Pediatrics
An 8-year-old male is brought to your office because of acute lower abdominal pain. He is
not constipated and has never had abdominal surgery. You suspect acute appendicitis.
Which one of the following would be most appropriate at this point?
A) Plain radiography
B) Ultrasonography
C) CT without contrast
D) CT with contrast
E) MRI
ANSWER: B
Ultrasonography is recommended as the first imaging modality to evaluate acute abdominal pain in
children. It avoids radiation exposure and is useful for detecting many causes of abdominal pain, including
appendicitis. After ultrasonography, CT or MRI can be used if necessary to diagnose appendicitis.
Abdominal radiography is helpful in patients with constipation, possible bowel obstruction, or a history
of previous abdominal surgery.
The American Academy of Pediatrics Choosing Wisely recommendation on the evaluation of abdominal
pain states that CT is not always necessary. The American College of Surgeons Choosing Wisely
recommendation on the evaluation of suspected appendicitis in children says that CT should be avoided
until after ultrasonography has been considered as an option.
A 25-year-old female is concerned about contracting human papillomavirus (HPV) and
cervical cancer because she has a new sexual partner who was recently treated for genital
warts. She has not received any medical care in over 5 years. She reports a lifetime total of
four sexual partners and denies any chronic medical problems, but is a smoker. Her maternal
grandmother died of cervical cancer. Her chart indicates that she completed the HPV
vaccination series. A physical examination is normal.
Which one of the following is the most appropriate screening test for this patient?
A) Colposcopy
B) HPV DNA typing
C) HPV antibodies
D) A Papanicolaou (Pap) test and HPV cotesting
E) A Pap test with reflex high-risk HPV testing
ANSWER: E
Women between the ages of 21 and 29 at average risk for cervical cancer should be screened with cytology
every 3 years (USPSTF A recommendation). Because of the high prevalence of HPV infection in this age
group and because there are no clear benefits to HPV testing, testing is not recommended (USPSTF grade
D). However, most clinicians will order reflex testing for high-risk HPV types if the Papanicolaou smear
shows atypical squamous cells of uncertain significance (ASCUS), based on a recommendation by the
American Society for Colposcopy and Cervical Pathology.
Women 30–65 years of age at average risk for cervical cancer may be screened with cytology with HPV
cotesting every 5 years or with cytology alone every 3 years (USPSTF grade A). HPV DNA typing and
colposcopy are not screening tests and are used for further evaluation of cytologic abnormalities. HPV
antibody results have no role in screening. Women with a history of HPV immunization should continue
to be screened according to usual guidelines.
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 dietary limitations
ANSWER: E
Patients with diverticulosis should increase dietary fiber intake or take fiber supplements to slow
progression of the diverticular disease. Avoiding nuts, corn, popcorn, and small seeds has not been shown
to prevent complications of diverticular disease. Limiting intake of dairy products, spicy foods, and wheat
flour would be appropriate for other gastrointestinal problems such as lactose intolerance, gastroesophageal
reflux disease (GERD), and celiac disease.
What are the current recommendations of the U.S. Preventive Services Task Force (USPSTF)
regarding screening for osteoporosis with bone mineral density testing?
A. only high risk women should be screened
B. there is strong evidence against screening
C. all post-menopausal women should be screened
D. all women over the age of 65 should be screened
E. evidence is insufficient to recommend for or against screening
ANSWER: D
The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis in
women 65 years of age and older and in younger women whose fracture risk is equal to or greater than that
of a 65-year-old white women who has no additional risk factors. All other answer options do not adhere
to these USPSTF standards—a postmenopausal person who is younger than 65 years of age can be at risk
and that answer could be potentially correct, but screening all women over 65 years of age is still the best answer available.
At a routine well child visit the mother of a 3-year-old male expresses concern that his toes
turn in, causing a clumsy gait when he walks. You diagnose internal tibial torsion, because
his feet point inward when his patellae face forward. The examination is otherwise normal.
Which one of the following is recommended at this time?
A) No intervention
B) Shoe modification with wedges to externally rotate the feet while walking
C) Night splinting with the feet externally rotated
D) Serial casting to gradually externally rotate the feet
E) Surgery to correct the deformity
ANSWER: A
Internal tibial torsion usually resolves spontaneously by age 5. Surgery may be considered in patients older
than 8 years of age who have a severe residual deformity, especially if it is symptomatic or cosmetically
unacceptable. Night splints, shoe modifications, other orthotics, casting, and braces are not recommended
for this condition.
At what time during pregnancy are group B streptococci cultures recommended?
A. 10-12 weeks
B. 18-20 weeks
C. 26-28 weeks
D. 35-37 weeks
E. at the onset of labor
ANSWER: D
The Centers for Disease Control and Prevention (CDC) recommend that vaginal and rectal group B
streptococci cultures be obtained in all women between 35 and 37 weeks’ gestation, and the American
College of Obstetricians and Gynecologists has endorsed this recommendation. Intrapartum antimicrobial
prophylaxis is given for those whose cultures are positive. Women with group B streptococci bacteriuria or
a previous infant with invasive disease are given empirical intrapartum prophylaxis. The correct answer is
the only option that fulfills these guidelines.
According to the Ottawa ankle rules, which of the following indicates the need for ankle radiographs?
