iodine, thereby suppressing thyroid hormone production; they are commonly used as
antithyroid agents when treating hyperthyroidism. Research is ongoing to determine if methotrexate plus
prednisone is an effective treatment for the ophthalmopathy associated with Graves hyperthyroidism.
A 20-year-old college wrestler is seen for an examination prior to the wrestling season. He tells you that
some friends have told him he should start taking dehydroepiandrosterone (DHEA), and he asks for your
advice. Which one of the following is true about the effects of this drug?
A. It enhances performance but not muscle strength
B. It enhances muscle strength but not performance
C. It enhances both performance and muscle strength
D. It does not enhance either performance or muscle strength
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 luteinizing hormone levels.
A 15-year-old white female who has had regular periods since age 12 comes to your office because of
secondary amenorrhea and a milky discharge from her breasts. A pregnancy test is negative. The best test
for initial evaluation of the pituitary in this patient is:
A. plasma antidiuretic hormone
B. plasma ACTH
C. serum prolactin
D. serum FSH and LH
E. fasting growth hormone
Anterior pituitary hormone overproduction is suspected on clinical grounds and confirmed by appropriate
laboratory evaluation. 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
(Cushings 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.
A 36-year-old female consults you because of concerns about fatigue. After carefully reviewing her
history and performing a physical examination, which one of the following would be LEAST valuable in
assessing this patient?

A. A baseline serum cortisol level

B. An erythrocyte sedimentation rate
C. A complete metabolic panel
D. A TSH level
E. A pregnancy test
In patients with fatigue, family physicians should complete an appropriate history and physical
examination. Laboratory studies should be considered, although the results affect management in only 5%
of patients. A baseline cortisol level would be valuable only in patients with significant findings of
Addisons disease. In addition to an erythrocyte sedimentation rate, a complete metabolic panel, and a TSH
level, many physicians request a CBC and a urinalysis. A pregnancy test should be ordered for women of
childbearing age. No other tests have been shown to be useful unless a specific medical condition is
suspected.
A 45-year-old female presents with a complaint of pain and swelling in her right index finger of 2 days
duration. She reports that 5 days ago she had artificial nails applied, which she removed yesterday due to
the pain. She used hydrogen peroxide on the finger, but it did not help. She denies any systemic symptoms
or fever. On examination there is erythema and swelling in the lateral nail fold of the right index finger,
with purulent material noted. Which one of the following would be the most appropriate treatment for this
patient?
A. Removal of the proximal nail fold
B. Topical corticosteroids
C. Topical antibiotics
D. Topical antifungals
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. Removal of the proximal
nail fold is used to treat chronic paronychia that is not responsive to other treatments. 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. Topical
antifungals are a treatment option for chronic paronychia, which can be associated with a fungal infection,
but not for acute paronychia.
A 30-year-old male complains of the gradual onset of anterior right knee pain on climbing the stairs. On
examination there is no effusion, but there is tenderness over the medial retinaculum. There is good
ligament strength, and range of motion is normal. When the knee is extended from 90 flexion to full
extension, the patella deviates laterally. Which one of the following would be the best initial treatment for
this condition?
A. Bracing
B. Taping
C. NSAIDs
D. Arthroscopic surgery
E. Physical therapy
This patient has patellofemoral stress syndrome. It is often called runner's knee or anterior knee pain. The
patellofemoral joint comprises the patella and femoral trochlea. The best initial treatment is physical
therapy. Bracing, taping, and medications are unlikely to have better outcomes. Arthroscopic surgery is not
indicated.
Which one of the following is appropriate at the routine postpartum visit?
A. A CBC

B. Screening for depression

C. Thyroid function tests
D. Glucose tolerance testing
E. A urine dipstick
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. This
scale has been shown to increase the identification of women at high risk for depression. 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.
The induction or inhibition of the cytochrome P450 (CYP) enzyme is responsible for many adverse drug
reactions. Which one of the following is an inducer of the cytochrome P450 enzyme?
A. Ciprofloxacin (Cipro)
B. Fluconazole (Diflucan)
C. Phenytoin (Dilantin)
D. Clarithromycin (Biaxin)
E. Grapefruit juice
All of the drugs listed are inhibitors of the cytochrome P450 enzyme except phenytoin, which is a potent
inducer. Grapefruit juice is also a cytochrome P450 enzyme inhibitor.
A 72-year-old Hispanic female with moderately severe Alzheimers disease is hospitalized for treatment of
a fracture of the left humerus. The first night after admission she becomes confused and agitated. The most
appropriate management at this point is which one of the following?
A. Physical restraints
B. Benzodiazepines for agitation
C. Meperidol (Demerol) for pain control
D. Moving the patient to the intensive-care unit for better monitoring
E. Having a bedsitter or family member stay in the room to reassure and orient the patient
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.
A 75-year-old otherwise healthy white female states that she has passed out three times in the last month
while walking briskly during her daily walk with the local senior citizens mall walkers club. This history
would suggest which one of the following as the etiology of her syncope?
A. Vasovagal syncope
B. Transient ischemic attack
C. Orthostatic hypotension
D. Atrial myxoma
E. Aortic stenosis
Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does
not rise (or even fall) with exertion. Syncope, commonly on exertion, is reported in up to 42% of patients
with severe aortic stenosis. 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.
Overweight and obesity in children should be determined by which one of the following?
A. Body weight
B. BMI percentile for age and gender
C. Individual BMI
D. Abdominal girth
E. Percentage of body fat
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 patients classification (SOR B).
Which one of the following is the preferred treatment for scabies?
A. Topical benzoyl peroxide, 10%
B. Topical crotamiton (Eurax), 10%
C. Topical permethrin (Elimite), 5%
D. Topical lindane, 1%
E. Oral ivermectin (Stromectol), 200 mg
Permethrin and lindane are the two most studied topical treatments for scabies. A Cochrane meta-analysis
of four randomized trials comparing these agents indicates that a single overnight application of permethrin
is more effective than lindane (odds ratio for clinical failure, 0.66; 95% confidence interval, 0.460.95).
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% versus 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.
A patient in the first trimester of pregnancy has just learned that her husband has acute hepatitis B. She
feels well, and her screening test for hepatitis B surface antigen (HBsAg) was negative last month. She has
not been immunized against hepatitis B. Which one of the following would be the most appropriate
management of this patient?
A. No further workup or immunization at this time, a repeat HBsAg test near term, and treatment of the
newborn if the test is positive
B. Use of condoms for the remainder of the pregnancy, and administration of immunization after delivery
C. Testing for hepatitis B immunity (anti-HBs), and immunization if needed
D. Administration of hepatitis B immune globulin (HBIG) now and hepatitis B vaccine after the first
trimester
E. Administration of both HBIG and hepatitis B vaccine now
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.

A 55-year-old white male notices a nodular thickening over the flexor tendons in his medial palm. He has
no difficulty using his hand, and he is able to lay his palm flat on a tabletop. You suspect Dupuytren's
disease. Which one of the following is true regarding this condition?
A. There is a strong association with diabetes mellitus
B. Surgical intervention is recommended at this point to prevent progression to contracture
C. Once a contracture develops, it is irreversible and no treatment is indicated
D. A single cortisone injection often leads to disease regression in mild to moderate cases
E. A search for an occult malignancy is indicated
Dupuytrens disease is characterized by 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. A series of 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 proximal interphalangeal joint
contracture of any degree. If surgery is delayed, irreversible joint contracture may occur. There is a strong
association between diabetes mellitus and Dupuytrens 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.
A 29-year-old white female is hospitalized following a right middle cerebral artery stroke confirmed by
MRI. Her past medical history is remarkable only for a history of an uncomplicated tonsillectomy during
childhood and a second-trimester miscarriage 3 years ago. The only remarkable finding on physical
examination is left hemiplegia.The initial laboratory workup reveals normal hematocrit and hemoglobin
levels, a normal prothrombin time, and a platelet count of 200,000/mm3 (N 140,000440,000). The
activated partial thromboplastin time is 95 sec (N 23.634.6), and it does not normalize when the patients
serum is mixed with normal plasma. A serum VDRL is positive, and a serum FTA-ABS is nonreactive.
Which one of the following is the most likely diagnosis?
A. Hemophilia
B. Neurosyphilis
C. Antiphospholipid syndrome
D. Thrombotic thrombocytopenic purpura
E. Protein C deficiency
The antiphospholipid syndrome is due to the appearance of a heterogeneous group of circulating antibodies
to negatively charged phospholipids, including most commonly a lupus anticoagulant and anticardiolipin
antibodies. The antibodies are usually detected by a false-positive serologic test for syphilis. Clinical
features include venous and 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 patients 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.
A 12-year-old male uses a short-acting bronchodilator three times per week to control his asthma. Lately he
has been waking up about twice a week due to his symptoms. Which one of the following medications
would be most appropriate?
A. Inhaled medium-dose corticosteroids
B. A scheduled short-acting bronchodilator
C. A scheduled long-acting bronchodilator
D. A leukotriene inhibitor

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.
In the United States, the number of deaths has increased in recent years for which one of the following
vaccine-preventable illnesses?
A. Tetanus
B. Hepatitis C
C. Rubella
D. Pertussis
E. West Nile virus
In the United States, 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 1965, 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.
An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now has
difficulty with normal activities such as getting out of a chair and brushing her teeth. Her medical problems
include hypertension, diabetes mellitus, and hyperlipidemia. Her medications include glipizide (Glucotrol),
simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on examination are within normal limits
except for diffuse proximal muscle weakness and normal deep tendon reflexes. A CBC, urinalysis,
erythrocyte sedimentation rate, TSH level, and serum electrolyte levels are normal. Her blood glucose level
is 155 mg/dL, and her creatine kinase level is 1200 U/L (N 40150). Which one of the following is the
most likely diagnosis?
A. Statin-induced myopathy
B. Polymyalgia rheumatica
C. Guillain-Barr syndrome
D. Diabetic ketoacidosis
This patient is most likely suffering from a drug-induced myopathy caused by the simvastatin, which is
associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated
erythrocyte sedimentation rate. Guillain-Barr syndrome is associated with depressed deep tendon reflexes.
This case has no clinical features or laboratory findings that suggest ketoacidosis.
Studies indicate that patients most frequently want physicians to ask about their spiritual beliefs in which
one of the following situations?
A. When being treated for a potentially fatal illness
B. During the annual preventive visit
C. During the initial office visit with the physician
D. Only if specifically requested by the patient, a family member, their minister, or a chaplain
E. When prayer is suggested by the patient or physician
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. Which

one of the following has the best evidence of effectiveness for preventing fractures in postmenopausal
women with osteoporosis?
A. Home-hazard assessment
B. Daily supplementation with vitamin D
C. Treatment with calcitonin
D. Treatment with alendronate (Fosamax)
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 (SOR A). 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 (SOR B).
To be eligible for Medicare hospice benefits, a patient must:
A. be enrolled in Medicare Part D
B. be referred to hospice by a physician
C. be debilitated and moribund
D. have a malignancy
E. have an estimated life expectancy of less than 6 months
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 patients
family members can also make a hospice referral. The patient must sign a statement choosing hospice, and
both the patients 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.
A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a
supine position, you palpate the tender area of her abdomen. When you have her raise both legs off the
table while you palpate the abdomen, her pain intensifies. Which one of the following is the most likely
diagnosis?
A. Appendicitis
B. A hematoma within the abdominal wall musculature
C. Diverticulitis
D. Pelvic inflammatory disease
E. An ovarian cyst
Carnetts sign is the 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.
A 14-year-old female sees you for follow-up after hypercalcemia is found on a chemistry profile obtained
during a 5-day episode of vomiting and diarrhea. She is now asymptomatic, but her serum calcium level at
this visit is 11.0 mg/dL (N 8.510.5). Her aunt underwent unsuccessful parathyroid surgery for
hypercalcemia a few years ago. Which one of the following laboratory findings would suggest a diagnosis
other than primary hyperparathyroidism?
A. Low 24-hour urine calcium
B. Decreased serum phosphate
C. High-normal to increased serum chloride
D. Elevated alkaline phosphatase
E. Elevated parathyroid hormone

Low urine 24-hour calcium levels or a low urine calcium to urine creatinine ratio is not characteristic of
hyperparathyroidism. This finding should suggest familial hypocalciuric hypercalcemia (SOR C).
Awareness of this condition is important to avoid unnecessary surgery. The parathyroid hormone level may
be mildly elevated. Parathyroid hormone 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.
A 70-year-old African-American male who has been hospitalized for 2 weeks for heart failure develops
severe, persistent diarrhea. For the past 3 days he has had abdominal cramps and profuse, semi-formed
stools without mucus or blood. The patients current medications include captopril (Capoten), digoxin,
furosemide (Lasix), subcutaneous heparin, spironolactone (Aldactone), and loperamide (Imodium). He has
coronary artery disease, but has been relatively pain free since undergoing coronary artery bypass surgery 4
years ago. An appendectomy and cholecystectomy were performed in the past, and the patient has since
been free of gastrointestinal disease. On physical examination his blood pressure is 100/80 mm Hg, pulse
100 beats/min and regular, and temperature 37.0C (98.6F). He has mild jugular venous distention and
crackles at both lung bases. Examination of his heart is unremarkable, although there is 1+ dependent
edema. His abdomen is diffusely tender without masses or organomegaly. Findings on a rectal examination
are normal. The results of routine laboratory tests, including a CBC, chemistry profile, EKG, and
urinalysis, are all normal. The stool examination shows numerous white blood cells. Of the following, the
most likely diagnosis is:
A. viral gastroenteritis
B. Clostridium difficile colitis
C. ulcerative colitis
D. gluten-sensitive enteropathy (celiac sprue)
E. digoxin toxicity
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.
A 63-year-old female with type 2 diabetes mellitus presents to the emergency department with unstable
angina. Her blood pressure is 150/90 mm Hg, her pulse rate is 70 beats/min, and her lungs are clear to
auscultation. The patient expresses a preference for conservative (i.e., noninvasive) therapy. In addition to
aspirin, which one of the following agents should be administered at this time?
A. Clopidogrel (Plavix) orally
B. Indomethacin (Indocin) orally
C. Nifedipine (Procardia) immediate-release, orally
D. Abciximab (ReoPro) intravenously
E. Enalaprilat intravenously
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 dosage should then be prescribed to be
taken daily for at least 1 month along with aspirin (SOR B). Immediate-release calcium channel antagonists
such as nifedipine are not indicated. If -blockers are contraindicated, verapamil or diltiazem would be the
preferred agents. Intravenous 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.
Increasing patient copayments for prescription medications results in:
A. an increase in the number of prescriptions filled by low-income medical-assistance recipients
B. little demonstrable change in purchasing patterns
C. increased hospitalizations for patients with chronic illnesses
D. improved efficiency in the utilization of outpatient medical services
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.
A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to
initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare. Which one of the
following would be the most appropriate advice for this patient?
A. Allow the rash to resolve without further treatment
B. Cover the rash because it is contagious
C. Treat the rash with systemic corticosteroids
D. Treat the rash with a stronger antifungal medication
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.
A 24-year-old female who works at a day-care facility presents to your office to discuss ways to avoid
getting all the infections the kids get. She plans to enroll her child in the facility. She is specifically
concerned about diarrheal illnesses, and a friend has suggested the use of probiotics.
A. can lessen the severity and duration of infectious diarrhea
B. are recommended only for patients who are immunocompromised
C. have no known side effects
D. often interact with common prescription medications
E. are not appropriate for use in children
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 (SOR A).
The recommended time to screen for gestational diabetes in asymptomatic women with no risk factors for
this condition is:
A. in the first trimester
B. at 1620 weeks gestation
C. at 2428 weeks gestation
D. at 3537 weeks gestation
The recommended time to screen for gestational diabetes is 2428 weeks gestation. The patient may be
given a 50-g oral glucose load followed by a glucose determination 1 hour later.

The 1990 Patient Self-Determination Act requires that:

A. the process for advance directives be standardized for all 50 states
B. a living will be implemented for patients upon admission to the hospital
C. hospitals ask patients about advance directives
D. verbally expressed wishes be honored for individuals who do not have a written advance directive
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. The living will, a written advance directive, allows a competent person to indicate his or her health
care preferences while cognitively and physically healthy. A living will may list medical interventions the
patient wishes to have withheld or withdrawn when he or she becomes unable to communicate. Another
type of advance directive, the durable power of attorney for health care, allows persons to designate a proxy
(or surrogate) to make decisions for them if they become incapacitated. Although PSDA mandates that
patients be asked about their advance directive status upon admission to the hospital, it does not require
hospitals or individual physicians to offer patients an opportunity to complete an advance directive. The
acceptance and precision of verbal preferences varies from state to state. Although verbal discussions are
binding in many states, five states require clear and convincing evidence of patient preferences. In
California, Delaware, Michigan, Missouri, and New York, advance directives must include such evidence
regarding a specific condition and/or treatment, even if a durable power of attorney states prior general
verbal preferences. Therefore, lack of an advance directive may result in continued medical interventions to
preserve life even if the patient may not want such treatment.
A 55-year-old male consults you because he wants to begin an exercise program. He is asymptomatic, but
because of his family history you determine that he should undergo a stress test with echocardiography.
Which one of the following would be considered a normal ejection fraction in this patient?
A. 48%
B. 65%
C. 76%
D. 84%
E. 92%
The ejection fraction value 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 echocardiography 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.
A 42-year-old asymptomatic female presents for a routine evaluation. On examination her uterus is
irregularly enlarged to the size seen at approximately 8 weeks gestation. Pelvic ultrasonography shows
several uterine fibroid tumors measuring <5 cm. The patient does not desire future fertility. Which one of
the following would be the most appropriate treatment option?
A. Laparoscopic myomectomy
B. Hysterectomy
C. A gonadotropin-releasing hormone (GnRH) agonist
D. An oral contraceptive
E. Observation
Uterine fibroid tumors (leiomyomas) are the most common female reproductive tract tumors, with some
evidence suggesting that the cumulative incidence in women ages 2545 is approximately 30%. Symptoms
related to fibroids can 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 (SOR B). 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. For women who are symptomatic, the data is insufficient to allow conclusions to be
made about the most appropriate therapy. Surgical options include myomectomy, hysterectomy, uterine
artery embolization, and myolysis, but data to allow direct comparison is lacking. With the exception of
trials of GnRH-agonist therapy as an adjunct to surgery, there is not enough randomized trial data to
support the use of medical therapies (oral contraceptives, NSAIDs, progestins) in the treatment of women
with symptomatic fibroids.
A 27-year-old male with a diagnosis of depression prefers to avoid pharmacologic treatment. You agree to
engage in a trial of therapy in your office. During the treatment process, you help the patient realize that
some of his perceptions and interpretations of reality may be false and lead to negative thoughts. Next, you
help him discover alternative thoughts that reflect reality more closely, and to learn to discard his previous
distorted thinking. By learning to substitute healthy thoughts for negative thoughts, he finds his mood,
behavior, and physical reaction to different situations are improved. Which one of the following best
categorizes this type of therapy?
A. Psychoanalysis
B. Biofeedback
C. Cognitive therapy
D. Group psychotherapy
E. Hypnosis therapy
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
patients 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.
A 24-year-old male sustains a boxers fracture of the fifth metacarpal. A radiograph shows no rotational
deformity and 25 of volar angulation. After an attempt at closed reduction the angulation remains
unchanged. Which one of the following would be most appropriate at this time?
A. Open reduction
B. Placement of a pin to prevent further displacement
C. A short arm-thumb spica cast
D. An ulnar gutter splint
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.
What is the recommended compression-to-breath ratio for basic life support with a single rescuer for a 2year-old child?
A. 10:2
B. 15:2
C. 20:2
D. 25:2
E. 30:2
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.
Which one of the following is associated with an increased risk of delirium in hospitalized patients?
A. Not having family members present at the time of admission
B. Vision or hearing impairment
C. Repeated reorientation for patients with cognitive impairment
D. Early mobilization
Delirium occurs in 11%42% of hospitalized patients. Risk factors for delirium in hospitalized patients
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.
A 70-year-old female becomes psychotic and risperidone (Risperdal) is prescribed. Which one of the
following should be used to monitor the patient for adverse cardiac effects of this drug?
A. Serum sodium levels
B. Echocardiography
C. Nuclear stress testing
D. Lower-extremity venous duplex ultrasonography
E. Electrocardiography
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.
Which one of the following historical or audiographic findings in an elderly person would indicate that
hearing loss is due to something other than presbycusis?
A. Conductive hearing loss
B. Bilateral hearing loss
C. Symmetric hearing loss
D. Gradual hearing loss
E. High-frequency hearing loss
Presbycusis, the hearing loss associated with aging, is gradual in onset, bilateral, symmetric, and
sensorineural.
Which one of the following sonographic measurements is most accurate for estimating gestational age?
A. Amniotic sac size at 5 weeks of pregnancy
B. Crown-rump length at 10 weeks of pregnancy
C. Femur length at 16 weeks of pregnancy
D. Biparietal diameter at 20 weeks of pregnancy
E. Abdominal circumference at 24 weeks of pregnancy
Estimation of gestational age by ultrasound 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. After 11 weeks gestation, combinations of biparietal diameter, femur length, head circumference,
and abdominal circumference are used to estimate the gestational age. These factors are used by the
software that generates ultrasonography reports.

Which one of the following treatment regimens is most appropriate for an HIV-positive 42-year old who
has latent tuberculosis infection?
A. Isoniazid daily for 9 months
B. Rifampin (Rifadin) daily for 4 months
C. Rifampin plus pyrazinamide daily for 2 months
D. Combination therapy with isoniazid, rifampin, pyrazinamide, and ethambutol (Myambutol) for 2
months
Latent tuberculosis infection carries a risk of progression to active disease, especially among patients who
are immunosuppressed. Isoniazid monotherapy is the treatment of choice for most patients with latent
tuberculosis infection. Rifampin is not recommended as monotherapy in patients with HIV infection
because of increased rates of resistance and drug interactions with many antiretrovirals. Rifampin plus
pyrazinamide is no longer recommended for treatment of latent tuberculosis infection because cases of
significant hepatotoxicity have occurred with preventive therapy. Combination drug therapy is reserved for
treatment of active tuberculosis in order to prevent drug resistance.
A 75-year-old female presents with a 2-month history of bilateral headache, diffuse myalgias, and diplopia.
On examination she has substantially diminished vision in her left eye, but no other neurologic findings. A
moderately tender, cordlike structure is palpable just anterior to her ear and extending up to her lateral
scalp. Blood tests show a markedly elevated erythrocyte sedimentation rate. Which one of the following
would be most appropriate at this point?
A. Clopidogrel (Plavix)
B. High-dose corticosteroids
C. NSAIDs
E. Dipyridamole/aspirin (Aggrenox)
The clinical findings in this patient are consistent with 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. Temporal arteritis is the most common
clinical pattern of giant cell arteritis, which can also involve other branches of the carotid artery.
A 25-year-old female presents with a maculopapular rash that has progressed to multiple areas and exhibits
target lesions. A cold sore appeared on her upper lip 2 days before the rash appeared. She is not
systemically ill and is on no medications. Which one of the following is true concerning this problem?
A. Herpes simplex virus is a likely cause
B. A skin biopsy will confirm the diagnosis
C. The lesions usually disappear within 24 hours
D. The palms of the hands and soles of the feet are not involved
E. Scarring from the lesions is often seen after resolution
Herpes simplex virus is the most common etiologic agent of erythema multiforme. Other infections,
particularly Mycoplasma pneumoniae infections and fungal infections, may also be associated with this
hypersensitivity reaction. Other causes include medications and vaccines. 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 35 weeks without sequelae.
A 44-year-old male sees you for evaluation of an episode of pink-tinged urine last week. He denies any
flank or abdominal pain, as well as frequency, urgency, and dysuria. He has no prior history of renal or
other urologic disease, and no other significant medical problems. He has a 24-pack-year smoking history.

A urinalysis today reveals 810 RBCs/hpf. You refer him to a urologist for cystoscopy. Which one of the
following would be the most appropriate additional evaluation?
A. KUB radiography
B. Transabdominal ultrasonography
C. Voiding cystourethrography
D. CT urography
E. Magnetic resonance urography
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.
The test of choice for immediate evaluation of an acutely swollen scrotum is:
A. a pelvic radiograph
B. radionuclide imaging
C. color Doppler ultrasonography
D. CT
E. MRI
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 ultrasonography is the test of choice for immediate evaluation of scrotal masses (SOR B) because
it can be done quickly and has a high sensitivity (86%88%) and specificity (90%100%) for detecting
testicular torsion, which is a surgical emergency. Radionuclide imaging is also accurate in diagnosing
testicular torsion, but involves too much of a time delay to be useful. CT and MRI should be used only if
ultrasonography is inconclusive or carcinoma is suspected, and are particularly useful for staging testicular
tumors. Pelvic radiographs are not recommended for evaluation of scrotal masses.
A 34-year-old white female visits your office complaining of a sore throat. She takes haloperidol, 2 mg
after each meal, for schizophrenia, and you notice that she seems unable to sit still and is extremely
anxious. The most likely diagnosis is:
A. drug-induced parkinsonism
B. akathisia
C. tardive dyskinesia
D. hysteria
E. dystonia
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. A diagnosis of hysteria is
inconsistent with the findings presented.
A 58-year-old male complains of leg claudication. Subsequent tests reveal that he has significant bilateral
peripheral arterial disease. His current medications include atenolol (Tenormin), 50 mg/day, and aspirin,
325 mg/day. His blood pressure is 128/68 mm Hg, and his pulse rate is 64 beats/min. His LDL-cholesterol
level is 123 mg/dL. The addition of which one of the following could reduce this patients symptoms?
A. Epoetin alfa (Epogen)
B. Nifedipine (Procardia)
C. Simvastatin (Zocor)
D. Testosterone supplementation
E. Warfarin (Coumadin) titrated to an INR of 2.03.0

Peripheral arterial disease (PAD) is a common malady that has several proven treatments. The outcomes of
these treatments can be separated into two primary categories: reducing PAD symptoms and preventing
death due to systemic cardiovascular events (CVEs), especially myocardial infarction. 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. A 55-year-old female sees you because
of a constant leakage of small amounts of urine. Her obstetric/gynecologic history includes two
pregnancies, with vaginal deliveries. Her current medications include hydrochlorothiazide, metformin
(Glucophage), and glyburide (DiaBeta). On examination she has mild diabetic retinopathy, decreased
sensation to monofilament testing on her feet, and suprapubic fullness. The most appropriate initial
treatment for this problem would be:
A. tolterodine (Detrol LA)
B. duloxetine (Cymbalta)
C. estrogen replacement therapy
D. bladder neck needle suspension
E. a set schedule for urination
There are four types of urinary incontinence in women: functional incontinence, which occurs when the
patient's inability to ambulate or transfer results in loss of urine; urinary stress incontinence, which is a
result of pelvic relaxation and is manifested as involuntary loss of urine with increases in abdominal
pressure such as that which occurs with laughing, sneezing, or coughing; detrusor instability or overactive
bladder, which is when the urge to urinate is quickly followed by loss of urine, usually a large volume; and
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 selfcatheterization of the bladder. Ultimately, the patient may require resection of the internal sphincter of the
bladder neck.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 ACE inhibitors have been shown to
reduce symptoms of PAD directly. Furthermore, the combination of atenolol and nifedipine has actually
been shown to worsen symptoms of PAD. The addition of warfarin to aspirin has no additional benefit in
either reduction of PAD symptoms or prevention of CVEs, but it may have a role in preventing clots in
patients who have undergone revascularization.
A 35-year-old white male presents to the emergency department with chest pain of 30 minutes duration. He
describes the pain as feeling like pressure on his chest, and says it radiates into his left arm. It is
accompanied by dyspnea, diaphoresis, anxiety, and palpitations. His past medical history is unremarkable
and he has no family history of premature heart disease. He smokes 2 packs of cigarettes per day and
admits to intranasal cocaine use 2 hours ago. Vital signs include a blood pressure of 180/110 mm Hg, a
pulse rate of 110 beats/min, a respiratory rate of 24/min, and a temperature of 37.2C (99.0F). Other than
the anxiety and diaphoresis, the general examination is unremarkable. An EKG shows sinus tachycardia
with an early repolarization pattern. Aspirin and nitroglycerin have been administered, as well as oxygen
via nasal cannula. Which one of the following would be most appropriate at this point?
A. Nifedipine (Procardia)
B. Enalaprilat intravenously
C. Lorazepam (Ativan) intravenously
D. Metoprolol (Toprol) intravenously
E. Thrombolytic therapy
Treatment of cocaine-associated chest pain is similar to that of acute coronary syndrome, unstable angina,
or acute myocardial infarction, but there are exceptions. The hypertension, tachycardia, and chest pain will
often respond to intravenous benzodiazepines as early management. While -blockers are recommended for

acute myocardial infarction, they can exacerbate coronary artery spasm in cocaineassociated chest pain.
Fibrinolytic therapy should be given only to patients who clearly have an STsegment elevation myocardial
infarction and cannot receive immediate direct percutaneous coronary intervention. 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 nitroglycerin. There are no recommendations regarding the use of
ACE inhibitors, but these agents would not address the tachycardia.
According to both the Centers for Disease Control and the American College of Sports Medicine, in order
to burn fat stores obese patients should exercise:
A. a minimum of 30 minutes 3 days/week
B. a minimum of 30 minutes at least 5 days/week
D. a minimum of 20 minutes every day
E. a minimum of 10 minutes at least 3 times daily
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.
In which one of the following scenarios would additional consent from a childs parent or guardian be
necessary prior to treatment?
A. A 6-year-old female with divorced parents who lives primarily with her mother is brought to the clinic
by her father to discuss his concerns of possible abuse
B. An 8-year-old unconscious male is brought to the emergency department by a neighbor after falling out
of a tree and striking his head
C. A 13-year-old male is brought to the clinic by a babysitter with a note giving permission to treat signed
by a parent
D. A 15-year-old female who is considered emancipated under state law comes to your office to discuss
family planning
E. A 16-year-old female who has driven herself to her clinic appointment reports a 2-day history of ear
pain; she says her mother made this appointment for her
Informed consent to treat is considered an important ethical and legal part of caring for children and
adolescents. Some situations can become confusing when trying to balance the need for treatment, a childs
assent, and a parent or guardians permission. In most states, 18 is the age when legal decisions can be
made; however, in some states it is 21. 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. Another exception to parental consent is when a child is
considered emancipated under state law. This can happen with a court order, or (in some states) if the child
is married, is a parent, is in the military, or is living independently. Either biologic parent can consent to
treatment unless one of them is explicitly denied guardianship. If a child presents with a non-emergent
condition and does not have evidence of permission from a parent or guardian, permission should be sought
before the physician interaction takes place.
A 50-year-old female presents with a 2-day history of four vesicles on her upper eyelid, but no pain or
swelling. She has not experienced any eye trauma, has had no vision changes, and has no other skin
changes. Which one of the following would be the most appropriate next step in treating this patient?
A. Referral to an ophthalmologist
B. A methylprednisolone (Medrol) dose pack
C. A topical corticosteroid
D. Topical mupirocin (Bactroban)
E. Topical metronidazole (MetroGel)

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.
A 70-year-old white male with hypertension has several abnormal liver function tests on routine testing. He
says he does not drink alcohol, and the prescription medications he is taking are unlikely to cause
hepatotoxicity. However, during more extensive history taking, he tells you that he does use some over-thecounter medications. Which one of these is most likely responsible for the abnormal laboratory findings?
A. Aspirin, used occasionally for headache
B. A fiber supplement taken to promote regular bowel habits
C. One long-acting niacin tablet per day
D. One 250-mg vitamin C tablet daily
E. Chewable simethicone after meals, almost daily
Hepatotoxicity resulting from timed-release formulations of niacin has been reported in elderly individuals.
Patients may be taking this supplement without their physicians 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.
A 35-year-old white male who has had diabetes mellitus for 20 years begins having episodes of
hypoglycemia. He was previously stable and well controlled and has not recently changed his diet or
insulin regimen. Which one of the following is the most likely cause of the hypoglycemia?
A. Spontaneous improvement of -cell function
B. Renal disease
C. Reduced physical activity
D. Insulin antibodies
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. 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 -cell function after 20 years would be very rare.
A 54-year-old male presents to the emergency department with an acute onset of chest pain. His cardiac
risk factors include hypertension, hyperlipidemia, and a positive family history. His temperature is 37.0C
(98.6F), pulse rate 80 beats/min, blood pressure 155/86 mm Hg, and respiratory rate 22/min. His oxygen
saturation is 95% on room air. An EKG shows rare unifocal PVCs and nonspecific ST-Twave changes.
Initial cardiac markers are negative. Which one of the following would be most appropriate at this point?
A. Helical (spiral) CT of the chest
B. Echocardiography
C. PA and lateral chest films
D. A ventilation-perfusion scan
E. Magnetic resonance angiography
PA and lateral chest radiographs 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 chest film 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.

A 19-year-old college freshman consults you at the request of her cross-country coach because she has not
had a period in 2 of the last 3 months. She notes that her current training regimen is much more intense
than in high school last year. She has an appropriate body image and denies caloric restriction. A pregnancy
test at the student health center was negative. On examination she is lean and highly trained. Her
examination is otherwise normal. Which one of the following would be the most appropriate
recommendation for this patient?
A. Estrogen supplementation
B. Cyclic oral contraceptive pills
C. Increased caloric intake
D. Bisphosphonate therapy
E. Discontinuation of elite-level athletics
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. Additionally, menstrual irregularity of varying severity is extremely common in
female distance runners, perhaps affecting as many as 60%. 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. 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. Ending an athletic career for
this reason alone is not justified.
At a routine visit in October, a 17-year-old primigravida at 10 weeks gestation asks whether she should get
influenza vaccine. Her mother recommended it, but she is concerned about the needle stick and potential
harm to the fetus. Which one of the following would you do?
A. Recommend intramuscular vaccine and tell her that evidence indicates some protection for the baby up
to 6 months of age
B. Recommend nasal vaccine because the patient is under age 50 and needle-averse
C. Recommend vaccine only if the patient has a coexistent chronic illness
D. Recommend that vaccination be delayed until the second trimester to reduce fetal risk
E. Recommend immunization of household contacts to reduce maternal risk, but no immunization of the
patient
Women who will be pregnant during the influenza season should receive the inactivated vaccine (SOR C).
The live nasal vaccine is not approved for use in pregnancy. The vaccine 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. 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.
A 50-year-old male comes to your office for a doctors excuse for days of work he missed last week. He
attended a picnic where he and other guests developed nausea and vomiting 2 hours after eating. Within 48
hours, the symptoms had resolved. The most likely etiology of the illness is which one of the following?
A. Staphylococcus
B. Clostridium botulinum
C. Clostridium perfringens
D. Clostridium difficile
E. Actinomycosis
This is a typical presentation of staphylococcal food poisoning. The symptoms usually begin 16 hours
after ingestion and resolve within 2448 hours. Foodborne botulism is most commonly found in
homecanned foods, and symptoms begin 1836 hours after ingestion. Clostridium perfringens is

transmitted in feces and water, and symptoms begin 624 hours after ingestion. Clostridium difficile is
associated with antibiotic use. Actinomycosis causes local abscesses, not gastroenteritis.
A 2-year-old Hispanic male with a 3-day history of nasal congestion presents with a barking cough and
hoarseness. He is afebrile. The examination reveals tachypnea, inspiratory and expiratory stridor, noticeable
intercostal retractions, and good color. Which one of the following is indicated?
A. Albuterol syrup and the use of a humidifier
B. Inhaled albuterol (Proventil, Ventolin)
C. Aerosolized epinephrine and intramuscular dexamethasone
D. Visualization of the epiglottis, and ceftriaxone (Rocephin)
This child has a history and physical findings typical of viral laryngotracheobronchitis, or croup. In rare
instances, this illness can be complicated by critical upper airway obstruction. The symptoms of cough,
respiratory stridor, and distress result from edema of the subglottic portion of the upper airway.
Humidification of inspired air is sometimes beneficial, but the child should not be sent home until
improvement is demonstrated. Because this child has stridor and intercostal retractions, aerosolized
epinephrine is indicated, along with 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 childs anxiety and worsen
the symptoms.
The most effective daily doses of vitamin D and calcium for hip fracture prevention in postmenopausal
women are:
A. 800 IU vitamin D and 500 mg calcium
B. 400 IU vitamin D and 500 mg calcium
C. 400 IU vitamin D and 1000 mg calcium
D. 800 IU vitamin D and 1200 mg calcium
The most effective daily dose of vitamin D for hip fracture prevention in postmenopausal women is 800 IU,
and the recommended daily dose of calcium is 1200 mg.
The physician counseling a 4-year-old child about the death of a loved one should keep in mind that
children in this age group:
A. often feel no sense of loss
B. often believe they are somehow responsible for the death
C. should not attend a funeral
D. should usually be told the loved one is having a long sleep
E. usually accept the finality of death with little question
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.
A 35-year-old white male presents with dyspepsia. He has had no symptoms that suggest gastroesophageal
reflux or bleeding, but a test for Helicobacter pylori is positive. After 2 weeks of treatment with omeprazole
(Prilosec), amoxicillin, and clarithromycin (Biaxin), he is asymptomatic. Which one of the following is
recommended to test for the eradication of H. pylori in this patient?
A. Immunoglobulin G serology
B. A urea breath test
C. Upper endoscopy with a biopsy
D. An upper gastrointestinal series

There is strong evidence that eradication of H. pylori improves healing and reduces the risk of recurrence
or rebleeding in patients with duodenal or gastric ulcer. A test-and-treat approach is recommended for most
patients with undifferentiated dyspepsia. This strategy reduces the need for antisecretory medications, as
well as the number of endoscopies. The currently recommended test for eradication of H. pylori in this
clinical setting is either the urea breath test or H. pylori stool antigen. Serology remains positive for months
after eradication and may give misleading information. Although upper endoscopy, with a biopsy for
histology, urease activity, or culture, can be used to test for eradication, it is an invasive procedure with a
higher cost and the potential for more morbidity compared to the urea breath test or the H. pylori stool
antigen test. Rather than recommending endoscopy for all patients, most national guidelines suggest a testand-treat strategy unless the patient is over 45 years old or has red flags for malignancy or a complicated
ulcer. Although an upper gastrointestinal series might provide information about gross pathology, it will not
provide information about the eradication of H. pylori following treatment.
Which one of the following is recommended for the treatment of patients with obsessive compulsive
disorder?
A. Cognitive-behavioral therapy
B. Psychoanalytic therapy
C. Family therapy
D. Psychodynamic psychotherapy
E. Motivational interviewing
Cognitive-behavioral therapy is the recommended treatment for obsessive-compulsive disorder
(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.
A 73-year-old male sees you for evaluation of a tremor. Based on the history and examination, you suspect
Parkinsons disease. Which one of the following would be most helpful for confirming the diagnosis?
A. CT of the brain
B. MRI of the brain
C. A positive response to levodopa
D. Confirming that the tremor occurs with movement
E. Confirming that the tremor had a symmetric onset
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 36 Hz.
Surgical management for an acute midshaft clavicle fracture would be appropriate in which one of the
following?
A. An 11-year-old male with a comminuted fracture
B. A 15-year-old female with a -cm displaced fracture
C. A 30-year-old male with a -cm displaced fracture
D. A 40-year-old male with a nondisplaced fracture
E. A 50-year-old female with a comminuted fracture
Midshaft clavicle fractures are usually treated nonoperatively, but have a higher risk of nonunion. Risk
factors for nonunion include female gender, fracture comminution 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.

A 32-year-old primipara is ready to be discharged after a full-term vaginal delivery that was complicated by
a prolonged second stage of labor. She required a second-degree posterior vaginal repair, but had no
periurethral trauma. A transurethral catheter was removed a few hours after delivery, but 48 hours later she
complained of abdominal pain and a persistent need to urinate. The catheter was replaced and yielded
approximately 2000 cc of straw-colored urine. Urinary symptoms quickly resolved, but the patient
continues to be unable to void on her own. A perineal examination is normal, as is a urinalysis. Which one
of the following would be the most appropriate management at this time?
A. Oxybutynin (Ditropan), 10 mg daily
B. Prednisone, starting with 60 mg/day and tapering quickly over 7 days
C. Urgent vaginal ultrasonography
D. Urology consultation for cystoscopy
E. Discharge with a catheter in place and close follow-up
This patient suffers from postpartum urinary retention (PUR). PUR is often defined as a post-void bladder
residual of at least 150 cc that is 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. The question of whether epidural
anesthesia promotes the condition is still debated. Most cases of PUR will resolve 26 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 patients ability to spontaneously micturate returns. Imaging studies and
referrals to a specialist are rarely necessary, and no medication has been proven helpful.
A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and
delivery were normal; the infant received phototherapy for 1 day for hyperbilirubinemia. He had an episode
of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up
small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An
examination is unremarkable except for mild wheezing. Which one of the following is the most likely
diagnosis?
A. Benign reactive airway disease of infancy
B. Gastroesophageal reflux
C. Unresolved respiratory syncytial virus infection
D. Early asthma
E. Cystic fibrosis
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 this is a major clue that this childs 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.
A patient with end-stage metastatic cancer is having continued significant pain despite regular use of 60 mg
of long-acting morphine sulfate every 12 hours. What is the maximum 24-hour dose of morphine sulfate
that you may safely titrate up to in order to relieve this patients pain?
A. 240 mg
B. 360 mg
C. 480 mg
D. 600 mg
E. No limit
Because there is no therapeutic ceiling for morphine, extremely large dosages can be used safely and
effectively if the drug is titrated properly.

On examination a 2-year-old child is found to have otalgia, a temperature of 39.0C (102.2F), and a
bulging, red tympanic membrane. She weighs 17 kg (35 lb). Which one of the following would be the
appropriate dosage of amoxicillin (Amoxil) for this child?
A. 375 mg/day
B. 500 mg/day
C. 750 mg/day
D. 1000 mg/day
E. 1500 mg/day
For treating acute otitis media in this patient, the current recommended dosage of amoxicillin is 8090
mg/kg/day.
Which one of the following surgical procedures is associated with the highest risk for perioperative
myocardial ischemia?
A. Femoropopliteal bypass
B. Pulmonary lobectomy
C. Hip arthroplasty
D. Transurethral resection of the prostate
E. Mastectomy
When deciding whether or not to recommend preoperative noninvasive cardiac testing, both patient risk
factors and surgical risk factors should be taken into account. Surgical procedures associated with a high
(>5%) risk of perioperative myocardial ischemia include aortic and peripheral vascular surgery and
emergent major operations, especially in patients over 75 years of age. Head and 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 (<1%)
procedures.
A 60-year-old white female with type 1 diabetes mellitus presents with early satiety, nausea, bloating, and
postprandial fullness. Laboratory tests are normal, as are upper endoscopy and biliary ultrasonography.
Which one of the following would help confirm the most likely diagnosis?
A. Pelvic ultrasonography
B. An exercise stress test
C. Psychiatric consultation
D. Gastric emptying scintigraphy
E. Colonoscopy
This patient has typical findings of gastroparesis, an autonomic neuropathy more commonly seen in type 1
diabetics and in women. The initial evaluation should include a patient history and examination, a CBC to
rule out infection, a metabolic panel, endoscopy, and a biliary tract evaluation, but the diagnosis is best
confirmed by scintigraphy. Pelvic ultrasonography and colonoscopy are not indicated because the patients
symptoms are upper intestinal. Cardiac evaluation and psychiatric consultation are not warranted with these
symptoms.
During a preparticipation examination of a 5-year-old male for summer soccer camp, his mother states that
he frequently awakens during the night with complaints of cramping pain in both legs, and that he seems to
experience this after a day of heavy physical activity. She says that he appears to drag his legs at times, but
she has never noticed a definite limp. A physical examination of the hips, knees, ankles, and leg
musculature is entirely normal. Which one of the following would be the most appropriate next step in the
evaluation and management of this patient?
A. Plain films of both hips and knees
B. Serum electrolyte levels
C. Recommending that he not participate in running sports

D. Reassurance, with no activity restrictions or treatment

E. Referral to a pediatric orthopedist
Benign nocturnal limb pains of childhood (growing pains) occur in as many as one-third of children, most
often between 4 and 6 years of age. 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,
most often in the shins and calves, but also may affect the thighs and the upper extremities. A characteristic
history coupled with a normal physical examination will confirm the diagnosis. Reassurance that no
additional tests or treatments are necessary and that the condition is self-limiting is the most appropriate
response.
A 45-year-old female with no family history of breast cancer presents for a routine examination. She has no
constitutional symptoms or obvious breast abnormalities, and a clinical breast examination is negative. U.S.
Preventive Services Task Force recommendations advise that until 50 years of age the patient should:
A. perform monthly breast self-examinations
B. have mammography every 12 years
C. have scintimammography every 12 years
D. have breast ultrasonography annually
E. have a breast MRI every 12 years
Previous recommendations for breast cancer screening included self-examination and clinical examination
on a regular basis. However, self-examination has been shown to be potentially harmful because it leads to
an increase in biopsies but does not decrease mortality; it is therefore no longer recommended.
Mammography is recommended every 12 years in women 4050 years old, with digital mammography
being more sensitive. Ultrasonography and scintimammography are not recommended for screening, but
may be used in the evaluation of a palpable breast lesion. MRI is also not recommended as a routine
screening tool, but may be appropriate in high-risk women.
A 26-year-old gravida 1 para 0 presents for a prenatal examination. She has two cats and expresses concern
about toxoplasmosis. Which one of the following would be most appropriate for this patient?
A. Recommend that she avoid directly handling the cats litter box
B. Immunize the patient against toxoplasmosis
C. Prophylactically treat the cats with antibiotics
D. Screen the patients urine for Toxoplasma antigens
E. Screen the patients serum for Toxoplasma antibody
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, the American College of Obstetrics and Gynecology does not recommend routine screening
except in patients who are known to be HIV positive. 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.
A previously healthy 18-month-old male is brought to your office with a 2-day history of cough and fever.
On examination the child has a temperature of 38.3C (100.9F), a respiratory rate of 30/min, and mild
retractions and mild wheezes bilaterally. Oxygen saturation is 90%. The most appropriate initial
management would be:
A. azithromycin (Zithromax)
B. a short course of corticosteroids
C. aerosolized racemic epinephrine every 4 hours

D. postural drainage
E. a single treatment with aerosolized albuterol, continued only if there is a positive response
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.
A 2-year-old female is brought to the emergency department with a 2-day history of fever and increasing
redness on the left forearm. She is otherwise healthy. On examination her temperature is 39.9C (103.8F),
pulse rate 140 beats/min, and respiratory rate 42/min. She is irritable, and the left forearm has a 4-cm
erythematous, warm, tender area, with a fluctuant area centrally. Her WBC count is 21,000/mm3 (N 4300
1 3 0,800), with 14% immature bands. In addition to incision and drainage, which one of the following is
the best initial treatment in this patient?
A. Intravenous vancomycin
B. Intravenous ampicillin/sulbactam (Unasyn)
C. Intravenous nafcillin
D. Intravenous clindamycin (Cleocin)
E. No antibiotics
This patient has systemic symptoms that suggest a severe underlying infection. Community-acquired
methicillin-resistant Staphylococcus aureus (CA-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 (SORB).
During a routine prenatal visit, a patient at 28 weeks gestation describes a worsening pain in her lower back
and pelvic area. She is averse to analgesics but is eager to try exercise to relieve the pain. Additional patient
history and an examination confirm that the pain is not due to underlying medical problems. Which one of
the following would be the most appropriate exercise prescription for this patient?
A. Isometric exercise
B. Concentric exercise
C. Core stability exercise
D. Closed kinetic chain exercise
E. Isotonic exercise
Low back pain and pelvic pain are commonly encountered in pregnancy, a time when medication or
physical modality use may prove undesirable or difficult. A properly prescribed exercise program is a
generally safe and effective method to treat this pain. The most appropriate exercises for pregnancyrelated
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.
You have just received test results confirming that a 78-year-old patient has metastatic lung cancer. She
informs you she does not want to know the results of the tests and is leaving it in Gods hands. You know
that additional issues need to be explored, such as her desire for chemotherapy and hospice care. Which one
of the following is the most appropriate strategy for determining her wishes?
A. Acknowledge her concerns, but proceed with a discussion of her diagnosis and prognosis
B. Ask family members to gently break the news to your patient and tell them you will return later to
discuss the details and answer questions

C. Have a hospice representative visit and discuss the diagnosis and options for care
D. Ask the patient to designate someone with whom you can discuss the results and prognosis
In a patient-centered approach to communication regarding end-of-life care, a patients 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 patients desire to
not know her diagnosis or prognosis.
You see a 30-year-old white male for the first time for a routine evaluation. He says that he has been
bothered by multiple skin lesions on the neck and axillae. On examination you note numerous skin tags.
The presence of these lesions indicates an increased risk for:
A. diabetes mellitus
B. squamous cell skin cancer
C. melanoma
D. glioblastoma multiforme
E. AIDS
Skin tags, or acrochordons, are associated with diabetes mellitus 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.
Which one of the following is considered first-line therapy for migraine prophylaxis in adults?
A. Gabapentin (Neurontin)
B. Propranolol (Inderal)
C. Fluoxetine (Prozac)
D. Vitamin B2 (riboflavin)
F. Naproxen (Naprosyn)
Propranolol is a first-line therapy for migraine prophylaxis in adults (SOR A). In a review of 26
placebocontrolled trials using data pooled from nine studies, the calculated responder ratio (comparable to
relative risk) was 1.9 (95% confidence interval 1.62.35). 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 (SOR B), and should
be used when no first-line agent or combination is effective or tolerable.
A 52-year-old white male is being considered for pharmacologic treatment of hyperlipidemia because of an
LDL-cholesterol level of 180 mg/dL. Before beginning medication for his hyperlipidemia, he should be
screened for:
A. hyperthyroidism
B. hypothyroidism
C. Addisons disease
D. Cushings disease
E. pernicious anemia
According to the National Cholesterol Education Program Adult Treatment Panel III Report of 2001, 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.
A 36-year-old female presents with a several-week history of polyuria and intense thirst. She currently
takes no medications. On examination her blood pressure and pulse rate are normal, and she is clinically
euvolemic. Laboratory tests, including serum electrolyte levels, renal function tests, and plasma glucose,

are all normal. A urinalysis is significant only for low specific gravity. Her 24-hour urine output is >5 L
with low urine osmolality. The most likely cause of this patients condition is a deficiency of:
A. angiotensin II
B. aldosterone
C. renin
D. insulin
E. arginine vasopressin
This patient has diabetes insipidus, which is caused by a deficiency in the secretion or renal action of
arginine vasopressin (AVP). AVP, also known as antidiuretic hormone, is produced in the posterior pituitary
gland and the route of secretion is generally regulated by the osmolality of body fluid stores, including
intravascular volume. Its chief action is the concentration of urine in the distal tubules of the kidney. 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.The urine is very dilute, with osmolality <300 mOsm/L. 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.
Sympathomimetic decongestants such as pseudoephedrine and phenylephrine can be problematic in elderly
patients because they can:
A. decrease blood pressure
B. cause bradycardia
C. worsen existing urinary obstruction
D. enhance the anticholinergic effects of other medications
E. enhance the sedative effects of other medications
Sympathomimetic agents can elevate blood pressure and intraocular
pressure, may worsen existing urinary obstruction, and adversely interact
with -blockers, methyldopa, tricyclic antidepressants, and oral
hypoglycemic agents and MAOIs. They also speed up the heart rate.
First-generation nonprescription antihistamines can enhance the
anticholinergic and sedative effects of other medications.
An 86-year-old female presents to your office with a complaint of
increasing cough, especially at night, over the past 23 weeks. On
examination you hear crackles at the bases of both lungs. The chest
radiograph shown in Figure 1 is consistent with which one of the
following causes of this patients cough?
A. Bilateral pneumonia
B. Asbestosis
C. Tuberculosis
D. Heart failure
E. Emphysema
The chest radiograph is consistent with heart failure. It shows
cardiomegaly, with a cardiothoracic ratio >6.50, as well as some
enlargement of pulmonary veins due to pulmonary venous hypertension.
The radiograph does not show an infiltrate, as would be expected with
community-acquired pneumonia. Pleural plaques would be expected with
asbestosis, and upper-lobe involvement or cavitary lesions with tuberculosis. With emphysema, there is
typically a small vertical heart and evidence of hyperexpansion.

A 70-year-old white male presents with fatigue, weakness, and foot paresthesias. His hemoglobin level is
10.5 g/dL (N 12.617.4). His peripheral smear is shown in
Figure 2. Which one of the following is the most likely
diagnosis?
A. Iron deficiency anemia
B. Vitamin B12 deficiency anemia
C. Hemolytic anemia
D. Acute myelogenous leukemia
E. Chronic myelogenous leukemia
The blood smear shows a hypersegmented polymorphonuclear
(PMN) white blood cell, typical of vitamin B12deficiency with
pernicious anemia. The anemia is of the macrocytic type (MCV
>100 m ). There is no evidence of hemolysis or
leukemia. While iron deficiency anemia can be a coexisting problem, the hypersegmented PMN is classic
for vitamin B12 deficiencyIt is important to note that elderly patients with vitamin B12 deficiency may
have neurologic signs and symptoms before developing hematologic abnormalities.
A 3-year-old female is brought to your office with a 3-hour history of skin
lesions that are prominent, warm, papular, and serpiginous (see Figure 3).
Which one of the following is the most likely cause of these lesions?
A. Heredity
B. Physical abuse
C. Infection
D. A topical agent
E. An oral medication
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.
An 84-year-old male is walking across the street and has to hurry to avoid
oncoming traffic. He suddenly develops extreme pain in his knee and falls
to the street, and has to be carried to the sidewalk. The following day he
comes to the emergency department. He is comfortable when placed in a
knee immobilizer, but is very tender just above the patella. He can bend
his knee, but when he tries to straighten his leg it is so weak that he
cannot move it at all. Radiographs of the knee are shown in Figure 4. What is the most likely diagnosis?
A. Patellar tendon rupture
B. Quadriceps tendon rupture
C. Tibial plateau fracture
D. Patellar subluxation
E. Lumbar radiculopathy
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. Quadriceps rupture often produces a sulcus
sign, a painful indentation just above the patella. If the patient is not seen until some time has passed since
the injury, the gap in the quadriceps can fill with blood, so that it is no longer palpable. The clinical
examination is usually diagnostic for this condition, but this patients radiograph shows some interesting
findings, especially on the lateral view. A small shard of the patella has been pulled off and has migrated

superiorly with the

quadriceps. The hematoma
filling the gap in the
quadriceps is the same
density as the muscle, but
wrinkling of the fascia over
the distal quadriceps
provides a clue that it is no
longer attached to the
superior margin of the
patella. Tibial plateau
fractures are intra-articular, so they produce a large
hemarthrosis. They are evident on a radiograph in almost all cases. Pain inhibits movement of the knee, but
the extreme weakness evident in this case would not be seen. Patellar subluxation is obvious acutely, when
the patella is displaced laterally. More often, the patient comes in after the patella has relocated. Findings
then include tenderness along the medial retinaculum, sometimes a joint effusion, and a positive
apprehension sign when the patella is pushed gently laterally. Lumbar radiculopathy can cause weakness of
the quadriceps if it involves the third lumbar root, but complete paralysis would not occur. Other findings
would include lumbar pain radiating to the leg, possibly with paresthesias and fasciculations if there were
significant neurologic impairment.
A 25-year-old female is in active labor at term and is dilated to 7 cm. An electronic fetal monitoring tracing
is shown in Figure 5. Which one of the following is a possible etiology for this fetal heart rate pattern?
A. Normal progress of
labor
B. Maternal fever
C. Effects of epidural
anesthesia
D. Post-dates
pregnancy
E. Umbilical cord
prolapse
This tracing shows fetal
tachycardia, defined as a
baseline fetal heart rate
>160 beats/min for at
least 15 minutes. This is
considered a
nonreassuring pattern.
Causes of fetal
tachycardia 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.
A hospitalized 55-year-old male has developed the tachyarrhythmia shown in Figure 6. He is alert and
denies chest pain, although he complains of palpitations and is mildly dyspneic since the onset of this
sustained dysrhythmia. His blood pressure is 116/76 mm Hg and pulse oximetry shows 93% saturation on
2L of oxygen. Which one of the following would be the best treatment for this patient?
A. Synchronized DC cardioversion
B. Metoprolol (Lopressor)

C. Amiodarone (Cordarone)
D. Adenosine (Adenocard)
E. Atropine
The patient has paroxysmal supraventricular tachycardia (PSVT) with a heart rate of approximately 170
beats/min. Intravenous 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.
A 12-year-old male who lives on a farm presents with lesions on his toes (shown in Figure 7). Which one of
the following items from the patients history is relevant to the
diagnosis?
A. Recent tooth extraction and gingival surgery
B. A family history of systemic lupus erythematosus
C. Recurrent fevers for the past 2 weeks
D. Exposure to cold temperatures
E. Vaccination of the sheep he is raising for a 4-H project
This patient has pernio, or chilblains, which is a 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 diseases.
These lesions are red-purple plaques with deep swelling, and are
accompanied by itching or burning. They are not associated with
infections or connective tissue disease.
A 90-year-old female nursing-home patient has a 1.52.0-cm lesion
on her face (shown in Figure 8). She states that the spot has been
present for years and that it doesnt bother her. Closer examination
reveals a flat maculopapular lesion with varying colors and an
irregular border. Which one of the following is the most likely
diagnosis?
A. Actinic keratosis
B. Metastatic breast carcinoma
C. Seborrheic keratosis
D. Lentigo maligna melanoma
E. Basal cell carcinoma
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.
A 5-year-old male fell while playing and complained that his wrist hurt. The next day he is brought to your
office because he refuses to use his arm. Which one of the following best describes the condition seen in
the radiographs shown in Figure 9?
A. A normal appearance

B. A radial fracture
C. An ulnar fracture
D. A radioulnar fracture
E. Indeterminate result
Even though they are the
most common fracture in
this age group, radial
fractures can be missed
byclinicians. The bend in the
cortex of the distal radius
indicates the fracture.
Sometimes referred to as a
buckle or torus 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.
In the elderly, the risk of heat wave-related death is highest in those who:
A. have COPD
B. have diabetes and are insulin-dependent
C. have a functioning fan, but not air conditioning
D. are homebound
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.
Your patient is moving to another state and requests transfer of his medical records. Which one of the
following is true regarding this patient's request?
A. The medical record should be released only with written permission from a patient or legal
representative
B. Although it is kept by the physician, the physical paper or electronic medical record is the property of
the patient
C. A physician may withhold medical record information that could cause undue stress to a patient
D. In spite of a patient request, the physician may withhold information from a third party
E. A physician has the right to withhold the medical record until medical bills are paid in full
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.

During a well child examination of a healthy-appearing 4-week-old white male born at term, his mother
questions you about a prominence in the left side of his scrotum, which she has noted since his baths were
begun. Your physical examination reveals an oblong, nontender, nonreducible, light-transmitting mass
closely adhered to or involving the testis. You should recommend which one of the following?
A. Further observation
B. Sterile aspiration of the mass
C. Immediate surgery
D. Surgery in 3-4 months
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
ineffective as it will quickly reaccumulate.
A generally healthy 35-year-old female has mild generalized anxiety, but is not depressed. She does not
want to take a prescription medication, and asks if an herbal or dietary supplement might be helpful. Which
one of the following botanical medications has the best clinical evidence of potential benefit for anxiety
disorders when used for a short time (up to 24 weeks)?
A. St. Johns wort
B. Valerian
C. Passionflower
D. Kava
E. Chamomile
The use of herbal and nutritional supplements has become commonplace in the United States.
Unfortunately, there is insufficient research for most herbal remedies, in terms of both efficacy and safety.
However, there is a significant body of evidence from randomized, controlled trials and various metaanalyses showing benefit from the use of kava in the short-term treatment of anxiety disorders (up to 24
weeks), including generalized anxiety disorder (SOR A). The other remedies listed have only single studies
or anecdotal evidence attesting to benefit for patients with anxiety. At best, information about them is
limited, and there are often conflicting results. Safety concerns about kava have been addressed by recent
randomized, controlled trials demonstrating that 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.
Physicians should be aware of all remedies their patients are taking, even if they are not prescribed. In
addition, it is important to be aware of remedies that have evidence supporting their use.
A 56-year-old African-American male has pain and tingling in the medial aspect of his ankle and the
plantar aspect of his foot. He jogs 3 miles daily and has no history of any injury. The symptoms are
aggravated by activity, and sometimes keep him awake at night. The only findings on examination are
paresthesias when a reflex hammer is used to tap just inferior to the medial malleolus. This patient probably
has:
A. a stress fracture
B. a herniated nucleus pulposus at L5 or S1
C. plantar fasciitis
D. diabetic neuropathy
E. tarsal tunnel syndrome
Entrapment of the posterior tibial nerve or its branches as the nerve courses behind the medial malleolus
results in a neuritis known as tarsal 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.
A 35-year-old male with a toothache presents to a local clinic for uninsured patients. On examination you
find a decayed left lower molar that is tender when tapped lightly, and surrounding gingival inflammation
and tenderness. There is no obvious mandibular swelling, but he does have a tender submandibular lymph
node. The earliest available dental appointment is in 1 week. He is allergic to penicillin. Which one of the
following would be the best antibiotic treatment for this patient?
A. Doxycycline
B. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
C. Clindamycin (Cleocin)
D. Ciprofloxacin (Cipro)
E. Cephalexin (Keflex)
This patient most likely has periodontitis of the tooths 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.
A 35-year-old white male has a blood pressure of 142/88 mm Hg, confirmed on repeat measurements. A
complete metabolic panel and urinalysis reveal a serum creatinine level of 1.9 mg/dL (N 0.6-1.5) and 2+
protein in the urine. Which one of the following would be the most appropriate initial treatment?
A. ACE inhibitors
B. Aldosterone antagonists
C. -Blockers
D. Calcium channel blockers
E. Diuretics
Although JNC-7 guidelines recommend a diuretic as the initial pharmacologic agent for most patients with
hypertension, the presence of compelling indications may indicate the need for treatment with
antihypertensive agents that demonstrate a particular benefit in primary or secondary prevention. JNC-7
guidelines recommend ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for hypertensive
patients with chronic kidney disease (SOR A). First-line therapy for proteinuric kidney disease includes an
ACEI or an ARB. Because these drugs can cause elevations in creatinine and potassium, these levels
should be monitored. A serum creatinine level as much as 35% above baseline is acceptable in patients
taking these agents and is not a reason to withhold treatment unless hyperkalemia develops. If an ACEI or
an ARB does not control the hypertension, the addition of a diuretic or a calcium channel blocker may be
required. The combination of ACEIs and diuretics may be used to control hypertension in patients with
diabetes mellitus, heart failure, or high coronary disease risk, as well as post myocardial infarction.
Calcium channel blockers are recommended for managing hypertension in patients with diabetes or high
coronary disease risk. -Blockers are useful as part of combination therapy in patients with hypertension
and heart failure, or post myocardial infarction.
A 45-year-old white male undergoes a health screening at his church. He has a carotid Doppler study,
abdominal ultrasonography, heel densitometry, and a multiphasic blood panel. He receives a report
indicating that all of the studies are normal, but a 0.7-cm thyroid nodule was noted. The TSH level is
normal. He schedules a visit with you and brings you the report. A neck examination and ENT examination
are normal, and you do not detect a nodule. You recommend:

A. a radionuclide thyroid scan

B. T3, T4, and calcitonin levels
C. repeat ultrasonography in 6-12 months
D. a fine-needle biopsy
E. hemithyroidectomy
This is a classic incidentaloma. Nodules are detected in up to 50% of thyroid sonograms and carry a low
risk of malignancy (<5%). 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.
An asymptomatic 40-year-old male presents for a routine examination and is found to have a total bilirubin
level of 1.8 mg/dL (N 1.0) and an indirect bilirubin level of 1.3 mg/dL. He drinks 3-6 beers/week. An
examination and laboratory tests, including a CBC and serum liver enzymes, are within normal limits.
Which one of the following is true regarding the diagnosis?
A. The most likely diagnosis is alcoholic liver disease
B. The most likely diagnosis is Dubin-Johnson syndrome
C. The most likely diagnosis is Gilbert syndrome
D. Ultrasonography of the liver and gallbladder are necessary to make a diagnosis
Gilbert syndrome is an autosomal dominant disease 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.
Which one of the following causes of anemia is associated with a normal red cell distribution width?
A. Vitamin B12 deficiency
B. Iron deficiency
C. -Thalassemia trait
D. Sideroblastic anemia
E. Myelofibrosis
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).
A 5-year-old female presents with a lesion on her forearm. It began as a red macule, turned into a small
vesicle that easily ruptured, then dried into a 1-cm honey-colored, crusted lesion seen now. Which one of
the following would be the most appropriate therapy?
A. Oral penicillin V
B. Oral erythromycin
C. Topical disinfectant (e.g., hydrogen peroxide)
D. Topical bacitracin
E. Topical mupirocin (Bactroban)
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 treatment is well suited to this localized lesion.
Topical disinfectants such as hydrogen peroxide are no more effective than placebo.
Which one of the following is true regarding temporomandibular joint disorder?
A. Dental splints are the treatment of choice
B. Mandibular clicking is an essential diagnostic element
C. Ultrasonic phonophoresis with cortisone is the treatment of choice
D. The majority of cases resolve without treatment
E. MRI is preferred over CT to confirm the diagnosis
Temporomandibular joint (TMJ) disorders 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. Dental occlusion problems, once thought to be the primary etiology, are not more common in
persons with TMJ disorder. 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.
A 62-year-old male is admitted to the hospital with acute renal failure. A renal biopsy confirms the
diagnosis of acute interstitial nephritis (AIN). Infection and immune-associated causes are ruled out, and
you consider medications as a potential cause. Which one of the following would be most likely to cause
AIN?
A. Chronic daily use of metoprolol (Lopressor)
B. Twice-daily use of ibuprofen for 2 weeks
C. Initiation of lisinopril (Prinivil, Zestril) therapy 1 week ago
D. A 5-day course of azithromycin (Zithromax) 6 months ago
E. Intermittent use of acetaminophen, up to 4 g/day
Acute interstitial nephritis (AIN) is often drug-induced. Discontinuation of medications that are likely to
cause AIN is the most important first step in management. If these medications are withdrawn early, most
patients can be expected to recover normal renal function. Of the medications listed, ibuprofen is the most
likely offending agent, because all NSAIDs are known to be associated with AIN. 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.
A 65-year-old female develops gram-negative septicemia from a urinary tract infection. Despite the use of
fluid resuscitation she remains hypotensive, with a mean arterial pressure of 50 mm Hg. Which one of the
following would be the most appropriate treatment for this patient?
A. Vasopressin (Pitressin)
B. Phenylephrine (Neo-Synephrine)
C. Epinephrine
D. Norepinephrine (Levophed)
E. Low-dose dopamine
In a patient with sepsis, vasopressors are indicated when fluid resuscitation does not restore organ perfusion
and blood pressure. 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.
The parents of three children ask your advice about the need for fluoride supplementation in order to
prevent tooth decay. Which one of the following is true regarding current U.S. Preventive Services Task
Force guidelines for fluoride supplementation?
A. It is not recommended due to potential fluoride toxicity
B. Dental fluoride varnish is too toxic for routine use
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride
D. Fluoridated toothpaste provides adequate protection if used as soon as the child has teeth
E. The need for fluoride supplementation is determined by serum fluoride levels
The current (2004) recommendation of the U.S. Preventive Services Task Force is 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 (B recommendation) that such supplementation reduces the incidence of
dental caries and conclude that the overall benefit outweighs the potential harm from dental fluorosis.
Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently recommended
doses, and has no other functional or physiologic consequences. Fluoridated toothpaste can cause fluorosis
in children younger than 2 years of age, and is therefore not recommended in this age group. By itself it
does not reliably prevent tooth decay. Fluoride varnish, applied by a dental or medical professional, is
another treatment option to prevent caries. It provides longer lasting protection than fluoride rinses, but
since it is less concentrated, it may carry a lower risk of fluorosis than other forms of supplementation. Oral
fluoride supplementation for children over the age of 6 months is based not only on age but on the
concentration of fluoride in the primary source of drinking water, whether it be tap water or bottled water.
Most municipal water supplies in the U.S. are adequately fluoridated, but concentrations vary. Fluoride
concentrations in bottled water vary widely. If the concentration is greater than 0.6 ppm no
supplementation is needed, and if given, may result in fluorosis. Lower concentrations of fluoride may
indicate the need for partial or full-dose supplementation.
The parents of three children ask your advice about the need for fluoride supplementation in order to
prevent tooth decay. Which one of the following is true regarding current U.S. Preventive Services Task
Force guidelines for fluoride supplementation?
A. It is not recommended due to potential fluoride toxicity
B. Dental fluoride varnish is too toxic for routine use
C. Oral fluoride supplementation is recommended if the primary drinking water source is low in fluoride
D. Fluoridated toothpaste provides adequate protection if used as soon as the child has teeth
E. The need for fluoride supplementation is determined by serum fluoride levels
The current (2004) recommendation of the U.S. Preventive Services Task Force is 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 (B recommendation) that such supplementation reduces the incidence of
dental caries and conclude that the overall benefit outweighs the potential harm from dental fluorosis.
Dental fluorosis is chiefly a cosmetic staining of the teeth, is uncommon with currently recommended
doses, and has no other functional or physiologic consequences. Fluoridated toothpaste can cause fluorosis
in children younger than 2 years of age, and is therefore not recommended in this age group. By itself it
does not reliably prevent tooth decay. Fluoride varnish, applied by a dental or medical professional, is
another treatment option to prevent caries. It provides longer lasting protection than fluoride rinses, but
since it is less concentrated, it may carry a lower risk of fluorosis than other forms of supplementation. Oral
fluoride supplementation for children over the age of 6 months is based not only on age but on the
concentration of fluoride in the primary source of drinking water, whether it be tap water or bottled water.
Most municipal water supplies in the U.S. are adequately fluoridated, but concentrations vary. Fluoride
concentrations in bottled water vary widely. If the concentration is greater than 0.6 ppm no
supplementation is needed, and if given, may result in fluorosis. Lower concentrations of fluoride may
indicate the need for partial or full-dose supplementation.

A 64-year-old white male appears to be depressed 2 weeks after hospital discharge for a myocardial
infarction. He experienced short runs of ventricular tachycardia during his hospitalization, and
echocardiography revealed an ejection fraction of 40% at the time of discharge, with no symptoms of heart
failure. He has a history of depression in the past. His current symptoms include depressed mood, sleep
disturbance, feelings of hopelessness, and anhedonia. He denies suicidal ideation. Which one of the
following would be most appropriate at this point?
A. Low-dose amitriptyline at bedtime
B. Sertraline (Zoloft)
C. Referral for electroconvulsive therapy
D. Referral for intense interpersonal psychotherapy
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.
A 35-year-old white female complains of unilateral frontotemporal headaches. During these episodes,
which occur every 2-3 weeks, she becomes nauseated, sometimes to the point of vomiting. The headaches
are throbbing in character and last for 1-3 hours, often causing her to leave work early. Relief is sometimes
obtained with simple analgesics, but more often with sleep or the passage of time. On the basis of this
history alone, the most likely diagnosis is:
A. sinusitis
B. a brain tumor
C. muscle tension headache
D. cluster headache
E. migraine headache
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.
A 3-year-old male is brought to your office because of ear pain. On examination you find a round, plastic
bead in the lower third of the ear canal close to the tympanic membrane. You restrain the child and are
unable to remove the object despite several attempts, first using water irrigation and then fast-acting glue
on an applicator. Which one of the following is the best option for removal?
A. A plastic loop curette through an otoscope
B. Referral for removal under anesthesia
C. Grasping with forceps
D. Applying acetone to dissolve the object
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.

A 55-year-old male has New York Heart Association Class II heart failure. He becomes dyspneic with
significant exertion. His only medication is an ACE inhibitor. Which one of the following additional
medications has been shown to improve longevity in this situation?
A. Digitalis
B. Warfarin (Coumadin)
C. -Blockers
D. Amiodarone (Cordarone)
E. Non-dihydropyridine calcium channel blockers
-Blockers are recommended to reduce mortality in symptomatic patients with heart failure (SOR A). 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.
A 59-year-old male reports nausea, vomiting, and progressive fatigue for the past few months. At his last
visit, 6 months ago, his blood pressure was poorly controlled and hydrochlorothiazide was added to his blocker therapy. At this visit he appears moderately dehydrated on examination. Laboratory testing reveals
a serum calcium level of 12.5 mg/dL (N 8.0-10.0), a BUN level of 36 mg/dL (N 6-20), and a creatinine
level of 2.2 mg/dL (N 0.6-1.1). A CBC, albumin level, and electrolyte levels are normal. His intact
parathyroid hormone level is reported a few days later, and is 60 pg/mL (N 10-65). What is the most likely
cause of his hypercalcemia?
A. Renal failure
B. Hyperparathyroidism
C. Milk alkali syndrome
D. Sarcoidosis
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. Conversely, renal failure usually causes hypocalcemia,
but can cause hypercalcemia resulting from tertiary hyperparathyroidism. This develops after severe
hyperphosphatemia and vitamin D deficiency eventually produce hypersecretion of PTH. This patient's
renal insufficiency is not severe enough to cause tertiary hyperparathyroidism. 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.
You see a patient for the first time who has AIDS and chronic hepatitis B. He is losing weight, and in spite
of adequate antiretroviral therapy, is becoming weaker, to the point of being virtually bedridden. Because
of ascites, low serum albumin, and elevated liver enzymes, you suspect chronic hepatitis as the cause of his
decline. Which one of the following would be most likely to improve this patient's condition?
A. Antiviral drugs for hepatitis B
B. Appetite stimulation with topical androgens
C. Appetite stimulation with dronabinol (Marinol)
D. Liver transplantation

E. No treatment, with palliative care being the only appropriate management

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. Various agents to stimulate appetite are used in declining HIV patients, but have little
benefit. Liver transplantation has been done in a few cases of coinfection with hepatitis B and HIV, but the
hepatitis B viremia has to be suppressed first.
A 47-year-old male with chronic kidney disease is being treated with epoetin alfa (Procrit). His
hemoglobin level is 11.3 g/dL (N 13.0-18.0). Which one of the following would be most appropriate with
regard to his epoetin alfa regimen?
A. Increase the dosage until the hemoglobin level is >12.0 g/dL
B. Increase the frequency of injections, using the same dose
C. Decrease the frequency of injections, using the same dose
D. Continue the current regimen
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 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 <12 g/dL.
A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has
excoriations from scratching in various areas. She says that she had the same problem during her last
pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of
which one of the following is most characteristic of this disorder?
A. -Glutamyltransferase (GGT)
B. Bile acids
C. Direct bilirubin
D. Indirect bilirubin
E. Prothrombin time
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 levels of total
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.
A 55-year-old male presents for an evaluation of heel pain. He has a relatively sedentary office job, but
exercises daily by jogging 3 miles. He has pain in the right heel at the medial aspect of the calcaneus and is
tender on examination. The pain is worse with the first few steps of the morning. Which one of the
following would be the most appropriate initial treatment for this patient?
A. Corticosteroid injection
B. Extracorporeal shockwave therapy
C. Surgical referral for bone spur removal
D. Non-weight bearing for 1 month
E. Stretching exercises for the Achilles tendon
Plantar fasciitis is an overuse injury due to microtrauma of the plantar fascia where it attaches at the medial
calcaneal tubercle. The patient experiences heel or arch pain, which often is worse upon arising and taking
the first few steps of the morning. Examination reveals tenderness at the site and pain with dorsiflexion of
the toes. Stress fractures often cause pain at rest that intensifies with weight bearing. Treatment strategies

include relative rest, ice, NSAIDs, and prefabricated shoe inserts that provide arch support, as well as 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.
A 45-year-old male sees you for follow-up after a pre-employment physical examination reveals blood in
his urine. He brings a copy of a urinalysis report that shows 3-5 RBCs/hpf. He has not seen any gross
blood himself. He is asymptomatic, is on no medications, and does not smoke. You perform a physical
examination, with normal findings. A repeat urinalysis confirms the presence of red blood cells but is
otherwise normal. Which one of the following would be most appropriate at this point?
A. Observation and reassurance
B. A repeat urinalysis in 6 months
C. Urine cytology only
D. Ultrasonography of the kidneys and urine cytology only
E. Ultrasonography of the kidneys, urine cytology, and cystoscopy
The American Urological Association (AUA) defines clinically significant microscopic hematuria as 3
RBCs/hpf. Microscopic hematuria is frequently an incidental finding, but may be associated with urologic
malignancy in up to 10% of adults. The upper urinary tract should be evaluated in this patient. There are no
clear evidence-based imaging guidelines for upper tract evaluation; therefore, intravenous urography,
ultrasonography, or CT can be considered. Ultrasonography is the least expensive and safest choice
because it does not expose the patient to intravenous radiographic contrast media. Urine cytology and
cystoscopy are used routinely to evaluate the lower urinary tract. The AUA recommends that patients with
microscopic hematuria have radiographic assessment of the upper urinary tract, followed by urine cytology
studies. The AUA also recommends that all patients older than 40 and those who are younger but have risk
factors for bladder cancer undergo cystoscopy to complete the evaluation. Cystoscopy is the only reliable
method of detecting transitional cell carcinoma of the bladder and urethra.
A 16-year-old white male is seen for a preparticipation sports examination. His height is 183 cm (72 in),
his weight is 64 kg (141 lb), and he appears to have long arms. A physical examination reveals a high
arched palate, kyphosis, myopia, and pectus excavatum. Which one of the following valvular abnormalities
is most likely in this patient?
A. Mitral stenosis
B. Pulmonic stenosis
C. Aortic stenosis
D. Aortic insufficiency
E. Bicuspid aortic valve
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 murmur, 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.
Which one of the following community health programs best fits the definition of secondary prevention?
A. A smoking education program at a local middle school
B. A blood pressure screening at a local church
C. A condom distribution program
D. Screening diabetic patients for microalbuminuria
Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary
prevention 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 prevention 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 prevention 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
-blockers and aspirin).
A 9-month-old male is brought to your office by his mother because of concerns about his eating. She
states that he throws tantrums while sitting in his high chair, dumps food on the floor, and refuses to eat.
She has resorted to feeding him cookies, crackers, and juice, which are all he will eat. A complete physical
examination, including a growth chart of weight, length, and head circumference, is normal. Which one of
the following would be the most appropriate recommendation?
A. Use disciplinary measures to force the child to eat a healthy breakfast, lunch, and dinner
B. Leave the child in the high chair until he has eaten all of the healthy meal presented
C. Play feeding games to encourage consumption of healthy meals or snacks
D. Skip the next meal if the child refuses to eat
E. Provide healthy foods for all meals and snacks, and end the meal if the child refuses to eat
It is estimated that 3%-10% of infants and toddlers refuse to eat according to their caregivers. Unlike other
feeding problems such as colic, this problem tends to persist without intervention. 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.
A 54-year-old white male presents with drooping of his right eyelid for 3 weeks. On examination, he has
ptosis of the right upper lid, miosis of the right pupil, and decreased sweating on the right side of his face.
Extraocular muscle movements are intact. In addition to a complete history and physical examination,
which one of the following would be most appropriate at this point?
A. A chest radiograph
B. MRI of the brain and orbits
C. 131I thyroid scanning
D. A fasting blood glucose level
E. An acetylcholine receptor antibody level
The clinical triad of Horners syndrome-ipsilateral ptosis, miosis, and decreased facial sweating-suggests
decreased sympathetic innervation due to involvement of the stellate ganglion, a complication of Pancoasts
superior sulcus tumors of the lung. Radiographs or MRI of the pulmonary apices and paracervical area is
indicated. Horners 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 Horners syndrome. Diabetes mellitus
and thyroid disease do not commonly present with Horners syndrome.
Which one of the following is the most likely cause of hearing loss in newborns?
A. Intraventricular hemorrhage
B. Anomalies of the external ear canal
C. Congenital cholesteatoma
D. Genetic disorders
E. Infectious diseases

Genetic disorders (e.g., Waardenburg syndrome, Ushers syndrome, Alport syndrome, and Turners
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.
A 66-year-old female presents for a preoperative evaluation prior to elective podiatric surgery. She has no
complaints other than her foot problem, and says she feels well. On examination she has an irregularly
irregular heart rate with a 2/6 holosystolic murmur. An EKG reveals atrial fibrillation with a rate of 110
beats/min. Echocardiography shows mild to moderate mitral regurgitation and a dilated left atrium, but is
otherwise normal. Which one of the following is the most appropriate initial treatment for this patient?
A. Digoxin, 0.125 mg/day
B. Quinidine gluconate, 324 mg 3 times daily
C. Atenolol (Tenormin), 50 mg/day
D. Sustained-release nifedipine (Adalat CC, Procardia XL), 60 mg/day
E. Unfractionated heparin sodium, 5000 units subcutaneously 3 times daily
The primary goals of atrial fibrillation treatment are rate control and prevention of thromboembolism.
Guidelines recommend rate control with atenolol, metoprolol, diltiazem, or verapamil (SOR A). Digoxin
does not control the heart rate with stress. Quinidine is proarrhythmic and does not control the heart rate.
Nifedipine does not control the heart rate, and heparin does not provide adequate anticoagulation or control
the heart rate.
Which one of the following is associated with testosterone supplementation in men with hypogonadism?
A. Muscle wasting
B. Polycythemia
C. Oteoporosis
D. An increased risk of benign prostatic hypertrophy
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.
A 53-year-old male presents for follow-up after a routine screening colonoscopy. He is healthy and takes
no medications, and his family history is negative for colon cancer. During a thorough, relatively easy
colonoscopy to the cecum, two rectal polyps measuring 0.7 mm were removed, both of which were found
to be hyperplastic on pathologic analysis. His next surveillance colonoscopy should be in:
A. 1 year
B. 3 years
C. 5 years
D. 7 years
E. 10 years
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.

A 34-year-old female with menorrhagia is found to have iron deficiency anemia. Which one of the
following is true regarding the treatment of this problem with oral iron?
A. An acidic environment enhances the absorption of iron from the gastrointestinal tract
B. Iron is absorbed better if taken with food
C. Diarrhea is a common complication
D. Iron supplementation can be discontinued once the hemoglobin reaches a normal level
E. Sustained-release formulations increase the total amount of iron available for absorption
Oral iron is absorbed better with an acidic gastric environment, which can be accomplished with the
concomitant administration of vitamin C. Agents that raise gastric pH, such as antacids, proton pump
inhibitors, and H2 blockers, should be avoided if possible. 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. Sustainedrelease oral iron products provide a decreased amount of iron for absorption.
Which one of the following skin infections should initially be treated with oral antifungal therapy?
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Erythrasma
E. Mycosis fungoides
Most tinea infections respond to topical therapy, but oral therapy is required for tinea capitis so that the
drug will penetrate the hair shafts (SOR B). Tinea corporis may require oral therapy in severe cases, but
usually responds to topical therapy (SOR A). Oral therapy has a higher likelihood of side effects.
Erythrasma and mycosis fungoides are not fungal diseases.
A 35-year-old female presents with pain in her neck, back, and shoulder, as well as a complaint of poor
sleep and fatigue. For the last 6 months she has experienced burning in her low back that radiates to her
buttocks, and she feels that her joints are swollen even though there is no objective evidence of this. She
also experiences morning stiffness that improves as the day progresses. A physical examination is
unremarkable with the exception of palpation of 14 different tender points above and below the diaphragm,
including the upper border of the trapezius muscle, the second rib space 3 cm lateral to the sternal border
bilaterally, both lateral epicondyles, the upper outer quadrants of both gluteal muscles, and the radial fat
pad of both knees. Laboratory tests, including a CBC, a chemistry profile, thyroid function tests, and an
erythrocyte sedimentation rate, all are within normal limits. Which one of the following would be the most
helpful treatment for this patient?
A. Massage therapy
B. NSAIDs
C. Trigger-point injections
D. Corticosteroids
E. Cognitive-behavior therapy
The etiology of fibromyalgia remains unknown, but it is a common condition that is underdiagnosed. It is
much more common in women than in men; additional risk factors include being divorced, having a low
income level, and not completing high school. The pathogenesis may be related to central sensitization and
dysregulation of the hypothalamic (pituitary) adrenal axis. Commonly associated symptoms include
headache (often migraine in type), anxiety, depression, and dizziness. The diagnosis is specific, and
requires the finding of at least 11 tender points in 18 possible specific anatomic locations, with the pain
occurring both above and below the waist on both sides of the body for at least 3 months. There is strong
evidence for the effectiveness of both pharmacologic therapies such as cyclobenzaprine and
nonpharmacologic therapies such as aerobic exercise, cognitive-behavioral therapy, and multidisciplinary
approaches that include patient education and exercise. The evidence of effectiveness is weak for

chiropractic therapy, electrotherapy, massage therapy, and ultrasound. There is no known benefit from
corticosteroids, opioids, thyroid hormone, NSAIDs, melatonin, flexibility exercises, or trigger-point
injections.
A 45-year-old white male is admitted to the intensive-care unit after being pinned in a car wreck for 2
hours. He has sustained several broken bones and crush injuries to both thighs. On admission his urine is
clear but the next morning it is burgundy colored. Some fresh urine is drawn from his Foley catheter and
sent for analysis, with the following results: Specific gravity 1.020, pH 6.0, Protein 30 mg/dL (N 1-14),
Glucose negative, Hemoglobin 4+, Urobilinogen 0.1 Ehrlich Units (N 0.1-1.0), Bile negative, RBCs 12/hpf, WBCs 0-2/hpf, Occasional hyaline casts. You immediately order a CBC which shows his hematocrit
to have dropped 4 percentage points overnight. Visual inspection of the serum shows it is light yellow. The
color of his urine is most likely due to:
A. myoglobinuria
B. hematuria from trauma to the urinary tract
C. a transfusion reaction with hemolysis of RBCs and free hemoglobin into the urine
D. hemoglobinuria resulting from reabsorption of hemoglobin from hematomas
E. acute porphyria provoked by trauma
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.
A 35-year-old female sees you because she has lost her voice. She has had no recent upper respiratory
infection symptoms, cough, or heartburn, and she has not done anything that would strain her voice.
Findings are normal on examination of the head and neck. A review of her chart shows this has happened
before, but an ear, nose, and throat evaluation found no abnormalities. She also has been seen numerous
times in the past few years for headaches, chest pains, abdominal pains, rectal pressure, and vaginal
symptoms. Despite several workups and referrals, no definite cause has been found and the symptoms
persist. Which one of the following would be the most reasonable plan of action?
A. Test for food allergies
B. Begin low-dose lorazepam (Ativan)
C. Begin a 6-week trial of a proton pump inhibitor
D. Schedule frequent office visits
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.

Dizziness is most likely to have a serious etiology when it:

A. is associated with diplopia
B. is associated with intense nausea and vomiting
C. occurs when the patient rolls over in bed
D. occurs when the patient first arises in the morning
E. occurs after 2 minutes of hyperventilation
Diplopia, along with other neurologic symptoms such as weakness or difficulty with speech, suggests a
central cause of vertigo and requires a complete workup. Dizziness on first arising, dizziness with rolling
over in bed, and dizziness with nausea and vomiting are consistent with peripheral causes of vertigo, such
as benign positional vertigo. Dizziness that occurs after a couple of minutes of hyperventilation suggests a
psychogenic cause.
A 3-year-old female is brought to your office for a health maintenance examination, and her father
expresses concern about her vision. Her visual acuity is 20/20 bilaterally on a tumbling E visual acuity
chart. With both eyes uncovered during a cover/uncover test, the corneal light reflex in the right eye is
medial to the pupil when focused on a fixed point, but the light reflex in the left eye is almost centered in
the pupil. When the left eye is covered, the right eye moves quickly inward to focus on the fixed point, and
the corneal light reflex is centered in the pupil. When the left eye is uncovered, the right eye returns to its
original position. When you cover the right eye, no left eye movement is noted. Which one of the
following is the most likely diagnosis?
A. Strabismus
B. Amblyopia
C. Cataract
D. Esotropia
E. Heterophoria
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 developmentmost 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.
When considering a diagnosis of pancreatitis, amylase levels:
A. can help determine the severity of the disease
B. are less likely to be elevated in alcoholics
C. are more sensitive and specific than serum lipase levels
D. are less likely to be affected by nonpancreatic conditions such as renal insufficiency
Amylase and lipase levels are used to help make the diagnosis of acute pancreatitis. The serum lipase level
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.
A 42-year-old previously healthy white female presents to your office with her third episode of abdominal
pain. This episode began 2 hours ago, and the pain is improving. She describes colicky right upper quadrant

and epigastric pain. On examination you note mild right upper quadrant tenderness, with otherwise
unremarkable findings. Renal function tests are normal. Which one of the following would be most
appropriate at this point?
A. KUB films
B. Ultrasonography of the right upper quadrant
C. Abdominal CT with intravenous contrast
D. Abdominal CT with intravenous and oral contrast
E. MRI of the abdomen
Ultrasonography of the right upper quadrant is recommended as the initial imaging study for right upper
quadrant pain (SOR C). KUB films can detect kidney stones but may miss gallstones. CT also may miss
gallstones, and is more invasive than ultrasonography. Abdominal CT with intravenous contrast is the
preferred test for right lower quadrant pain, and abdominal CT with intravenous and oral contrast is
preferred for left lower quadrant pain. MRI is preferred for detecting tumors, and is inappropriate as the
initial imaging study for right upper quadrant pain.
A 60-year-old male has moderate anemia, with a suggestion of hemolysis on a peripheral blood smear.
Which one of the following patterns would be consistent with the presence of hemolysis?
A. Elevated LDH, decreased haptoglobin, elevated indirect bilirubin
B. Elevated LDH, elevated haptoglobin, decreased indirect bilirubin
C. Decreased LDH, elevated haptoglobin, elevated indirect bilirubin
D. Decreased LDH, decreased haptoglobin, elevated indirect bilirubin
E. Decreased LDH, decreased haptoglobin, decreased indirect bilirubin
Hemolytic anemia is established by reticulocytosis, increased unconjugated bilirubin, elevated lactate
dehydrogenase (LDH), decreased haptoglobin, and peripheral blood smear findings.
A 43-year-old male complains of difficulty washing his face and combing his hair with his right hand. On
examination a nodule, band, and slight contracture are noted in the palm proximal to the fourth finger. This
patient's symptoms are associated with which one of the following?
A. Hyperparathyroidism
B. Diabetes mellitus
C. Hyperthyroidism
D. Hypothyroidism
E. Adrenal insufficiency
The patient has Dupuytrens 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 Dupuytrens contracture in patients with
diabetes mellitus; however, these patients tend to have a mild form of the disease with slow progression.
A 75-year-old patient with underlying chronic renal failure requires cardiac catheterization. Which one of
the following interventions is most likely to help prevent acute renal failure due to contrast-induced
nephropathy?
A. Hydration with normal saline and mannitol
B. Hydration with sodium bicarbonate-containing fluids
C. Hydration plus a loop diuretic
D. Administering fenoldopam (Corlopam) prior to the procedure
E. Infusion of natriuretic peptides prior to the procedure
Several studies have demonstrated that hydration with sodium bicarbonate-containing fluids reduces the
risk of contrast-induced nephropathy in those undergoing cardiac catheterization. Studies of interventions

to prevent renal failure in patients at high risk have shown that mannitol plus hydration does not reduce
acute renal failure compared to hydration alone. Randomized, controlled trials have shown that
fenoldopam does not decrease the need for dialysis or improve survival. One systematic review found that
low-osmolality contrast media reduced nephrotoxicity in persons with underlying renal failure requiring
studies using contrast. One systematic review and one subsequent randomized, controlled trial found that
adding loop diuretics to fluids was not effective and may actually increase the possibility of acute renal
failure compared to fluids alone. A large randomized, controlled trial found no significant difference
between natriuretic peptides and placebo in preventing acute renal failure induced by contrast media.
A 36-year-old female has been seen multiple times in the past several months for various pain-related
complaints. On each occasion, no physical or laboratory findings were found to explain the symptoms.
The patient is involved in a workers compensation case and could make a significant amount of money if it
is demonstrated that her physical complaints are related to work conditions. Which one of the following
diagnoses characterizes her unexplained physical symptoms?
A. Somatization disorder
B. Conversion disorder
C. Hypochondriasis
D. Malingering
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.
One day after a nurse performs CPR on an emergency-department patient, she learns that the patient had
meningococcal meningitis. Which one of the following is the most appropriate chemoprophylaxis for this
condition?
A. Penicillin G benzathine (Bicillin LA), 1.2 million units intramuscularly
B. Rifampin, 600 mg every 12 hours for 2 days
C. Oral prednisone, 40 mg daily for 5 days
D. Quadrivalent meningococcal vaccine
E. No prophylaxis
Health-care workers exposed to a patient with meningococcal meningitis are at increased risk of developing
systemic disease and should receive chemoprophylaxis, especially if the contact is intimate. Secondary
cases usually occur within 4 days of the initial case. Therefore, prophylactic treatment should begin as
soon as possible. Rifampin has been shown to be 90% effective in eliminating meningococcus from the
nasopharynx. 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.
A 3-year-old male was treated for acute otitis media last month. His mother brings him in for follow-up
because she believes his hearing has not been normal since then. He attends day care and has had several
upper respiratory infections. On examination the tympanic membranes are not inflamed, but the membrane
is retracted on the right side. An office tympanogram shows a normal peak (type A) on the left side, but a
flat tracing (type B) on the right side. Which one of the following would be the most appropriate
recommendation?
A. Audiometry
B. Observation with follow-up
C. An antihistamine/decongestant combination

D. Intranasal corticosteroids
E. Systemic corticosteroids
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 may indicate a
need for 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.
A 15-year-old male presents for a routine evaluation. He has no complaints. He has a BMI of 30 kg/m2,
which places him in the 97th percentile for his age. The remainder of his examination is normal; however,
a random blood glucose level is 162 mg/dL. Which one of the following would be the most appropriate
next step for this patient?
A. Obtain a fasting blood glucose level
B. Start metformin (Glucophage), 500 mg daily, and follow up in 4 weeks
C. Order a hemoglobin A1c level
D. Advise the patient to start a weight-loss program and follow up in 4 weeks
This patient should have further testing for diabetes mellitus. Current recommendations for diagnosing
diabetes mellitus are based on either a fasting glucose level or a 2-hour 75-g oral glucose tolerance test. A
casual blood glucose level >200 mg/dL is also diagnostic of diabetes mellitus in patients with symptoms of
hyperglycemia. If unequivocal hyperglycemia is not present, the diagnosis must be confirmed by testing on
another day. Metformin can be used to treat diabetes mellitus in adolescents, but it is not recommended for
prevention in this age group. A diagnosis of diabetes mellitus should be established prior to starting
metformin. Current recommendations for treating adolescents with type 2 diabetes mellitus include weight
loss through dietary modification and exercise.
A 26-year-old female presents with a 1-year history of recurring abdominal pain associated with
intermittent diarrhea, 5-7 days per month. Her pain improves with defecation. There has been no blood in
her stool and no weight loss. Laboratory findings are normal, including a CBC, chemistry profile, TSH
level, and antibodies for celiac disease. Which one of the following would be most appropriate at this
point?
A. Colonoscopy
B. An upper GI series with small-bowel follow-through
C. Abdominal CT with contrast
D. A gluten-free diet
E. Loperamide (Imodium)
This patient has classic symptoms of irritable bowel syndrome (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.
A 45-year-old female with rheumatoid arthritis has a hemoglobin level of 9.5 g/dL (N 11.5-16.0). Her
arthritis is well controlled with methotrexate. Further evaluation reveals the following: Hct 29.0% (N 35.047.0), MCV 78 m3 (N 80-98), Platelets 230,000/mm3 (N 150,000-400,000), WBCs 6900/mm3 (N 4000-

11,000), Differential normal, Serum iron 15 g/dL (N 50-170), TIBC 150 g/dL (N 45-70), Iron saturation
10% (N 15-50), Serum ferritin 7 ng/mL (N 12-150), Reticulocyte count 8 x 109/L (N 10-100), Stool guaiac
negative x 3. Which one of the following would be the most appropriate next step?
A. Evaluation for a source of blood loss
B. Hemoglobin electrophoresis to screen for thalassemia
C. Stopping the methotrexate and beginning an alternative treatment for rheumatoid arthritis
D. No further evaluation
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 patients 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.
An 18-year-old female basketball player comes to your office the day after sustaining an inversion injury to
her ankle. She says she treated the injury overnight with rest, ice, compression, and elevation. You
examine her and diagnose a moderate to severe lateral ankle sprain. In addition to rehabilitative exercises,
you advise:
A. a short-term cast
B. a posterior splint that allows no flexion or extension
C. a semi-rigid stirrup brace (Air-Stirrup, Aircast)
D. an elastic bandage
E. no external brace or support
In acute ankle sprains, functional treatment with a semi-rigid brace that allows flexion and extension, 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.
A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder
will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has
emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms
include upper respiratory congestion for 3 days which he has treated with an over-the-counter decongestant
with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain
incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthyappearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no
abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard
stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter;
and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography
shows a post-void residual volume of 250 mL (normal for age <100). Which one of the following must be
done urgently in this complicated patient?
A. Foley catheterization
B. Hospitalization for intravenous antibiotics
C. Digital disimpaction of the rectum, and Fleet enemas until clear
D. MRI of the lumbosacral spine
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 the presence of a serious
neurologic etiology such as 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.
A 50-year-old male with a history of methamphetamine abuse requests medication to treat this problem.
According to evidence-based studies, which one of the following would be most likely to help this patient
overcome methamphetamine dependence?
A. Fluoxetine (Prozac)
B. Amlodipine (Norvasc)
C. Imipramine
D. Bupropion (Wellbutrin)
E. Cognitive therapy
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.
You see a 20-month-old male approximately 1 hour after he had a generalized seizure that lasted 2-3
minutes according to his mother. His past medical history is unremarkable except for two episodes of otitis
media. On examination his temperature is 38.9C (102.0F), and he is awake, interactive, and consolable,
with obvious otitis media of the left ear. A neurologic examination is unremarkable, and there are no
meningeal signs. Which one of the following would be most appropriate at this point?
A. Lumbar puncture
B. Electroencephalography
C. Neuroimaging studies
D. Serum levels of electrolytes, calcium, phosphate, and magnesium, plus a blood glucose level and a CBC
E. No diagnostic studies at this time
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 electroencephalography performed either at the time of presentation or within the
following month will predict the likelihood of recurrence.
An 18-year-old male seen in your office is found to be overweight and to have acanthosis nigricans. Both
of his parents have a history of diabetes mellitus. His fasting plasma glucose level is 111 mg/dL (N <100).
Which one of the following is the correct diagnosis?
A. Prediabetes
B. Type 1 diabetes mellitus

C. Type 2 diabetes mellitus

D. Maturity-onset diabetes of the young
This patient has prediabetes, which is defined as having a fasting plasma glucose level of 101-125 mg/dL.
These patients are at high risk for developing diabetes mellitus later in life. Prediabetes is associated with
metabolic syndrome, and weight loss, exercise, and certain pharmacologic agents have been shown to
prevent or delay the subsequent development of diabetes mellitus. Diabetes mellitus is diagnosed in three
ways: symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) plus a random plasma glucose
level 200 mg/dL; a fasting plasma glucose level 126 mg/dL; or a glucose level 200 mg/dL on a 2-hour
75-g oral glucose tolerance test. It is important to note that in the absence of unequivocal hyperglycemia
the diagnosis must be confirmed by repeat testing on a subsequent day. Once the diagnosis of diabetes is
confirmed, further testing is needed to differentiate between type 1, type 2, and maturity-onset diabetes of
youth.
Which one of the following laboratory test results would confirm a diagnosis of vitamin B12 deficiency?
A. Low epogen
B. Low folic acid
C. High methylmalonic acid (MMA)
D. Low homocysteine
E. A normal peripheral smear
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 (SOR A).
A 32-year-old female who is an avid runner presents with knee pain. You suspect patellofemoral pain
syndrome. Which one of the following signs or symptoms would prompt an evaluation for an alternative
diagnosis?
A. Peripatellar pain while running
B. Knee stiffness with sitting
C. A popping sensation in the knee
D. Locking of the joint
E. A positive J sign (lateral tracking of the patella when moved from flexion to full extension)
Patellofemoral pain syndrome is a clinical diagnosis and is the most common cause of knee pain in the
outpatient setting. It is 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.
Which one of the following is true regarding medication dosage adjustments for patients with chronic
kidney disease?
A. Loading doses should usually be adjusted
B. Adjustments typically are not necessary until the glomerular filtration rate is <20 mL/min/1.73m2>
C. A normal serum creatinine value indicates that no adjustment is necessary
D. Serum drug levels are usually required for making adjustments
E. A reduction of dose, an increase in dosing interval, or both may be necessary

Many medications require dosage adjustments in patients with chronic kidney disease. Medications are
adjusted based on the estimated glomerular filtration rate (GFR) or creatinine clearance. Most medication
adjustments require a reduction in the dose, lengthening of the dosing interval, or both. Loading doses of
medications usually do not need to be adjusted. 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 <10 mL/min/1.73m2. 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.
Which one of the following would be the most effective monotherapy for alcohol withdrawal syndrome?
A. Clonidine (Catapres)
B. Phenytoin (Dilantin)
C. Atenolol (Tenormin)
D. Phenobarbital
E. Chlordiazepoxide (Librium)
Alcohol withdrawal syndrome encompasses a wide range of symptoms involving primarily the central
nervous, cardiovascular, and gastrointestinal systems, and is mediated by the abrupt removal of alcoholenhanced GABA inhibition of excitatory glutamate receptors in the central nervous system. 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.
A 36-year-old female presents with the sudden onset of severe headache, nausea, and photophobia. Her
level of consciousness is progressively diminishing. Which one of the following would be the most
appropriate next step?
A. Head CT without contrast
B. Head CT with contrast
C. Head MRI
D. Lumbar puncture
E. CT angiography
The first study ordered in any patient with suspected subarachnoid hemorrhage should be a head CT
without contrast. It will reveal subarachnoid hemorrhage in 100% of cases within 12 hours of the bleed,
and it is useful for identifying other sources for the headache, for predicting the site of the aneurysm, and
for predicting cerebral vasospasm and poor outcome. As blood is cleared from the affected area, CT
sensitivity drops to 93% within 24 hours, and to 50% at 7 days. Patients with a positive CT result for
subarachnoid hemorrhage should proceed directly to angiography and treatment. Patients with a suspected
subarachnoid hemorrhage who have negative or equivocal results on head CT should have a lumbar
puncture. MRI and CT with contrast are not used for the diagnosis of acute subarachnoid hemorrhage.
32-year-old white male undergoes an emergency splenectomy after a motor vehicle accident. Which one of
the following should he receive after the surgery?
A. Pneumococcal vaccine and meningococcal vaccine
B. Pneumococcal vaccine alone
C. Meningococcal vaccine alone
D. No immunizations

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.
Which one of the following tests is most specific for diagnosing rheumatoid arthritis?
A. Anti-cyclic citrullinated peptide (anti-CCP) antibody
B. Antinuclear antibody
C. Erythrocyte sedimentation rate
D. Serum complement levels
E. Anti-Sm antibody
Rheumatoid arthritis is primarily a clinical diagnosis and no single laboratory test is considered definitively
diagnostic. Anti-cyclic citrullinated peptide (anti-CCP) antibody is recommended by rheumatologists to
improve the specificity of testing for rheumatoid arthritis. Anti-CCP is more specific than rheumatoid
factor, 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.
A 44-year-old female is distressed because of incontinence. She reports frequent episodes of an immediate
need to urinate, which cannot always be deferred. She admits to urinating more than 10 times a day, but
denies any urine leakage with coughing, laughing, or straining. Which one of the following is the most
appropriate initial treatment for this patient?
A. Solifenacin (Vesicare)
B. Oxybutynin (Ditropan XL)
C. Tamsulosin (Flomax)
D. Phenazopyridine (Pyridium)
E. Pelvic floor muscle training and bladder training
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.
A 24-year-old gravida 1 para 1 who is 2 weeks post partum complains of double vision, shortness of breath,
and almost dropping her baby while trying to hold her. She says her symptoms worsen as the day
progresses. She has no family history of neurologic or muscular illness. A physical examination is normal
except for unilateral ptosis and 4/5 proximal weakness of both arms. Breath sounds are generally
decreased. Routine blood tests, including TSH and creatine kinase levels, are normal. A chest radiograph
and an MRI of the brain and cervical spine are also normal. Of the following, this presentation is most
consistent with:
A. fibromyalgia syndrome
B. Sheehan's syndrome (postpartum hypopituitarism)
C. polymyositis
D. myasthenia gravis
E. stroke
Common neurologic disorders in young women include multiple sclerosis, Guillain-Barr syndrome, and
myasthenia gravis. Myasthenia gravis is part of the differential diagnosis for sudden neurologic weakness,
and Guillain-Barr syndrome must also be considered in this patient. Multiple sclerosis would not result in

respiratory compromise. Myasthenia gravis 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; shortness of breath; 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.
A 33-year-old white female presents with tremor and a history of weight loss. On examination she is found
to have mild, regular tachycardia and exophthalmos. Laboratory tests confirm hyperthyroidism. Which one
of the following treatments has been found to potentially worsen Graves ophthalmopathy?
A. Radioactive iodine
B. Propylthiouracil
C. Methimazole (Tapazole)
D. Thyroid hormone replacement plus propylthiouracil
E. Thyroidectomy
The ophthalmopathy of Graves 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.
A 22-year-old male with no previous history of shoulder problems is injured in a fall. He has immediate
pain and is unable to abduct his arm. You examine him and order an MRI, which reveals an acute tear of
the rotator cuff. Which one of the following is the best initial treatment for this injury?
A. Observation without treatment for 1 month
B. Immobilization for 1 month
C. Physical therapy for 1 month
D. Corticosteroid injection
E. Surgical repair
An acute rupture of any major tendon should be repaired as soon as possible. Acute tears of the rotator cuff
should be repaired within 6 weeks of the injury if possible (SOR C). 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.
A 79-year-old male presents with left-sided hemiparesis. His previous medical history is significant for
long-standing hypertension and type 2 diabetes mellitus. On examination his blood pressure is 220/130 mm
Hg and his pulse rate is 96 beats/min. CT of the head shows no acute bleeding. An EKG shows left
ventricular hypertrophy with diffuse nonspecific changes. Which one of the following would be most
appropriate with regard to his blood pressure at this time?
A. Watchful waiting
B. Reduction of systolic blood pressure (SBP) to 190 mm Hg
C. Reduction of SBP to 170 mm Hg
D. Reduction of SBP to 150 mm Hg
E. Reduction of SBP to 130 mm Hg

Cautious reduction of systolic blood pressure by 10%-15% while monitoring neurologic status seems to be
the safest treatment goal in the setting of acute ischemic stroke when the systolic blood pressure is >220
mm Hg or the diastolic blood pressure is 120-140 mm Hg. According to JNC-7, more aggressive blood
pressure reduction may increase cerebrovascular complications.
A 70-year-old female with type 2 diabetes mellitus is admitted to the hospital with a 4-week history of
fever, anorexia, and weight loss. Two blood cultures are positive for Streptococcus bovis. In addition to
being treated for the infection, she should be evaluated for which one of the following?
A. B-cell lymphoma
B. T-cell lymphoma
C. Multiple myeloma
D. Lung cancer
E. Colorectal cancer
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.
A 75-year-old female is admitted to the hospital with a change in mental status. The initial workup
includes a chemistry profile that reveals a plasma potassium level of 6.4 mEq/L (N 3.7-5.2). Which one of
the following should be given now to rapidly lower the plasma potassium level?
A. Corticosteroids
B. Albuterol
C. Furosemide (Lasix)
D. 0.45% saline
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, but this takes
longer to affect the plasma potassium level than translocation methods. In the most severe cases, acute
hemodialysis can be instituted.
You see a patient with a serum sodium level of 122 mEq/L (N 135-145) and a serum osmolality of 255
mOsm/kg H2O (N 280-295). Which one of the following would best correlate with a diagnosis of
syndrome of inappropriate antidiuretic hormone secretion?
A. Fractional excretion of sodium <1%
B. Elevated urine osmolality
C. Elevated serum glucose
D. Elevated BUN
E. Low plasma arginine vasopressin
The syndrome of inappropriate antidiuretic hormone secretion (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. Most, but not all, cases are associated with
increased levels of the antidiuretic hormone arginine vasopressin (AVP). For a diagnosis of SIAD to be
made, the patient must be euvolemic and not on diuretics (within 24-48 hours), and the urine osmolality
must be high in conjunction with both low serum sodium and low osmolality. The BUN is normal or low
and the fractional excretion of sodium is >1%. Fluid restriction (<800 cc/24 hours) over several days 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.
A 45-year-old male asks about using nicotine replacement therapy (NRT) to help him quit smoking. You
tell him that recent evidence shows that:
A. NRT usually doubles a smokers chance of quitting
B. NRT must be tapered off
C. NRT should be used for at least 6 months to be effective
D. nicotine patches are the most effective form of NRT
E. using combinations of NRT reduces the likelihood that a relapsed smoker will quit
A Cochrane meta-analysis of nicotine replacement therapy (NRT) found that it almost doubles a smokers
chances of quitting (SOR A). 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.
Cows milk should be withheld from a childs diet until what age?
A. 4 months
B. 6 months
C. 9 months
D. 12 months
E. 15 months
Whole cows milk does not supply infants with enough vitamin E, iron, and essential fatty acids, and
overburdens their system with too much protein, sodium, and potassium. 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
cows 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.
Osmotic demyelination can result when which one of the following is corrected too rapidly?
A. Hypocalcemia
B. Hypoglycemia
C. Hypomagnesemia
D. Hypokalemia
E. Hyponatremia
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 <10-12 mmol/L in 24 hours and to
<18 mmol/L in 48 hours.
A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3C (101.0F),
but does not appear toxic. The remainder of the examination is within normal limits. Which one of the
following would be the most appropriate management for this patient?
A. Admit to the hospital; obtain urine, blood, and CSF cultures; and start intravenous antibiotics
B. Admit to the hospital and treat for herpes simplex virus infection
C. Follow up in the office in 24 hours and admit to the hospital if not improved
D. Order a CBC and urinalysis with urine culture, and send the patient home if the results are normal

Any child younger than 29 days old with a fever and 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 (SOR A). Observation only, with close follow-up, is
recommended for nontoxic infants 3-36 months of age with a temperature <39.0C (102.2F) (SOR B).
Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies,
including a CBC and urinalysis, can be sent home with precautions and with follow-up in 24 hours (SOR
B). 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 (SOR C).
A 45-year-old male was admitted to the hospital for nausea resulting from chemotherapy for colon cancer.
He has no other chronic diseases and takes no routine medications. He was mildly dehydrated on
admission and has been receiving intravenous fluids (D5 -normal saline with potassium chloride) at
slightly higher than maintenance rates through an indwelling port for the last 24 hours. The nausea is being
controlled by antiemetics, and his condition is improving. Results of routine blood work at the time of
admission and from the following morning are shown below.
Admission
Following Morning
Glucose
109 mg/dL (N 65-110)
371 mg/dL
BUN
13 mg/dL (N 7-21)
9 mg/dL
Creatinine
0.9 mg/dL (N 0.6-1.6)
0.9 mg/dL
Sodium
143 mmol/L (N 136-144)
129 mmol/L
Potassium
3.7 mmol/L (N 3.6-5.1)
6.6 mmol/L
Chloride
110 mmol/L (N 101-111)
108 mmol/L
Total CO2
20 mmol/L (N 22-32)
22 mmol/L
Which one of the following would be the most appropriate next step?
A. Start an intravenous insulin drip
B. Order blood work taken from a peripheral vein
C. Restrict the patient's free water intake
D. Switch from normal saline to hypertonic saline
E. Treat with diuretics
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.
Which one of the following is the leading cause of death following bariatric surgery?
A. Pulmonary embolism
B. Adult respiratory distress syndrome
C. Peritonitis secondary to an anastomotic leak
D. Sepsis related to a wound infection
E. Hemorrhage from an anastomotic ulcer
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.

A white male adolescent is concerned because he is the shortest boy in his class. His age is 14.3 years and
his parents are of normal height. He has a negative past medical history and no symptoms. On physical
examination you note that he is 151 cm (59 in) tall. The average height for his age is 165 cm. His weight
is 43 kg (95 lb). His sexual maturity rating is 3 for genitalia and 2 for pubic hair. A wrist radiograph shows
a bone age of 12.2 years (the average height is 152 cm for this bone age). On the basis of this evaluation
you can tell the patient and his parents that:
A. he should have a growth hormone stimulation test
B. his adult height will be below average
C. his sexual development is about average for his age
D. he will begin to grow taller within a year or so
E. an underlying nutritional deficiency may be the cause of his short stature
Constitutional growth delay, defined as 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.
A 4-year-old male has a fever of 1 weeks duration. It has been at or slightly above 38 C (101 F) and has
responded poorly to antipyretics. The patient complains of photophobia, burning in his eyes, and a sore
throat. His mother also notes that his eyes look red, his lips are red and cracked, and he has a strawberry
tongue. The childs palms and soles are erythematous and the periungual regions show desquamation of
the skin. He has minimally painful nodes located in the anterior cervical region, about 22 cm in size. A
Streptococcus screen is negative. The most appropriate management at this time would be:
A. Intramuscular benzathine penicillin G (Bicillin L-A), 600,000 U
B. Intravenous nafcillin (Nallpen)
C. Intravenous immune globulin and aspirin
D. Prednisone, 23 mg/kg daily
E. A fine-needle biopsy of the lymph nodes
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; and, 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 rheumatoid arthritis, measles, adenovirus infection,
echovirus infection, and drug reactions. Treatment significantly diminishes the risk of complications.
Current recommendations are to hospitalize the patient for treatment with intravenous immune globulin. In
addition, aspirin is used for both its anti-inflammatory and antithrombolitic effects. 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.
At a routine prenatal visit at 16 weeks' gestation a 38-year-old gravida 3 para 2 has a pulse rate of 110
beats/min and has lost 2 kg (4 lb) since her previous visit. At age 26, she was treated for Graves disease
with radioactive iodine and has been euthyroid on no medication for over 10 years. A CBC shows a mild

anemia. Her hematocrit is 34% (N 3545) and her TSH level is 0.00 U/mL (N 0.55.0). Which one of the
following would be most appropriate at this time?
A. Propylthiouracil
B. Propylthiouracil plus levothyroxine (Synthroid)
C. Methimazole (Tapazole)
D. Radioactive iodine therapy
E. Immediate surgery
There is a 5%-10% recurrence rate for Graves disease after treatment with radioactive iodine. Years may
pass before recurrence. Radioactive iodine therapy is contraindicated in pregnancy, and immediate surgery
might present hazards to both the mother and the fetus. Propranolol would control the patients heart rate,
but would do nothing about the underlying hyperthyroidism. Propylthiouracil has been used extensively in
pregnancy and has never been shown to have any teratogenic effect. The combination of propylthiouracil
and levothyroxine is frequently used for hyperthyroidism in nonpregnant patients, but transplacental
passage of the levothyroxine would be harmful to the developing fetus. Methimazole crosses the placenta
more readily than propylthiouracil and is associated with aplasia cutis.
A 9-month-old white male is brought to your office for a well-child visit. You note that the childs weight
gain has been flat over the last several months. He has fallen from the 75th percentile to the 15th for
weight, and his percentile for length is beginning to decline as well. The mother states that the child began
having diarrhea as soon as she began giving him various grain cereals and baby foods 5 months ago. The
remainder of a review of systems and a social and family history is unremarkable. Physical examination
reveals an undernourished infant with mild abdominal distention. A check of the infants hemoglobin shows
a microcytic anemia with a low serum ferritin level. Which one of the following is the most likely
diagnosis?
A. Thalassemia minor
B. Celiac sprue
C. Cystic fibrosis
D. Congenital megacolon (Hirschsprungs disease)
E. Inborn error of metabolism
Celiac sprue is a condition of acquired malabsorption that resolves when the patient is exposed to a glutenfree diet. Gluten is a substance found in wheat, rye, and barley, but not in corn or rice products. Children
with this sensitivity will 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.
A 25-year-old female presents with abdominal pain localized to the right lower quadrant. Which one of the
following would be most helpful in diagnosing acute appendicitis?
A. A CBC
B. Urinalysis
C. Plain abdominal films
D. Abdominal/pelvic ultrasonography
E. Abdominal/pelvic CT
Seventy to ninety percent of patients with acute appendicitis have leukocytosis, but this is also a
characteristic of other conditions, and thus has poor specificity for acute appendicitis. The urinalysis may
exhibit microscopic pyuria or hematuria in a patient with acute appendicitis, but these findings may also be
present with urinary tract disease. Plain radiographs of the abdomen are of limited value in diagnosing
acute appendicitis. Ultrasonography can be useful, especially in ruling out gynecologic problems, but is
technician-dependent and is not as specific nor sensitive as CT scanning, which has a sensitivity,

specificity, and overall accuracy in excess of 90%. In cases where the CT scan is indeterminate, patients
should be admitted to the hospital for close observation with repeated physical examinations to monitor
clinical status.
A 65-year-old white female presents with weight loss and fatigue. On examination, she has
lymphadenopathy, hepatomegaly, and mild splenomegaly. Her hemoglobin level is 9.0 g/dL (N 12.016.0),
and a chemistry panel reveals a serum protein level of 9.0 g/dL (N 6.08.0). You order a chest radiograph,
which shows clear lung fields and no evidence of lytic lesions in the thoracic spine. Serum protein
electrophoresis reveals a monoclonal gamma-globulin spike, which on immunoelectrophoresis is found to
be due to IgM kappa-protein. Urine for Bence-Jones protein is positive. A bone marrow biopsy from the
iliac crest demonstrates hypercellularity, with a large number of lymphocytes, but normal-appearing plasma
cells. Which one of the following is the most likely diagnosis?
A. Multiple myeloma
B. Waldenstrms macroglobulinemia
C. Sarcoidosis
D. Monoclonal gammopathy of undetermined significance
E. Non-Hodgkins lymphoma
The patient has symptoms, signs, and laboratory findings consistent with a diagnosis of Waldenstrms
macroglobulinemia. This illness is 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 monoclonal gammopathy of undetermined significance. 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-Hodgkins
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.
A 30-year-old white male visits your clinic after being in a bar fight. He describes hitting another man in
the mouth with his closed fist. He reports a painful distal fifth metacarpal with a superficial abrasion. After
assessing tetanus status and copiously irrigating the wound, you should do which one of the following?
A. Obtain a radiograph and give prophylactic antibiotics
B. Obtain a radiograph only
C. Give prophylactic antibiotics only
D. Probe the abrasion
This presentation is consistent with a common injury called a fight bite. Radiographs 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.
A 19-year-old female runner has a 1-week history of constant groin pain. There is limited hip motion on
flexion and internal rotation of the right hip. Radiographs of the hip and pelvis are normal. Which one of
the following is the most likely diagnosis?
A. Iliotibial band syndrome
B. Stress fracture of the right femoral neck
C. Osteitis pubis
D. Pelvic inflammatory disease

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.
A 10-year-old female is brought in for a scheduled physical examination. The mother notes that her
daughters allergies seem to be getting worse and that her eyes are puffy in the morning. The patient
has been healthy on previous examinations. Examination today reveals no other allergic stigmata. You note
a trace of ankle edema and 3+ proteinuria on urinalysis. The remainder of the examination is normal. The
patient returns the following morning for further studies. She is fasting. Laboratory Findings: Hct 42% (N
3646), WBCs 6200/mm3 with normal differential, Creatinine 0.8 mg/dL (N 0.61.5), BUN 18 mg/dL (N
825), Liver function tests normal, Calcium 7.4 mg/dL (N 8.510.5), Sodium 128 mmol/L (N 135145),
Potassium 3.7 mmol/L (N 3.44.8), Total cholesterol 320 mg/dL, Antinuclear antibody negative,
Antistreptolysin negative, Urinalysis: 3+ protein, no WBCs, RBCs, or casts The most likely diagnosis is:
A. Acute glomerulonephritis
B. Acute renal failure
C. Nephrotic syndrome
D. Orthostatic proteinuria
E. Congenital renal artery stenosis
This scenario is a classic presentation for nephrotic syndrome. The most common histologic type in this age
group is minimal change disease. Acute glomerulonephritis would likely present with hypertension and red
cell casts in the urine. The normal BUN and creatinine rule out acute renal failure. Orthostatic proteinuria,
while much more common, is not associated with edema or the markedly elevated total cholesterol of 320
mg/dL. Congenital renal artery stenosis is an uncommon cause of problems in childhood and typically
presents with hypertension in adults.
A 24-year-old male, new to your practice, presents for a mental health evaluation. The patient has a past
history of schizophrenia, diagnosed several years ago. Which one of the following, if present, would lead to
a reconsideration of this diagnosis?
A. Auditory hallucinations
B. Loose associations
C. Elated mood
D. Social dysfunction
E. Incoherent speech
Schizophrenia can be very difficult to definitively diagnose, and there are many subtypes. There are many
sets of diagnostic criteria, but most, including DSM-IV, include the presence of thought disorders such as
hallucinations, delusions, and loose associations; disorganized speech; catatonic behavior; and apathy or
flat affect. (Two of these must be present to meet DSM-IV criteria.) Additionally, there must be social or
occupational impairment and a minimum duration of symptoms (6 months for DSM-IV). Mood disorders,
including depression, mania, and schizoaffective disorder, must be excluded in order to diagnose
schizophrenia. Obviously, treatment of these disorders is very different from that of schizophrenia.
Children of an elderly man who suffers from Alzheimers disease are bothered by his wandering and pacing
behaviors. You have started treatment with a cholinesterase inhibitor, but the behavior persists. They ask
you to prescribe additional drug therapy. You would recommend which one of the following?
A. No additional drug therapy
B. Risperidone (Risperdal)
C. Citalopram (Celexa)
D. Lorazepam (Ativan)

E. Valproic acid (Depakote)

Behavioral symptoms such as agitation and wandering become common as Alzheimers disease progresses.
Cholinesterase inhibitors may improve some of these symptoms. If they persist, use of a psychotropic agent
may be necessary. Atypical agents can help control problematic delusions, hallucinations, severe
psychomotor agitation, and combativeness. Typical agents 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.
A 25-year-old white male exhibits a syndrome of fever, headache, myalgia, and aching joints 3 days after a
summer camping trip. He subsequently develops a generalized maculopapular eruption that initially
involves the palms and soles and then becomes hemorrhagic. Splenomegaly is noted. A protracted 3-week
course of the illness occurs in spite of antibiotic therapy and is followed by gradual resolution of the illness.
Which one of the following is the most likely diagnosis?
A. Lyme arthritis
B. Systemic lupus erythematosus in exacerbation
C. Subacute immune complex disease
D. Gonococcemia
E. Rocky Mountain spotted fever
Fever, headache, and myalgia must be recognized as the classic triad of Rocky Mountain spotted fever in
all patients who might have been bitten by a tick, as commonly occurs in campers. This patient exhibits a
classic picture of the disease, which often has a virulent 3-week course even when treated with tetracycline
or chloramphenicol. A 10% mortality rate has been noted for this illness, which is not uncommon in the
southeastern United States. Lyme disease is also the result of tick transmission, but is otherwise unlike
Rocky Mountain spotted fever; gonococcemia is associated with monoarticular pain and a papular rash;
systemic lupus erythematosus and immune complex diseases do not produce the clinical picture seen in this
patient.
In assessing the nutritional status of an infant it is useful to know that birth weight is expected to be
regained within:
A. 5 days
B. 14 days
C. 21 days
D. 28 days
A helpful guideline for assessing normal growth in the very young infant is that birth weight should be
regained by the 14th day.
Physiologic changes in the elderly lead to which one of the following?
A. Resistance to dehydration
B. A tendency toward hypernatremia due to diminished thirst response
C. Lower than usual concentrations of medications distributed in body fluids
D. Greater than usual required dosages of medications
There is no known resistance to dehydration in the elderly. There is a smaller volume of dilution for drugs
distributed in body fluids. This may result in higher concentrations of medications, sometimes approaching
toxic levels, especially if the usual adult dosages are given. Because elderly patients have a diminished
thirst response, they are prone to develop hypernatremia when water is not immediately available.

Female victims of domestic assault:

A. Are less likely to be abused during pregnancy
B. Seldom spontaneously offer accounts of partner abuse
C. Usually resent unsolicited questions about abuse
D. Usually seek medical care for their injuries
Sexual abuse has been reported in 54% of violent marriages. Abuse generally escalates during pregnancy.
Victims are often reluctant to speak out spontaneously, and often respond to neutral questioning by their
family physician. Studies estimate that only 8%39% of females who are abused seek care.
A 72-year-old male is brought by ambulance to the emergency department with weakness and numbness of
his left side which began earlier this morning. While in the emergency department he becomes comatose
with infrequent, gasping breaths and is quickly intubated and placed on a ventilator. A full evaluation shows
an acute ischemic right-sided stroke. His wife states that she wishes to have the ventilator stopped, as she
believes this would be consistent with her husbands wishes in this circumstance. She understands that this
would precipitate the patients death. The wife presents a legally valid advance directive confirming her as
the patients health-care proxy. Which one of the following responses to the wifes request is most ethically
appropriate?
A. Withdraw the ventilator as requested
B. Contact the hospital ethics committee to initiate the legal requirements to process the wifes request
C. Inform the wife that all life-sustaining care should be given until the patients condition has been
determined to be irreversible
D. Inform the wife that intubation may have been avoided in the emergency department, but once lifesustaining care has been initiated it should not be withdrawn
E. Promptly contact hospital security or the local law enforcement agency to report the wifes request
Competent adult patients have the right to refuse any medical intervention, even if forgoing this treatment
may result in their death. Legally and ethically it does not matter whether the patient requests that care be
withheld before it is started, or that it be withdrawn once it is begun. All states currently allow competent
patients to legally designate a health-care proxy to make these decisions for them if they become unable to
communicate or incompetent to decide for themselves. The patient in this example has instituted such a
legal advance directive and his proxys desires 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 patients condition does not need to be
terminal or irreversible in order to allow the removal of life-sustaining therapy. Legal involvement is rarely
required in situations where advance directives are already available and valid.
A 25-year-old white female presents to your office with the following complaints: sudden onset of intense
apprehension, fear, terror associated with impending doom, dyspnea, palpitations, and a feeling of loss of
control. Which one of the following is the most likely diagnosis?
A. Pheochromocytoma
B. Panic attack
C. Hypochondriasis
D. Hypoglycemia
E. Hyperthyroidism
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.
A 4-year-old female has had three urinary tract infections in the past 6 months. She complains of difficulty
with urination and on examination is noted to have labial adhesions that have resulted in near closing of the
introitus. Which one of the following is the most appropriate management?
A. No treatment at this time
B. Reporting your suspicion of child abuse to the appropriate authorities
C. Application of estrogen cream to the site
D. Gentle insertion of progressively larger dilators over a period of several days
E. Referral to a gynecologist for surgical correction
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 urinary tract infections, 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.
Which one of the following is a major risk factor for prostate cancer?
A. Asian ethnicity
B. A family history of prostate cancer
C. Age <50
D. Urinary hesitancy and nocturia
E. Uncontrolled diabetes mellitus
The main risk factors for prostate cancer include a positive family history, African-American race, and age
over 50. Urinary symptoms associated with benign prostatic hypertrophy are not associated with increased
risk, nor is uncontrolled diabetes mellitus.
A 6-year-old male is brought to your office 10 days after the onset of a cough and low-grade fever. On
examination, his temperature is 37.9 C (100.2 F), pulse 100 beats/min, respirations 22/min, and O2
saturation 94%. He has diffuse wheezes on auscultation of his chest. His WBC count is 9800/mm3 (N
450011,000) with a slight left shift. His C-reactive protein level is mildly elevated and a chest radiograph
reveals an interstitial infiltrate. Which one of the following would be the most appropriate initial therapy?
A. A beta-lactam antibiotic
B. A macrolide antibiotic
C. Amoxicillin
D. Ceftriaxone (Rocephin)
The most common cause of pneumonia in children ages 515 is Mycoplasma pneumoniae, which is
sensitive to macrolides. The low-grade temperature, borderline WBC count, and lack of a markedly
elevated C-reactive protein do not suggest pneumococcal disease. Wheezing is characteristic of both viral
and mycoplasmal disease. Respiratory syncytial virus is the most common cause of pneumonia in children
age 4 months to 4 years. A 6-year-old is more likely to have mycoplasmal disease.
Treatment of mild persistent asthma with a low-dose inhaled corticosteroid alone would be the preferred
treatment for a patient whose asthma symptoms occur:
A. Once a week
B. 3 times a week
C. Daily

D. Continuously
E. 2 times a week, but only with exercise
Low-dose inhaled corticosteroids are preferred for patients with mild persistent asthma, defined as the
occurrence of symptoms more than twice a week but less than once a day. Patients with severe persistent
asthma, defined as continual symptoms, should be treated with high-dose inhaled corticosteroids and longacting inhaled beta2-agonists. Moderate asthma, defined as daily symptoms, should be treated with low- to
medium-dose inhaled corticosteroids and long-acting inhaled beta2-agonists. Mild intermittent asthma,
with symptoms 1 or 2 days per week, does not require daily medication.
In 2001, the National Cholesterol Education Program published updated guidelines for cholesterol testing
and management, as recommended by its Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults. According to these guidelines and the 2004 Adult Treatment Panel (ATP) III
Update, the target LDL cholesterol for patients with type 2 diabetes mellitus is:
A. 60 mg/dL
B. 100 mg/dL
C. 130 mg/dL
D. 160 mg/dL
E. 200 mg/dL
The 2001 National Cholesterol Education Program Adult Treatment Panel III guidelines and the 2004
update, as well as guidelines previously published by the American Diabetes Association, have established
a target LDL cholesterol level of 100 mg/dL for patients with diabetes. This target is also applicable for
individuals with known coronary artery disease (CAD), symptomatic carotid artery disease, abdominal
aortic aneurysm, peripheral vascular disease, and multiple risk factors that confer a 10-year risk for
coronary heart disease that is >20%. An LDL level of 130 mg/dL is acceptable for other individuals with
only two risk factors for CAD and a 10-year CAD risk <20%, and 160 mg/dL is the upper limit of
acceptability for patients with no more than one risk factor for CAD and a 10-year CAD risk <20%.
An 81-year-old retired electrical engineer whose wife is a diabetic was experimenting with his wifes
glucose meter and found that his glucose level was 198 mg/dL. He used her strips and lancets, and started
his own log. After a week, he brings the log to you. His premeal glucose levels range from about 150
mg/dL to 250 mg/dL. A review of his medications shows none that would be likely to increase his glucose
level. A physical examination does not suggest glucose intolerance secondary to a process other than
diabetes. His hemoglobin A1c is 9.0%. Additional laboratory studies should be performed before
prescribing which one of the following for this patient?
A. Insulin NPH (Humulin N)
B. Metformin (Glucophage)
C. Glimepiride (Amaryl)
D. Miglitol (Glyset)
The use of insulin therapy can be as appropriate in the older adult with diabetes as in younger individuals.
In patients with reduced muscle mass, such as the elderly (especially those older than 80 years of age),
using serum creatinine concentration to estimate the glomeruler filtration rate may be misleading, and
creatinine clearance should be determined. If creatinine clearance is <70 mL/min, metformin should not be
prescribed. The other two oral antidiabetic agents are safe to use in an elderly patient without other initial
laboratory data.
Which one of the following is true concerning nausea and vomiting in pregnancy?
A. Psychological factors play a causative role
B. Pharmacologic therapy, in general, is no more effective than placebo in relieving symptoms and
preventing hospitalization

C. Metoclopramide (Reglan) is contraindicated in the first trimester but is safe and effective for nausea and
vomiting in later trimesters
D. If nausea and vomiting begin after 9 weeks' gestation, secondary causes are more likely to be present
While the exact etiology of nausea and vomiting in pregnancy remains unclear, there are few data to
support the theory that psychological factors play a role. Although nausea is usually a self-limited
condition, other causes must be ruled out. Secondary causes are more likely to be present if the onset of
symptoms occurs after 9 weeks' gestation. Several pharmacologic treatments are proven safe and are
superior to placebo in relieving symptoms and preventing hospitalization. Metoclopramide is more
effective than placebo and has not been associated with an increased risk of adverse effects on the fetus.
A 25-year-old white female with heavy menstrual periods is noted to have a hemoglobin level of 9.8 g/dL
(N 12.016.0). The red cell distribution width is 16.0% (N 11.514.5) and the mean corpuscular volume is
75 m3 (N 78102). The appropriate treatment for this condition can be enhanced by the use of:
A. Antacids
B. Soy milk
C. Iced tea
D. Bran
E. Ascorbic acid
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.
A 32-year-old female presents with bilateral pretibial tender, mildly red nodules 24 cm in diameter. A
nodule that appeared earlier resolved, leaving a bruised area. She had a similar problem once when she
was pregnant but it resolved spontaneously. Her medications include lovastatin (Mevacor) for
hyperlipidemia and a low-dose oral contraceptive prescribed 5 months earlier. Her past history and a review
of systems are otherwise unremarkable. The most appropriate next step would be to:
A. Order a serum creatine phosphokinase level
B. Obtain a cervical culture for gonorrhea
C. Discontinue her oral contraceptive
D. Discontinue lovastatin
Erythema nodosum (EN) is a panniculitis most often appearing on the shins. In 35%55% of cases, no
cause is found. EN has been associated with pregnancy and oral contraceptives. Other drugs including
sulfonamides, bromides, iodides, and omeprazole have been associated with EN. Statins have not been
associated with EN. Infectious agents associated with EN include beta-hemolytic streptococci,
Mycobacterium, Yersinia, fungi, syphilis, Campylobacter, hepatitis C, and Epstein-Barr virus.
Inflammatory conditions associated with EN include inflammatory bowel disease, sarcoidosis, Lofgrens
syndrome, and Behets syndrome.
A 70-year-old female had a lumbar vertebral fracture 3 years ago. At that time she had a dual-energy x-ray
absorptiometry (DEXA) scan, with a T score of 2.6, and was placed on alendronate (Fosamax), calcium,
and vitamin D. She recently quit smoking. Her BMI is 21. A DEXA scan today shows her bone mineral
density to be 2.1. Which one of the following would be most appropriate in the management of this
patient?
A. Replace alendronate with raloxifene (Evista)
B. Stop alendronate, but continue calcium and vitamin D
C. Add raloxifene to her regimen
D. Add teriparatide (Forteo) to her regimen
E. Make no change to her regimen

Even though the patients 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.
Of the following, which is the most frequent cause of seizures in the elderly?
A. Alcohol withdrawal
B. Stroke
C. Head trauma
D. Hypoglycemia
E. Dementia
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.
In a day-care center for which you are the medical consultant, two children develop systemic Haemophilus
influenzae type b infections within the same month. You recommend prophylaxis with which one of the
following for all children and staff in the classroom?
A. Ceftriaxone (Rocephin)
B. Chloramphenicol (Chloromycetin)
C. Trimethoprim/sulfamethoxazole (Bactrim, Septra)
D. Cefaclor (Ceclor)
E. Rifampin (Rifadin)
Whereas many antibiotics temporarily suppress nasopharyngeal colonization by Haemophilus influenzae
type b, only rifampin is effective in eradicating the organism. It should therefore be administered to all
attendees and staff of a day-care facility in which two or more children have been diagnosed with disease
caused by H. influenzae, regardless of previous immunization status. The patients should also receive
rifampin before returning to the center. Prophylaxis after a single case is controversial.
In the Stages of Change model of behavior change (also called the Transtheoretical Model), relapses:
A. Are usually permanent
B. Indicate failure of motivation by the patient
C. Indicate failure in the behavior change technique of the physician
D. Are usually recurrent, and are a part of the change process
E. Suggest the need to check the patients health beliefs about the desired change
In the Stages of Change model, relapses are usually recurrent and are a part of the change process. It does
not necessarily indicate failure of motivation or a failure in the technique of the physician, but should be
used by the patient to identify ways to improve their future attempts at the same behavior change. Relapses
are not usually permanent. The patients health beliefs are more important when he or she is in the
precontemplation or contemplation stage of behavior change.
A 28-year-old white female sees you for preconception counseling. For the past 3 years she has been
successfully treated with fluoxetine (Prozac) for depression, and she asks if she can continue taking it when
she becomes pregnant. It is labeled by the FDA as category C for use in pregnancy. Which one of the
following would you advise?
A. There is evidence of harm to the human fetus, and she should discontinue it
B. Controlled studies in women fail to demonstrate risk to the fetus; it is safe to continue it

C. Animal studies do not indicate any risk to the fetus; there are no studies in women
D. Animal studies demonstrate some risk to the fetus; there are no studies in women
E. There is evidence of risk to the human fetus
Family physicians are often asked to advise women on the use of medicines during pregnancy, even if they
are not providing the primary obstetrical care. FDA category C means that animal studies demonstrated
teratogenic or embryocidal effects, but there are no controlled studies in women. Fluoxetine caused a
higher incidence of stillbirths in rat reproductive studies, but the surviving litter mates showed no evidence
of neurotoxicity. There are no controlled studies in humans, although there are no reports of major
malformations in babies born to mothers who took fluoxetine in the first trimester. Category A medications
are those for which controlled studies in women show no risk to the fetus. Category B indicates that animal
studies have shown no risk but there are no controlled human studies. Category D agents have positive
evidence of human fetal risk but their use is allowed in situations where the benefit outweighs that risk.
Category X medicines are those which have evidence of harm to human fetuses and should not be used at
all during pregnancy.
A 3-week-old white male presents with a history of several days of projectile vomiting after feeding, and
documented weight loss despite a good appetite. There is a questionable history of a paternal uncle having
surgery for a similar problem when he was an infant. Which one of the following findings is a characteristic
sign of this disease?
A. Hypochloremic alkalosis
B. Pneumonia
C. Generalized abdominal distention
D. Currant jelly stool
E. Direct hyperbilirubinemia
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.
The latter is a characteristic sign of pyloric obstruction. As the child vomits chloride and hydrogen-rich
gastric contents, hypochloremic alkalosis sets in. Pneumonia is not a common problem with pyloric
stenosis, as it can be with congenital tracheoesophageal fistulae for example. 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. Currant jelly stool is a common clinical
manifestation of intussusception. Mild jaundice with elevated indirect bilirubin is seen in about 5% of
infants with pyloric stenosis, but is not a characteristic sign.
A 65-year-old white female develops a burning pain in the left lateral thorax, followed 2 days later by an
erythematous vesicular rash. Of the following, the best treatment is:
A. Topical corticosteroids
B. Oral corticosteroids
C. Topical acyclovir (Zovirax)
D. Oral valacyclovir (Valtrex)
E. Topical capsaicin (Zostrix)
The rash described is typical of herpes zoster. This commonly occurs in older individuals who have had
chickenpox in childhood. 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. Topical and oral
corticosteroids may have some use for combatting the inflammatory process, and may decrease the
incidence of postherpetic neuralgia in certain individuals. Topical capsaicin may be useful in treating the
pain of acute herpes zoster infection, as well as postherpetic neuralgia.

You see a 30-year-old male who has just fallen on an outstretched hand. He complains of wrist pain and
edema. Examination reveals tenderness over the anatomic snuffbox and over the scaphoid tubercle at the
proximal wrist crease with the hand in extension. Radiographs of the wrist are negative. Which one of the
following would be the most appropriate action at this point?
A. Order a bone scan for the next day
B. Order high-spatial-resolution ultrasonography of the wrist
C. Immobilize in a cast for 68 weeks
D. Immobilize in a thumb spica splint for 12 weeks and then order repeat radiographs
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. Plain films are
recommended as the next step. A bone scan or follow-up films after immobilization for 2 weeks should be
done if the initial films are negative. Bone scans may be negative until enough time has passed for
osteoblastic activity to begin. Ultrasonography is not helpful for evaluation of scaphoid fractures.
A 72-year-old female with longstanding diabetes mellitus presents to your office. During the review of
systems, she complains of difficulty voiding and frequent dribbling. A urinalysis is negative for infection
and her post-void residual volume is 250 mL. Which one of the following is the most likely cause of this
patients urinary incontinence?
A. Excess urine output due to hyperglycemia
B. Atrophic vaginitis
C. A grade II cystocele
D. Asymptomatic bacteriuria
E. Autonomic neuropathy
Dribbling and increased post-void residual volume (>100 mL) are signs of overflow incontinence.
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
neuropathies. 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.
A 34-year-old female presents to the emergency department with a severe migraine headache unresponsive
to tramadol (Ultram) and sumatriptan (Imitrex) at home. She takes fluoxetine (Prozac) for depression. Soon
after being given an injection of meperidine (Demerol), she develops agitation, diaphoresis, tremor,
diarrhea, fever, and incoordination. The most likely cause of this patients symptoms is:
A. Serotonin syndrome
B. Thyrotoxic storm
C. Sepsis
D. Viral encephalitis
E. Panic attack
Physicians who prescribe SSRIs such as fluoxetine should be aware of potential drug interactions. Several
of the SSRIs may increase the effects of warfarin and raise tricyclic antidepressant levels. 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 monoamine oxidase inhibitors,
tramadol, sibutramine, meperidine, sumatriptan, lithium, St. Johns wort, ginkgo biloba, and atypical
antipsychotic agents.

Which one of the following is a contraindication to immunization with MMR?

A. The patient had a tuberculosis skin test (PPD) within the previous 2 days
B. A household member of the patient has an immunodeficiency
C. The mother of the patient is pregnant
D. The patient is pregnant
E. The patient is breastfeeding her newborn infant
The failure to provide immunizations because of perceived contraindications is one of the most common
reasons for an inadequately protected population. A PPD may be falsely negative if administered 2-30 days
after MMR administration, not the reverse. If the patient is immunodeficient or pregnant, rather than a
household contact, then MMR is contraindicated. Breastfeeding is not a contraindication.
A married couple bring their newly adopted 5-month-old for his first well child visit. They ask when the
child can sit in a safety seat in the car facing forward. You would advise that the child should face rearward
until he is:
A. 12 months of age AND weighs 20 lb
B. 15 months of age AND weighs 25 lb
C. 15 months of age OR weighs 25 lb
D. 18 months of age AND weighs 30 lb
E. 18 months of age OR weighs 30 lb
If a child faces forward in a crash, the force is distributed via the harness system across the shoulders, torso,
and hips, but the head and neck have no support. Without support, the infants head moves rapidly forward
in flexion while the body stays restrained, causing potential injury to the neck, spinal cord, and brain. In a
rear-facing position, the force of the crash is distributed evenly across the babys torso, and the back of the
child seat supports and protects the head and neck. For these reasons, the rear-facing position should be
used until the child is 12 months old and weighs 20 lb (9 kg). For example, a 13-month-old child who
weighs 19 lb should face rearward, and a 6-month-old child who weighs 21 lb should also face rearward.
Which one of the following statements regarding varicoceles is true?
A. Repair of varicoceles usually results in infertility
B. The incidence of varicoceles in adult males is <5%
C. Most varicoceles are bilateral
D. Varicoceles usually begin between 5 and 8 years of age
E. A unilateral varicocele on the right side should be referred for further evaluation
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 12 years. Varicoceles are the most common surgically correctable cause of subfertility in
men and the goal of surgery is to maximize chances for fertility. Varicoceles in men are common, with an
incidence of approximately 15%. The appearance of a varicocele on the right side only, or in a child less
than 10 years of age, is abnormal and may indicate an abdominal or retroperitoneal mass.
Which one of the following causes rhinitis medicamentosa with prolonged use in the treatment of rhinitis?
A. Intranasal antihistamines
B. Intranasal decongestants
C. Intranasal anticholinergics
D. Intranasal mast cell stabilizers
E. Leukotriene antagonists
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.

A 72-year-old white female who is otherwise healthy complains of occasional incontinence. She reports
that this occurs mainly at night when she awakens with an intense desire to void, and by the time she is able
to get to the bathroom she has wet herself. The most likely diagnosis is:
A. Sphincter incompetence
B. Detrusor instability
C. Detrusor hypotonia
D. Uninhibited neurogenic bladder
Urinary incontinence is very common in the elderly female. Treatment depends entirely on a careful history
to ascertain the exact circumstances when the patient wets herself. 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 patients voluntary attempt to hold the sphincter closed;
hence, the common term urge incontinence. Other common causes of incontinence include a weak
sphincter (sphincter incompetence), which leads to leakage associated with ordinary activities such as
coughing or lifting (stress incontinence). Another common cause is overflow of urine from an abnormally
distended, hypotonic, poorly contractile bladder (detrusor hypotonia). This is probably more common in
males with longstanding obstruction due to prostatic hypertrophy. A rare type of incontinence is caused by
spinal cord damage. This reflex incontinence is due to the patient being unable to sense the need to void.
A previously healthy 22-year-old female presents for her regular prenatal checkup at 38 weeks' gestation.
She has a blood pressure of 145/95 mm Hg today and this is unchanged 1 hour later. Her blood pressure
was normal before pregnancy. She is otherwise feeling well. She has moderate edema at the ankles and 3+
reflexes at the knees and ankles. A urinalysis for protein is normal. Given this presentation, which one of
the following is the most likely diagnosis?
A. Preeclampsia
B. Unmasked chronic hypertension
C. Essential hypertension
D. Gestational hypertension
E. Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome
This patient has gestational hypertension. This condition is diagnosed when elevated blood pressure
without proteinuria develops after 20 weeks' gestation and blood pressure returns to normal within 12
weeks of delivery. The new criteria for preeclampsia specify a new onset of hypertension (systolic pressure
>140 mm Hg or diastolic pressure >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.
A 70-year-old alcoholic male is recovering from a nontransmural myocardial infarction. On the fourth
hospital day, he describes a sudden onset of excruciating abdominal pain, which is not significantly reduced
by large doses of morphine. He becomes nauseated, begins to vomit, and has diarrhea. The patient appears
agitated and confused, and his heart rate increases. He also becomes hypotensive. Physical examination of
his abdomen reveals minimal tenderness, decreased bowel sounds, and a moderately enlarged liver.
Laboratory Findings: WBCs 17,600/mm3 with a left shift (N 430010,800), Hct 54% (N 3749), BUN 40
mg/dL (N 825), Creatinine 1.0 (N 0.61.5), Serum amylase 250 U/L (N 43115), Serum lipase 100 U/L
(N 0160), pH 7.14 (N 7.357.45). The most likely diagnosis is:
A. Alcohol withdrawal syndrome
B. Pulmonary embolus
C. Pancreatitis

D. Acute mesenteric artery embolism

The hallmark of acute mesenteric artery ischemia is severe abdominal pain that is out of proportion to
physical findings. This is a life-threatening event, which often follows myocardial infarction when a mural
thrombus occludes a superior mesenteric artery. Patients rapidly become acidotic and hypotensive, and
experience a high mortality rate. Alcoholic withdrawal syndrome has a much more insidious onset, with
tremors, agitation, and anxiety being the prominent features. Abdominal pain is not a common prominent
symptom or finding. Although pulmonary embolism is possible in the setting described, dyspnea and chest
pain are the major symptoms. Abdominal pain and tenderness are not the usual manifestation of this
disease. A normal serum lipase level should point to a non-pancreatic origin for this patients problem. A
mildly elevated serum amylase level is not specific to the diagnosis and is commonly seen in other
pathologies.
An 18-year-old primigravida at 38 weeks' gestation complains of a headache. Her blood pressure is 130/92
mm Hg. The fetal heart rate is 140 beats/min. A urine dipstick shows 2+ protein. Laboratory Findings: Hgb
10.8 g/dL (N 12.016.0), Hct 32.4% (N 36.046.0), Platelets 110,000/mm3 (N 150,000400,000), WBCs
14,900/mm3 (N 400010,000), Creatinine 0.5 mg/dL (N 0.81.3), AST (SGOT) 31 U/L (N 037), ALT
(SGPT) 60 U/L (N 065), LDH 240 U/L (N 100190), Bilirubin 1.9 mg/dL (N 0.01.0). A non stress test is
reactive and the amniotic fluid index is 9.4 (N 8.0-20.0). The patient is admitted for further testing. After 24
hours repeat testing shows the following: Hgb 9.8 g/dL, Hct 30.2%, Platelets 92,000/mm3, WBCs
15,200/mm3, Creatinine 0.6 mg/dL, AST (SGOT) 72 U/L, ALT (SGPT) 98 U/L, LDH 620 U/L, Bilirubin
2.4 mg/dL, 24-hour urine protein 2400 mg. Which one of the following would be the most appropriate
course of action at this point?
A. Continued monitoring, repeating the 24-hour urine collection, and repeating the laboratory studies
tomorrow
B. Immediate delivery by cesarean section
C. Discharge to home on bed rest, with close follow-up
D. Induction of labor with oxytocin (Pitocin) if the cervix is favorable
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.
A 70-year-old white female presents with a pruritic rash on her sacrum that has occurred intermittently over
the last 6 years. She reports that the area is always very tender just before the blister-like lesions erupt. She
is otherwise in good health, and takes no medications. Her past medical history is unremarkable. You
provide appropriate treatment for the condition. You should advise the patient to avoid which one of the
following during future outbreaks?
A. Excessive intake of green, leafy vegetables
B. Sexual contact
C. Perfumed soaps or body lotions
D. Sun exposure
E. Prolonged sitting
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 sexually transmitted disease 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.

In an 11-year-old male with dark brown urine and hand and foot edema, which one of the following would
be most suggestive of glomerulonephritis?
A. WBC casts in the urine
B. RBC casts in the urine
C. Eosinophils in the urine
D. Positive serum antinuclear antibody levels
E. Elevated C3 and C4 complement levels
Acute glomerulonephritis (AGN) in children manifests as brown or cola-colored urine, which may be
painless or associated with mild flank or 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 721 days later). In cases with more severe renal involvement, patients may develop hypertension,
edema, and oliguria. RBC casts are the classic finding on urinalysis in a patient with AGN. WBC 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.
A mother brings her 12-month-old son to your clinic, concerned that he is repeatedly banging his head
against the floor, wall, or crib. She reports that this behavior began about 2 months ago. It now occurs
several times per week, and at times is incited when the child is frustrated with a toy or when he does not
get what he wants from his parents. The mother notes that she is sometimes awakened at night by the sound
of her son rhythmically banging his head against the rail of his crib. Physical examination reveals a normal
child with some soft-tissue swelling of the forehead, but no broken skin, ecchymosis, or signs of bony
damage. Developmental milestones and growth have been normal, and the child is not on any medications.
Children with this presentation are most likely to have which one of the following?
A. A history of child abuse
B. A skin laceration or skull fracture
C. An eventual diagnosis of Lesch-Nyhan syndrome
D. Extinction of this habit by age 3
E. Future cognitive delay when compared with children without this habit
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.
A 65-year-old Hispanic male with known metastatic lung cancer is hospitalized because of decreased
appetite, lethargy, and confusion of 2 weeks duration. Laboratory evaluation reveals the following: Serum
calcium 15.8 mg/dL (N 8.410.0), Serum phosphorus 3.9 mg/dL (N 2.64.2), Serum creatinine 1.1 mg/dL
(N 0.71.3), Total serum protein 7.3 g/dL (N 6.08.0), Albumin 4.1 g/dL (N 3.74.8). Which one of the
following is the most appropriate INITIAL management?
A. Calcitonin (Calcimar) subcutaneously
B. Pamidronate disodium (Aredia) by intravenous infusion
C. Normal saline intravenously
D. Plicamycin (Mithramycin) intravenously
E. Furosemide (Lasix) intravenously
Initial management of hypercalcemia of malignancy calls for fluid replacement with normal saline to
correct the volume depletion that is invariably present and to enhance renal calcium excretion. The use of

loop diuretics such as 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 intravenous pamidronate has become the mainstay 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.
An 84-year-old male with advanced dementia develops a fever, mental status changes, and bacteremia. No
other history is available. What is the most likely source of his infection?
A. A urinary tract infection
B. Pneumonia
C. Cholecystitis
D. Diverticulitis
E. Cellulitis
Many signs and symptoms of infection that are common in younger adults present less frequently or not at
all in older adults. This patient has no obvious source of infection, and must be treated empirically. The
other conditions listed must be considered, but the most common source of bacteremia in older adults is a
urinary tract infection.
According to the U.S. Preventive Services Task Force, which one of the following strategies for
osteoporosis screening is supported by current clinical evidence?
A. Begin universal screening 5 years after the date of the last menstrual period
B. Begin universal screening at age 55
C. Begin universal screening at age 65
D. Screen only those women at increased risk for hip fracture based on a multiple risk-assessment scale
No single study has evaluated the effectiveness of osteoporosis screening. The U.S. Preventive Services
Task Force (USPSTF) recommends universal screening for women over the age of 65, as well as for
women age 6064 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.
A 4-week-old full-term male is brought to your office by his parents. They report that their child started
vomiting just after his 1-week visit. The parents are concerned because they think the vomiting is
worsening, occurring after every feeding, and shooting across the room. You note that the baby is
afebrile, but has not gained any weight since birth. Based on this information, the most likely diagnosis is:
A. Formula intolerance
B. Meningitis
C. Viral gastroenteritis
D. Pyloric stenosis
E. Inappropriate feeding
Pyloric stenosis fits the described scenario; it is 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.
You are the student health director for a community college. An administrator calls regarding
recommendations for students exposed to another student with meningococcal meningitis. The most
appropriate action would be to:

A. Close the dormitories and send the students home for at least 10 days
B. Place all exposed students on prophylactic antibiotics
C. Place all students that have not received meningococcal vaccine on antibiotic prophylaxis
D. Immunize all students who have not yet received meningococcal vaccine
The quadrivalent A, C, Y, W-135 meningococcal vaccine does not provide immunity against type B
Meningococcus, which is responsible for 30%50% of cases of invasive meningococcal disease. Therefore,
antibiotic prophylaxis with rifampin, ciprofloxacin, or ceftriaxone is indicated for all exposed persons.
A 38-year-old white male wants to go to New Mexico to ski. In the past he has experienced moderate
symptoms of acute mountain sickness (AMS), including headache, nausea, shortness of breath, and sleep
disturbance. He has been otherwise healthy. Which one of the following has been shown to be helpful in
minimizing or preventing the symptoms of AMS?
A. Furosemide (Lasix)
B. Erythromycin
C. Acetazolamide (Diamox)
D. Beta-blockers
E. Fluid restriction
Acute mountain sickness (AMS) is a clinical syndrome which may affect as many as 12%67% of persons
ascending to altitudes of 8000 feet or greater. While a standard definition of AMS does not exist, persons
having three or more of the following symptoms may be considered to have AMS: headache, nausea,
vomiting, sleep disturbance, anorexia, fatigue, or dyspnea. Gradual ascent is recommended to allow
acclimatization. Measures which may help minimize symptoms include avoidance of alcohol, increased
fluid intake, and a high-carbohydrate diet. Fluid restriction and diuretics should be avoided because of the
diuresis associated with acclimatization, which may by itself cause dehydration. Antibiotics are of no
benefit. Beta-blockers would be harmful, by interfering with the physiologic responses of tachycardia and
increased cardiac output at higher altitudes. Acetazolamide speeds the process of acclimatization. The drug
is a carbonic anhydrase inhibitor which results in a renal bicarbonate diuresis and metabolic acidosis,
thereby increasing ventilation and arterial oxygenation. The respiratory stimulation is particularly important
during sleep, when it reduces the severe hypoxemia caused by periodic breathing. The drug also lowers
cerebrospinal fluid volume and pressure, which may play an additional role in its therapeutic and
prophylactic utility.
Of the following, which one is the most common adverse event to complicate the hospital course of
patients age 65 and over?
A. Falls
B. Wound infections
C. Drug-related events
D. Procedure-related events
E. Anesthesia-related events
It has been observed that drug-related problems are the most common type of adverse event, and for
hospitalized patients the rate of these events increases with the patients age. One study showed that in
patients who are >65 years of age, the number of events per 1000 discharges was 11.46 for drug-related
events, 6.15 for wound infection, 3.85 for procedure-related events, 3.19 for falls, and 0.09 for anesthesiarelated events.
Positron emission tomography (PET) scans used to detect cancer most commonly use a radioactive tracer
tagged to a molecule that is an analogue of:
A. Oxygen
B. Glucose
C. Hemoglobin

D. Nitrate
E. Phosphate
The fluorine-18labeled tracer fluorodeoxyglucose (FDG) is a glucose analogue taken up by metabolically
active cells using glucose as a substrate for their metabolism. This enables the PET scanner to detect
metabolically active tissues such as cancer metastases.
Which one of the following statements regarding antidepressant drug therapy is true?
A. The response rate to most antidepressants is 90%95%
B. Patients unimproved after 2 weeks should receive a different drug
C. Patients unresponsive after 6 weeks should have their treatment altered
D. Patients unresponsive to one class of drugs are unlikely to respond to another class
E. In patients who have not improved after 6 weeks of drug therapy, depression is unlikely to be the cause
of their symptoms
An adequate trial of antidepressant therapy is 46 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.
Compared to anesthesia using only parenteral opioids, the use of epidural anesthesia in labor and delivery
increases the rate of which one of the following?
A. Cesarean section
B. Low Apgar scores (<7)
C. Maternal low backache 3 months post delivery
D. Prolonged second stage of labor
Multiple systematic reviews have been conducted to examine the effects of epidural anesthesia on maternal
and neonatal outcomes. There are many confounding variables in the studies and, as a result, only a few
effects of epidural anesthesia are consistently seen on a statistically significant basis: an increased duration
of the second stage of labor, an increased rate of instrument-assisted vaginal deliveries, and 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.
A 78-year-old Hispanic male comes to see you after attending a health fair. He is concerned because he had
a prostate-specific antigen (PSA) level of 5.0 ng/mL (N 0.04.0). He has never had his PSA checked
before. His medical history is significant for class IV heart failure treated with furosemide (Lasix), enalapril
(Vasotec), carvedilol (Coreg), digoxin, and spironolactone (Aldactone). His review of systems is positive
for longstanding nocturia and gradually worsening weakness of the urinary stream. His physical
examination is noteworthy for bibasilar rales, an S3 gallop, and moderate lower extremity edema. His
prostate is diffusely large and smooth. His urinalysis is unremarkable. Which one of the following is the
most appropriate management for his elevated PSA?
A. No intervention
B. Repeat testing after a course of antibiotics
C. Referral for a CT scan or MRI of the pelvis
D. Referral for prostate ultrasonography and biopsy
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.

In early February, you receive a call from your office nurse. Her 5-month-old daughter has been ill for
several days. What started as a mild upper respiratory infection has progressed and she now has profuse
rhinorrhea, a temperature of 100.2 F (37.9 C), and audible wheezing. In spite of an almost nonstop cough,
she does not appear acutely ill. The organism responsible for this childs illness is most likely to be:
A. Group B Streptococcus
B. Mycoplasma pneumoniae
C. Bordetella pertussis
D. Parainfluenza virus 3
E. Respiratory syncytial virus
The most common cause of pneumonia in children age 4 months to 4 years is respiratory syncytial virus.
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.
A 34-year-old white mechanic felt a slight impact on his left eye while hammering on an axle 2 days ago.
He has experienced some discomfort since that time, and complains of blurring of vision. Physical
examination discloses no local erythema or other evidence of injury to the eye. Fluorescein staining is
negative. His visual acuity is 20/40 in the affected eye. The most likely diagnosis is:
A. Traumatic iritis
B. Corneal abrasion
C. Intraocular foreign body
D. Bacterial corneal ulcer
E. Retinal detachment
Complaints of discomfort in the eye with blurred vision and a history of striking steel should arouse strong
suspicion of an intraocular foreign body.
A 68-year-old white female presents to your office and reports that yesterday she had a 20-minute episode
of difficulty speaking and weakness of the right side of the face and right arm. She has never experienced
any episodes similar to this in the past and reports her overall health to be excellent. In fact, she tells you
that she has not seen a physician since her hysterectomy for fibroids 20 years ago. Her only medication is
occasional acetaminophen or ibuprofen for knee pain. Physical examination reveals a blood pressure of
160/90 mm Hg, an irregularly irregular heartbeat with a rate of 90/min, an otherwise normal cardiovascular
examination, and a completely normal neurologic examination. Her EKG confirms atrial fibrillation with
evidence for left ventricular hypertrophy but no Q waves or ST elevation. You are able to obtain an
emergent CT scan of the brain without contrast, which is negative. Which one of the following is the most
appropriate immediate management?
A. Lowering blood pressure
B. Antiplatelet therapy with clopidogrel (Plavix)
C. Anticoagulation with warfarin (Coumadin)
D. Electrical or chemical cardioversion
E. An MRI scan of the brain with contrast
The patient described presents with a history most consistent with a recent, resolved transient ischemic
attack (TIA). This was most likely due to an embolus related to her atrial fibrillation. Her risk for a
recurrent neurologic event (TIA or stroke) is high. 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.

Which one of the following is most likely to induce withdrawal symptoms if discontinued abruptly?
A. Venlafaxine (Effexor)
B. Divalproex (Depakote)
C. Fluoxetine (Prozac)
D. Olanzapine (Zyprexa)
E. Donepezil (Aricept)
The abrupt discontinuation of venlafaxine, or a reduction in dosage, is associated with withdrawal
symptoms much more severe than those seen with other SSRIs such as fluoxetine. Although more
pronounced with higher dosages and prolonged administration, they also occur at lower dosages. 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.
Which one of the following intravenous agents given to the mother during labor is the drug of choice for
prophylaxis of neonatal group B streptococcal disease?
A. Clindamycin (Cleocin)
B. Erythromycin
C. Gentamicin (Garamycin)
D. Metronidazole (Flagyl)
E. Penicillin G
Intravenous penicillin G is the drug of choice for prophylaxis of neonatal group B streptococcal disease,
although shortages during 1999 required the interim use of broader-spectrum antibiotics. Group B
streptococci have remained sensitive to penicillin, but they may be resistant to clindamycin and
erythromycin, the drugs recommended for women allergic to penicillin.
Children under 1 year of age should not be given honey because of possible contamination with which one
of the following?
A. Staphylococcus aureus
B. Clostridium botulinum
C. Clostridium difficile
D. Escherichia coli
E. Hepatitis A
The most common cause of infant botulism is ingestion of Clostridium botulinum spores in honey.
The most common hospital errors associated with preventable adverse drug effects are in the stage of:
A. Ordering
B. Transcription
C. Dispensing
D. Administration
Adverse drug events are common and are often preventable. Studies of the incidence of preventable
adverse drug events reveal that 49% of errors occurred in the ordering stage, 11% in the transcription stage,
14% in the dispensing stage, and 26% in the administration stage. Errors are much more likely to be
intercepted if they occur in an early stage. Wrong dose was the most common ordering error encountered,
with other errors including wrong choice of medicine, known allergy, wrong frequency, and drug-drug

interaction. The economic implications of this study could potentially be important if prevention procedures
are adhered to.
The most appropriate initial pharmacologic treatment of panic disorder is:
A. An SSRI
B. A tricyclic antidepressant
C. Valproic acid (Depakene)
D. Lithium
An SSRI is the treatment of choice for patients who have never had pharmacotherapy for panic disorder.
A 56-year-old female presents for a health maintenance examination. She has a history of a total
hysterectomy for benign disease 4 years ago. You are able to document that the hysterectomy pathology
was benign and that she has had normal Papanicolaou (Pap) tests for 10 years. The patient asks about
regular Pap smears. Which one of the following would be the most appropriate recommendation?
A. Routine Pap smears should be continued until age 70
B. A Pap smear should be done every 3 years
C. A Pap smear is not indicated
D. A Pap smear should be done yearly for 3 years and only if indicated thereafter
After a hysterectomy for documented benign disease, cytologic screening may be discontinued.
Papanicolaou (Pap) smears in this population are low yield and may cause unnecessary testing due to falsepositives. 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.
You are evaluating a 5-month-old with fever, tachypnea, and mild respiratory distress in the emergency
department. You hear mild basilar rales. The child does not appear toxic. Which one of the following tests
would be the most appropriate as an initial study?
A. A chest radiograph
B. A CBC
C. A C-reactive protein level
D. Oxygen saturation by pulse oximetry
Pulse oximetry should be obtained on all pediatric patients with significant tachypnea, pallor, or respiratory
distress. It has been found that CBCs, C-reactive protein levels, and erythrocyte sedimentation rates are not
effective in differentiating between viral and bacterial pneumonia. Chest radiographs 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.
A 72-year-old female has stable but moderately severe COPD requiring 2 L of continuous oxygen. She
plans to attend the college graduation of her first grandchild, and wants to fly to avoid a 12-hour car ride.
Her PaO2 on room air is 55 mm Hg. According to the Federal Air Regulations, she MUST:
A. Bring her own oxygen from home
B. Bring a medical certificate from you certifying that she is cleared to fly without oxygen
C. Arrange through the airline for oxygen to be available on board and in the airports
D. Find a form of transportation other than air travel
E. Undergo preflight testing, including pulmonary function testing and high-altitude simulation testing,
before she can be cleared to fly

According to Federal Air Regulations, passengers who require oxygen for stable medical conditions cannot
bring their own supplies and equipment and must arrange through the airline, 2448 hours in advance, for
oxygen to be made available on board, at layovers, and at final destinations. Anyone with a preflight sea
level PaO2 below 6870 mm Hg is advised NOT to fly unless supplemental oxygen can be arranged. This
is because commercial aircraft maintain a relative cabin altitude between 5000 and 8000 feet during routine
flight. This altitude corresponds to a decreased barometric pressure, which causes a corresponding drop in
the normal baseline PaO2. In normal healthy individuals, this corresponds to a drop from a PaO2 of 98 mm
Hg to a PaO2 of 6070 mm Hg. On the oxyhemoglobin dissociation curve, a PaO2 of 60 mm Hg is the
point at which there is a steep gradient of the pressure/saturation relationship. This patient has a baseline
PaO2 of only 55 mm Hg, so she certainly could not sustain a flight without oxygen. While it may be
prudent to have a given patient complete some respiratory testing prior to flying, no specific preflight
testing is required.
A 58-year-old male who works with heavy machinery at a local factory presents to your office for
evaluation of hearing loss of several years progression. He notes that the loss is mainly in the left ear and
he also has mild tinnitus. He has had no trauma to his head, and he has no history of ear infections.
Examination of the ears reveals normal tympanic membranes and a neurologic examination is negative.
When a tuning fork is placed in the center of his forehead, he says the sound is much louder on the right
side (Weber test). Comparing sound in front of the ear to the sound when the tuning fork is placed on the
mastoid (the Rinne test) reveals that air conduction is better than bone conduction in the left ear. Which one
of the following is true regarding further evaluation and management?
A. No treatment or further diagnostic studies are indicated
B. A hearing aid plus better hearing protection is all that is needed
C. Carotid ultrasonography should be ordered
D. A tympanogram is indicated
E. Audiometry is the best initial screening test
Acoustic neuroma symptoms are due to cranial nerve involvement and progression of tumor size. Hearing
loss is present 95% of the time and tinnitus is very common. The loss is usually chronic (over 3 years) and
as many as one-third of patients are unaware it has occurred. 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. The diagnosis of acoustic
neuroma is based on asymmetric sensorineural hearing loss or another cranial nerve deficit, with
confirmation based on MRI with gadolinium contrast or a CT scan. The best initial screening laboratory
test is audiometry, as only 5% of patients with acoustic neuroma will have a normal test. 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.
A 57-year-old white male with coronary artery disease suffered a cardiac arrest while jogging 10 days ago.
He was resuscitated after 45 minutes but has remained unresponsive and on a ventilator since then. Which
one of the following is required to diagnose brain death in this patient?
A. Hypothermia
B. Continuous mechanical ventilation
C. The absence of spontaneous body movements
D. Electroencephalographic confirmation
E. Normal corneal reflexes
An electroencephalogram (EEG) is one of the most well-validated tests for confirming brain death. The
presence of hypothermia will confound any attempt to determine brain death; the patient must be warm to
ensure the diagnosis. The mechanical ventilator may give false readings and must be discontinued to get a
real picture of the patients ability to breathe. Spontaneous body movements can occur even hours after
actual brain death. Corneal reflexes never occur after death.

A 28-year-old gravida 2 para 1 at 32 weeks' gestation presents with severe itching. She denies fever or
vomiting. Her physical examination is remarkable for jaundice, but is otherwise benign. Laboratory studies
reveal a normal CBC, normal platelets, normal glucose and serum creatinine levels, normal transaminase
levels, and a bilirubin level of 4.0 mg/dL (N 0.01.0). Which one of the following is the most likely
diagnosis?
A. Intrahepatic cholestasis of pregnancy
B. Acute viral hepatitis
C. Acute fatty liver of pregnancy
D. Pruritic urticarial papules and plaques of pregnancy (PUPPP)
E. Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome
Intrahepatic cholestasis of pregnancy is rare, occurring in 0.01% of pregnancies. It usually presents in the
third trimester. 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 <5 mg/dL), and occasional elevations in cholesterol and triglyceride levels. It is important
to recognize and diagnose this entity, as it is associated with prematurity, fetal distress, and increased
perinatal mortality. 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 (50%100% of cases). It presents with nausea and vomiting, anorexia, jaundice, abdominal
pain, headache, and neurologic abnormalities. Transaminase levels are moderately elevated, PT and 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.
An 80-year-old male presents with the chief complaint of a bone spur, describing mid-heel pain that
worsens as the day progresses. The pain is not relieved with ibuprofen. Examination reveals tenderness in
the central aspect of the heel and a radiograph of the foot is unremarkable. The most likely diagnosis is:
A. Multiple myeloma
B. Fat-pad atrophy
C. Tarsal tunnel syndrome
D. S1 radiculopathy
E. Plantar fasciitis
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.
An 84-year-old African-American female is brought to your office by her daughter, who is concerned that
the mother has memory problems and is neglecting to pay her monthly bills. The mother also is forgetting
appointments and asks the same questions repeatedly. This problem has been steadily worsening over the
last 12 years. The patient has very little insight into her problems, scores 24 out of a possible 30 points on
the Mini-Mental State Examination, and has difficulty with short-term recall and visuospatial tasks. Her
physical examination and a thorough laboratory workup are normal. A CT scan of the brain reveals diffuse
atrophy. Which one of the following is the most likely etiology for this patients memory problem?
A. Alzheimers disease
B. Dementia resulting from depression
C. Lewy body dementia

D. Multi-infarct dementia
E. Normal aging
The patient shows classic symptoms of early Alzheimers disease, with difficulties in at least two cognitive
domains that are severe enough to influence daily living. Normal aging changes can decrease ones 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.
In a 27-year-old white female with irregular menstrual cycles and infertility, which one of the following
would be more indicative of Cushings syndrome rather than the more common polycystic ovarian
syndrome?
A. Easy bruising
B. Acne
C. Hirsutism
D. Androgenic alopecia
E. Acanthosis nigricans
Easy bruising, moon facies, buffalo hump, abdominal striae, hypertension, and proximal myopathy suggest
Cushings 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.
A 43-year-old white male cut his foot when he stepped on a walnut shell while walking barefoot in his back
yard. On examination the laceration is deep, with ragged edges. Your records indicate that the patient has
completed a full primary immunization series with tetanus toxoid. His last tetanus toxoid injection was 7
years ago. This patient should be given:
A. Tetanus immune globulin (TIG) and tetanus toxoid
B. Combined tetanus and diphtheria toxoid (Td)
C. TIG and Td
D. No immunizations at this time
This patient presents with a contaminated wound and a completed primary immunization series for tetanus.
According to Centers for Disease Control guidelines, he should receive tetanus prophylaxis, because it has
been more than 5 years since his previous tetanus immunization. Combined tetanus and diphtheria toxoid is
preferred, as it also enhances diphtheria protection. Half-doses are not recommended.
Total parenteral nutrition is most appropriate for patients:
A. With poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding
B. Who cannot swallow because of an esophageal motility problem
C. Who refuse to eat
D. In whom maintenance nutrition is desired for a short period following recovery from surgery
Total parenteral nutrition (TPN) is indicated for patients with poorly functioning gastrointestinal tracts who
cannot tolerate other means of nutritional support and for 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.

A new drug treatment is shown to reduce the incidence of a complication of a disease by 50%. If the usual
incidence of this complication were 1% per year, how many patients with this disease would have to be
treated with this medication for 1 year to prevent one occurrence of this complication?
A. 20
B. 50
C. 100
D. 200
E. 500
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. In 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).
A 23-year-old sexually active female presents to your office with a 2-week history of vaginal discharge and
mild coital discomfort. On physical examination, you note the presence of a mucopurulent vaginal
discharge and cervical friability. She is afebrile and there are no other positive physical findings. No
trichomonads or yeast is seen on vaginal preparations. Material for Chlamydia trachomatis~04-specific
DNA testing is submitted and results will be available in 2 days. Which one of the following is true
regarding appropriate management?
A. A 7-day course of doxycycline is superior to a 1-g dose of azithromycin (Zithromax)
B. 2-g dose of metronidazole (Flagyl) given now will clear her discharge
C. No treatment is indicated until laboratory results are known
D. The patient should be instructed to refrain from sexual intercourse until 7 days after initiating therapy
Patients with suspected genital chlamydial infections and their partners should be instructed to refrain from
sexual intercourse until therapy is completed (specifically, until 7 days after a single-dose regimen or until
the completion of a 7-day regimen). Suspicion of chlamydial infection warrants treatment, with or without
positive laboratory findings. Metronidazole is not useful for treatment and there is no difference in random
clinical trials with regard to the efficacy of a 7-day course of doxycycline compared to that of a single 1-g
dose of azithromycin.
A 14-year-old male is brought to your office by his mother to establish care. The patient has been diagnosed
with asthma, but has not been on any medications for the past year. When questioned, he reports that his
asthmatic symptoms occur daily and more than one night per week. On examination, he is found to have a
peak expiratory flow of 75%. Based on these findings, the most accurate classification of this patients
asthma is:
A. Mild intermittent
B. Mild persistent
C. Moderate persistent
D. Severe persistent
The National Asthma Education and Prevention Program (NAEPP) classifies asthma into four categories.
Mild intermittent asthma is characterized by 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 asthma is characterized
by 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 asthma is
characterized by daytime symptoms daily and nighttime symptoms more than 1 night per week. PEF or
FEV1 is 60%80% of predicted. Severe persistent asthma is characterized by continuous daytime
symptoms and frequent nighttime symptoms. PEF or FEV1 is 60% or less of predicted.

A 75-year-old African-American female is diagnosed with macular degeneration. She is being treated for
type 2 diabetes mellitus, hypothyroidism, hypertension, hypercholesterolemia, and gout. Which one of her
conditions is associated with macular degeneration?
A. Type 2 diabetes mellitus
B. Hypothyroidism
C. Hypertension
D. Gout
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.
Which one of the following has been shown to reduce the croup score in children and lead to shorter
hospital stays?
A. Dexamethasone (Decadron), 0.6 mg/kg in a single oral dose
B. Amoxicillin, 45 mg/kg/day divided into two doses, for 10 days
C. Azithromycin (Zithromax), 10 mg/kg the first day, then 5 mg/kg daily for 4 days
D. Albuterol (Ventolin), 0.63 mg by aerosol every 4 hours
E. Ceftriaxone (Rocephin), 50 mg/kg intramuscularly in a single dose
Croup is a viral illness and is not treated with antibiotics. Racemic epinephrine may be used acutely, but
rebound can occur. Albuterol has not been shown to be helpful. 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.
Which one of the following Papanicolaou (Pap) test results is most likely to indicate a cancerous lesion?
A. Atypical squamous cells of undetermined significance (ASC-US)
B. Atypical squamous cells cannot exclude high-grade intraepithelial lesion (ASC-H)
C. Atypical glandular cells not otherwise specified (AGC-NOS)
D. Low-grade squamous intraepithelial lesion (LSIL)
E. High-grade squamous intraepithelial lesion (HSIL)
Papanicolaou (Pap) tests are intended to screen for cervical cancer, but most abnormal Pap tests are
associated with precancerous lesions or with no abnormality. The category of atypical glandular cells not
otherwise specified (AGC-NOS) has a benign sound to it, although it is associated with a 17% rate of
cancer (8% carcinoma in situ and 9% invasive carcinoma). High-grade squamous intraepithelial lesion
(HSIL), which would seem worse intuitively, has only a 3% associated cancer rate. AGC-NOS is associated
with higher rates of cancer than the other choices listed.
Which one of the following is the preferred treatment for patients with obsessive-compulsive disorder?
A. Lithium carbonate
B. Alprazolam (Xanax)
C. Fluoxetine (Prozac)
D. Amitriptyline (Elavil)
E. Valproic acid (Depakene)
Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive behaviors that
impair everyday functioning. SSRIs such as fluoxetine and fluvoxamine are FDA-approved and considered
first-line agents in the treatment of this condition. None of the other agents listed is recommended for the
treatment of obsessive-compulsive disorder. Lithium is useful in bipolar disease and depression, alprazolam

is used in generalized anxiety and panic disorder, and amitriptyline is used in depression and chronic pain
syndromes. Valproic acid is primarily an anti-epileptic agent.
The results of a given study are reported as achieving significance at a p-value of <0.05 (the 5% level).
True statements about this finding include which one of the following?
A. There is a 5% likelihood of the results having occurred by chance alone
B. If the study were replicated 100 times, 95 studies would repeat this finding and 5 would not
C. The confidence interval is 0%10%
D. The null hypothesis has a 5% chance of being true
E. The B or type II error is < 5%
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 falsenegative rate, or 1 - specificity, and cannot be calculated from the information given.
A 5-year-old male is scheduled for elective hernia repair at 11:00 a.m. Which one of the following would be
the most appropriate recommendation?
A. No solid food for 8 hours prior to surgery and clear liquids until 2 hours prior to surgery
B. No solid food 4 hours prior to surgery and clear liquids until 2 hours prior to surgery
C. No solid food after midnight and nothing by mouth 8 hours prior to surgery
D. Nothing by mouth 2 hours prior to surgery
E. Nothing by mouth 8 hours prior to surgery
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.
An elderly couple is having trouble paying for the considerable number of medications they require. They
ask you about the safety of obtaining drugs from Canada. Which one of the following is true concerning
Canadian drugs?
A. Few of the drugs available from Canada have been approved by the Food and Drug Administration
(FDA)
B. Most of the drugs available from Canada come from the same manufacturers as in the U.S.
C. The approval process for a drug by Health Canada is shorter than the FDAs process
D. Many drugs discontinued for safety reasons by the FDA are still available in Canada
E. Drugs obtained through websites advertising Canadian drugs are well regulated
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.
A 6-year-old white male visits your office with chief complaints of a recent onset of fever, bilateral knee
and ankle pain, colicky abdominal pain, and rash. On examination, his temperature is 38.3 degrees C (101.0
degrees F), and there is a prominent palpable reddish-brown rash on the buttocks and thighs. There is pain

on motion of his knees and ankles, and mild diffuse abdominal tenderness. The stool is positive for occult
blood. Laboratory Findings: Hgb 11.0 g/dL (N 11.5-13.5), Hct 33% (N 34-40), WBCs 14,500/mm3 (N
5500-15,000); 85% segs, 15% lymphs, Platelets 345,000/mm3 (N 150,000-400,000), PT 12 sec (N 11-15).
Which one of the following is the most likely diagnosis?
A. Systemic onset juvenile rheumatoid arthritis
B. Rocky Mountain spotted fever
C. Henoch-Schonlein purpura
D. Disseminated anthrax
E. Acute iron ingestion
Henoch-Schonlein purpura typically follows an upper respiratory tract infection, and presents with lowgrade fever, fatigue, arthralgia, and colicky abdominal pain. The hallmark of the disease is the 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 gastrointestinal 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 erythrocyte sedimentation rate. Treatment is
typically symptomatic and supportive, although corticosteroids are indicated in the rare patient with lifethreatening gastrointestinal or central nervous system 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.
A 78-year-old male comes to your office with a 3-day history of pain in the right side of his chest. The pain
is described as burning and intense. Two days ago he noted a rash at that site. Examination reveals groups
of vesicles on an erythematous base in a T-5 dermatome distribution on the right. Which one of the
following would be the most appropriate treatment to minimize the chance of post-herpetic neuralgia?
A. Famciclovir (Famvir)
B. Prednisone
C. Capsaicin (Zostrix)
D. Carbamazepine (Tegretol)
The key indicator of postherpetic neuralgia is persistent pain 36 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 (1025 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.
A 62-year-old female with numbness in the lower extremities and macrocytosis has a normal serum folate
level and a serum B12 level of 200 pg/mL (N 150800). Which one of the following laboratory findings
would confirm the diagnosis of B12 deficiency?
A. Elevated angiotensin converting enzyme
B. Elevated methylmalonic acid
C. Elevated free erythrocyte protoporphyrin
D. Low haptoglobin
E. Low homocysteine
This patient has several clinical features of vitamin B12 deficiency. 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 150400 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.
At a routine 6-week postpartum visit, a tearful, despondent-appearing patient reports depressed mood, poor
appetite, decreased sexual drive, fatigue, and loss of interest in her usual activities. She denies suicidal
ideation. Which one of the following should you do now?
A. Reassure the patient that her postpartum blues should resolve in the next few weeks
B. Prescribe a 10-day per month regimen of medroxyprogesterone (Provera)
C. Prescribe daily sertraline (Zoloft)
D. Prescribe no medications and see the patient back in the office in 2 weeks
E. Hospitalize the patient
Postpartum depression is a highly prevalent disorder with consequences that can be profound. The
postpartum blues affect up to 85% of women and typically resolve by the tenth postpartum day, whereas
the onset of postpartum depression may not occur until 6 months following delivery. Evidence regarding
the benefit of hormonal therapy for patients with postpartum depression is lacking. Generally, postpartum
depression can be managed on an outpatient basis unless the illness is severe. SSRIs are ideal first-line
agents and should be used for similar periods of time and in dosages comparable to those prescribed to
patients who suffer from nonpuerperal illness.
A 47-year-old male presents with a history of fatigue, arthralgias, nonspecific abdominal pain, and erectile
dysfunction. The initial laboratory workup reveals a normal CBC and basic metabolic profile, but slightly
elevated transaminases. Which one of the following is the most appropriate initial test to evaluate for
hereditary hemochromatosis?
A. Serum ferritin testing
B. Serum transferrin saturation
C. Serum ceruloplasmin testing
D. Serum alpha-fetoprotein testing
E. HFE gene testing
Hereditary hemochromatosis is the most common single-gene disorder in white Americans. Approximately
1 in 250300 Caucasians are homozygous for the mutation, and 1 in 10 is a carrier. The classic description
for this disorder has been the triad of cutaneous hyperpigmentation, diabetes mellitus, and cirrhosis;
however, this represents very late manifestations. If treatment is initiated early, life expectancy is normal
and many of the irreversible manifestations of the disease can be avoided. Unfortunately, while it is
estimated that the average primary care doctor sees one patient every 2 weeks with the disorder, most will
actually diagnose only a few cases in their careers. The disease results from increased intestinal iron
absorption with subsequent deposition of iron in organs such as the heart, liver, skin, pituitary gland, and
genitalia. The differential diagnosis should include iron overload from other sources such as chronic
anemia, prolonged iron supplementation, multiple transfusions, and chronic liver disease. Alcohol use and
hepatitis C may accelerate the expression of the disease. Early symptomatology commonly includes
arthralgias, fatigue, and impotence, but approximately 75% of patients are asymptomatic early on. The
serum transferrin saturation is the best initial screening test. It is calculated by dividing the serum iron
concentration by the total iron-binding capacity and multiplying by 100. The normal range is 14%50%,
with the range for hereditary hemochromatosis being 51%100%. However, it may be normal early in the
course of the disease and can be elevated in other states such as alcoholic liver disease and viral hepatitis.
While serum ferritin is a sensitive assessment of iron overload, it is an acute phase reactant and is often
elevated in inflammatory and infectious conditions. It is not the recommended screening test for hereditary
hemochromatosis. Serum ceruloplasmin is elevated in neoplastic disorders, inflammatory states, systemic
lupus erythematosus, primary biliary cirrhosis, and rheumatoid arthritis, and low in Wilsons disease,
advanced liver disease, total parenteral nutrition, malabsorption, and nephrotic syndrome. It is not useful in
the evaluation of hemochromatosis. Serum alpha-fetoprotein is useful in screening for hepatocellular

carcinoma in patients with cirrhosis, but is not a screening test for hemochromatosis. Genetic testing for
this disorder is available and the gene, HFE, is located on the short arm of chromosome 6. However, this
would not be appropriate as an initial screening test.
A 2-year-old white female is brought to your office by her parents, who are concerned about the childs
flat feet. On evaluation, the childs feet are flat with weight-bearing, but with toe standing and with
sitting the arch appears. You would:
A. Reassure the parents
B. Recommend orthotics
C. Recommend surgery
D. Recommend casting
E. Recommend foot-stretching exercises
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.
A 5-year-old African-American male presents with behavior problems noted in the first 3 months of
kindergarten. The mother explains that the child does not pay attention and often naps in class. He averages
10 hours of sleep nightly and is heard snoring frequently. The mother has a history of attention-deficit
disorder and takes atomoxetine (Strattera). The boys examination is within normal limits except for his
being in the 25th percentile for weight and having 3+ tonsillar enlargement. The most reasonable plan at
this point would include which one of the following?
A. An electroencephalogram
B. Polysomnography
C. Atomoxetine
D. Methylphenidate (Ritalin)
Obstructive sleep apnea is increasingly recognized in children. The peak incidence is in the preschool-age
range of 25 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.
Which one of the following statements regarding nutrition during pregnancy is correct?
A. Maternal age is not related to nutritional status
B. In an uncomplicated pregnancy, iron supplementation is most important during the first trimester
C. In nonobese women, lack of weight gain is associated with an increased risk of fetal growth retardation
D. Vitamin B12 is the only vitamin supplementation required with the usual diet during pregnancy
E. Adding extra salt to foods must be avoided
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. In women of average or low weight, lack of weight gain throughout pregnancy is often
associated with fetal growth retardation.
Metformin (Glucophage), which is normally used in the management of diabetes mellitus, has also been
shown to have a beneficial effect in:

A. Osteoporosis
B. Hyperthyroidism
C. Polycystic ovary syndrome
D. Right ventricular hypertrophy
E. Morbid truncal obesity
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.
You are considering recommending surgical treatment for obesity in selected patients. All other attempts to
control weight have failed in these patients, including diet education, medication, exercise, and behavior
modification. Each of these individuals is a well-informed and motivated patient with acceptable operative
risks and is able to participate in treatment and long-term follow-up. They strongly desire substantial
weight loss because their obesity impairs the quality of their lives, and they have asked about surgical
options. Which one of these patients would meet the criteria for surgical treatment of obesity?
A. A 44-year-old with a BMI of 34 and degenerative joint disease of the knees that significantly limits his
ability to walk
B. A 45-year-old with a BMI of 36 and controlled diabetes mellitus
C. A 48-year-old with a BMI of 42 and no other health problems
D. A 52-year-old with a BMI of 29 and sleep apnea
E. A 55-year-old with a BMI of 29 and uncontrolled diabetes mellitus
The 1991 National Institutes of Health Consensus Development Panel recommended that 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.
You are considering how useful a new treatment might be in preventing stroke. A well designed study is
reported with 200 patients in the treated group and 200 patients in the untreated group. The study finds a 5year risk of stroke of 3% in the treated group versus 5% in the untreated group. Assuming this study is valid
and applicable to your patient population, how many patients would you have to treat for 5 years to prevent
one stroke (number needed to treat, or NNT)?
A. 400
B. 200
C. 100
D. 50
E. 25
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 patients 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?

Which one of the following agents used for tocolysis has the unique adverse effect of respiratory
depression?
A. Magnesium sulfate
B. Ritodrine (Yutopar)
C. Terbutaline (Brethine, Bricanyl)
D. Indomethacin (Indocin)
E. Nifedipine (Adalat, Procardia)
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.
Patients often use echinacea for the prevention and treatment of:
A. Memory loss
B. Upper respiratory symptoms
C. Gastrointestinal illnesses
D. Depression
E. Fatigue
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.
Three members of the same family present with a high fever and cough that began abruptly yesterday. All
three report having fevers over 40 C (104 F), painful coughs, moderate sore throats, and prostration. They
have loss of appetite, but no vomiting or diarrhea. Two other family members have similar symptoms. On
examination the patients appear ill and flushed. There is no cervical adenopathy, no visible pharyngeal
inflammation, and no significant findings on examination of the chest. Which one of the following is the
most likely diagnosis?
A. Mycoplasma pneumonia
B. Influenza-like illness
C. Bacterial bronchitis
D. Upper respiratory infection
E. Legionnaires disease
Influenza has a very abrupt onset, and a fever with a nonproductive cough is almost always present.
Unconfirmed cases are referred to as influenza-like illness (ILI) or suspected influenza. Patients with
confirmed cases 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 upper respiratory infections, and is not contagious. While
the phrase cold and flu is often used, upper respiratory infections 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.
A 73-year-old Hispanic male presents to the emergency department with a 3-day history of abdominal and
right flank pain. He is lethargic and pale, and his skin is clammy. His blood pressure is 86/30 mm Hg, pulse
106 beats/min, and temperature 38.6 degrees C (101.5 degrees F). His chest is clear and no murmurs are
heard. He responds to painful stimuli. The abdomen is soft with no guarding or rebound. Immediate fluid
resuscitation is begun and after an hour he has received 2 L of normal saline. In that hour he has had a urine
output of only 30 cc. A chest film and an EKG are normal Laboratory Findings WBCs15,500/mm3 (N

4300-10,800) Platelets70,000/mm3 (N 150,000-300,000) Base deficit13 mEq/L Serum pH7.21 (N 7.357.45) Urinalysispacked WBCs, 3+ bacteria Which one of the following is most likely to enhance survival in
this patient?
A. Low-dose dopamine
B. Recombinant human activated protein C (Xigris)
C. Antithrombin
D. Bicarbonate
E. Erythropoietin
This clinical scenario should lead one to think of septic shock. Recent comprehensive investigations and
reviews have demonstrated that the use of recombinant activated protein C in patients with severe sepsis
and a high risk for death does improve survival. Low-dose dopamine should not be used for maintenance or
improvement of renal function. Antithrombin administration is not recommended for the treatment of
severe sepsis and septic shock. As a specific treatment for anemia associated with severe sepsis,
erythropoietin has not been shown to be of benefit. There is no evidence to support the use of bicarbonate
in the treatment of hypoperfusion-induced acidemia associated with sepsis.
The presence of nonthrombocytopenic palpable purpura, colicky abdominal pain, and arthritis is most
consistent with which one of the following?
A. Kawasaki disease
B. Takayasu arteritis
C. Wegener granulomatosis
D. Polyarteritis nodosa
E. Henoch-Schonlein purpura
The most common pediatric vasculitis is Henoch-Schonlein purpura. It is an 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, gastrointestinal symptoms such
as postprandial abdominal pain, and cardiac lesions.
A 75-year-old white female presents with hyponatremia, with a serum level of 118 mEq/L, a urine
osmolality >100 mOsm/kg H2O, and a serum osmolality of 242 mOsm/kg H2O. She complains of some
fatigue, but is alert and oriented. Her blood pressure is 136/82 mm Hg. She has normal thyroid, adrenal,
cardiac, hepatic, and renal function. You admit her to the hospital for treatment and observation. Which one
of the following is the most appropriate initial treatment?
A. Administration of 3% normal saline
B. Administration of normal saline
C. Free water restriction
D. Demeclocycline (Declomycin)
This patient probably has the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
SIADH can be caused by CNS tumors, various infections such as meningitis, and pneumonia. Several
drugs can cause this condition, including 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.
You see a 16-year-old white female for a preparticipation evaluation for volleyball. She is 183 cm (72 in)
tall, and her arm span is greater than her height. She wears contacts for myopia. Which one of the following
should be performed at this time?
A. An EKG
B. Echocardiography
C. A stress test
D. A chest radiograph
E. Coronary MRI angiography
Marfan's 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 Marfans disease should be screened by echocardiography 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
echocardiographic evidence of aortic abnormalities should be placed on beta-blockers and monitored with
echocardiography every 6 months.
A 14-year-old male presents to your office with a high fever that began suddenly. He has a diffuse petechial
rash and some nuchal rigidity on examination. A lumbar puncture is performed, and gram-negative
diplococci are found. You admit him to the hospital. Which one of the following would be most appropriate
at this time?
A. Immediate chemoprophylaxis for his entire school
B. Immediate vaccination of all contacts
C. Chemoprophylaxis for family members and very close contacts only
D. Isolation of all family members for 1 week
E. No preventive measures until culture results are available
Meningococcal disease remains a leading cause of sepsis and meningitis. Those in close contact with
patients who have presumptive meningococcal disease are at heightened risk. While secondary cases have
been reported, they are rare because of prompt chemoprophylaxis of household members and anyone
directly exposed to the index patients oral secretions. There is no need to isolate family members. The risk
for secondary disease among closest contacts is highest during the first few days after the onset of illness in
the index patient, mandating immediate chemoprophylaxis of those exposed. The delay in immunity post
vaccination makes it necessary to use other preventive measures instead.
False-positive urine screens for drug abuse can occur as a result of:
A. passive inhalation of crack cocaine
B. passive inhalation of marijuana smoke
C. eating poppy seed muffins
D. consuming products containing hemp
E. use of black cohosh
Eating as little as one poppy seed muffin can produce amounts of morphine and codeine detectable by
immunoassay, as well as by gas chromatography and mass spectrometry. 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. 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.
Having all patients over age 50 take low-dose (81 mg) aspirin daily would result in:
A. a decrease in cardiovascular mortality in men and women
B. a decrease in hemorrhagic stroke in women
C. a decrease in myocardial infarction in men
D. a decrease in strokes in men
E. no increase in major bleeding episodes
A meta-analysis of six well controlled clinical trials of aspirin prophylaxis showed a 32% decrease in
myocardial infarctions in men taking aspirin. There was no decrease in cardiovascular mortality or allcause mortality in either sex, and there was a trend toward increased risk of stroke, primarily hemorrhagic
stroke. There was a 24% decrease in ischemic stroke in women, however. 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.
A 7-year-old African-American male is brought to your office with a 1-day history of purulent, crusted
eyelashes in the morning, and red eye. There is no history of visual change, foreign body, or injury. The
child is otherwise in good health and has normal developmental milestones. No fever or respiratory distress
is noted. A clinical diagnosis of bacterial conjunctivitis is made. The mother is anxious to keep the child in
school. Which one of the following would be the most appropriate time for the child to return to school?
A. Once treatment is started
B. When there is no crusting or drainage in the morning
C. After 1 week of treatment
D. When the absence of fever for 24 hours is documented
E. When there is resolution of conjunctival erythema
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.
A 58-year-old white male has a negative screening colonoscopy. He has no symptoms and no family history
of colon carcinoma. His next screening colonoscopy should be scheduled in:
A. 1 year
B. 3 years
C. 5 years
D. 10 years
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.