A. patient is able to walk immediately after the injury
B. swelling is present in the ankle joint
C. tenderness is noted at the base of the first toe
D. tenderness is noted at the posterior aspect of the lateral malleolus
E. tenderness is noted distal to the lateral malleolus
ANSWER: D
According to the Ottawa ankle rules, ankle radiography is indicated only if a patient has pain in the
malleolar zone and either of the following findings:
bone tenderness at the distal posterior malleoli
inability to bear weight (4 steps) immediately after injury and in the emergency department or
physician’s office
Foot radiography is indicated only if a patient has pain in the midfoot zone and any of the following
findings:
bone tenderness at the head of the fifth metatarsal
bone tenderness at the navicular bone
inability to bear weight (4 steps) immediately after injury and in the emergency department or
physician’s office
Swelling is not a component of the Ottawa ankle rules. Pain limiting walking immediately and at early
medical assessment is. The first metatarsal is not mentioned in the ankle rules. Tenderness at the distal
malleoli is noted as an indication in Ottawa ankle rules; however, tenderness distal to a malleolus is not an
indication for radiography.
Acne appearing at which one of the following ages should prompt detailed endocrine
laboratory testing for possible underlying systemic disease?
A) 3 weeks
B) 7 months
C) 5 years
D) 9 years
E) 13 years
ANSWER: C
As many as 20% of newborns will be affected by neonatal acne, usually in the form of pustules confined
to the cheeks, chin, eyelids, and forehead. This is typically mild, self-limited, and best managed by
reassuring the parents. Acne can also appear in infants, typically males 6–12 months of age, and is also
usually self-limited and not associated with underlying endocrine pathology in the absence of any other
findings suggesting hormonal abnormalities such as clitoromegaly, breast or testicular development, pubic
hair growth, hirsutism, or a growth abnormality consistent with increased muscle development. Acne
appearing during mid-childhood is rare and, if present, warrants referral for extensive laboratory testing
to identify an underlying endocrine abnormality. Preadolescents and adolescents are very likely to develop
acne as a result of normal ovarian/testicular development. In the absence of other findings to suggest an
endocrine problem, developing an effective treatment regimen is most appropriate for these individuals.
14. A 40-year-old female has a Pap smear finding of atypical glandular cells. The most appropriate next
step is
A. loop electrosurgical excision procedure (LEEP)
B. perform a colposcopy and endocervical curettage
C. refer the patient to a gynecologic oncologist
D. repeat the Pap smear in six months
E. repeat the Pap smear in three months utilizing thin prep methodology
ANSWER: B
Atypical glandular cells are cells that have undetermined significance (AGUS) are glandular cells that have
nuclear atypia; they are abnormal but lack the features of cancer. Per recommendations, a patient needs
further evaluation following a finding of atypical glandular cells on Pap smear. The appropriate next step
in management depends on which of the 2 categories of atypical glandular cells is found. If there are atypical
endometrial cells found, then an endometrial biopsy is warranted. If there are any other type of glandular
cells found, then colposcopy to more closely examine the cervix and a possible biopsy is warranted. A loop
electrosurgical excision procedure (LEEP) is treatment for cervical dysplasia, which this patient has not yet
been diagnosed with. Repeating the Pap smear will only demonstrate the cytology of the abnormal cells; it
is important to understand the pathology of the cells and the only method of doing so is by colposcopy and
possible biopsy with endocervical curettage. A referral to a gynecologic oncologist would be premature.
The patient has not been diagnosed with cancer; she just needs additional preliminary screening with
colposcopy and endocervical curettage.
A 65-year-old male has severe liver cirrhosis from a combination of hepatitis C infection and
alcohol abuse. He previously underwent a transjugular intrahepatic portosystemic shunt
(TIPS) procedure.
While the TIPS procedure reduces the likelihood of most complications of cirrhosis, it may
increase the risk for which one of the following?
A) Anasarca
B) Ascites
C) Hepatic encephalopathy
D) Upper gastrointestinal bleeding from esophageal varices
E) Upper gastrointestinal bleeding from portal hypertensive gastropathy
ANSWER: C
The transjugular intrahepatic portosystemic shunt (TIPS) procedure, by shunting blood destined for the liver
into the systemic circulation, lowers pressure in the portal veins, thereby decreasing portal system
hypertension and making variceal bleeding and portal hypertensive gastropathy less likely. TIPS may
decrease the likelihood of variceal bleeding by as much as 90%. TIPS also reduces the pressure that leads
to ascites and lower extremity edema, or the massive edema of anasarca. The diversion of blood from the
liver circulation compromises the liver’s role in removing toxins, including the serum marker ammonia.
This may make patients more vulnerable to episodes of hepatic encephalopathy.
A 75-year-old male with a history of hypertension, TIA, and atrial fibrillation sees you for
follow-up. Ten days ago he was on vacation in another state when he developed chest pain.
He went to a local hospital where he was diagnosed with an ST-elevation myocardial
infarction (STEMI) and was taken immediately for cardiac catheterization. He had a
drug-eluting stent placed in his left anterior descending artery. He brings some discharge
paperwork with him, including a medication list, but has not yet seen a local cardiologist.
He is concerned that he is taking too many blood thinners. He feels well and does not have
any chest pain, shortness of breath, or excessive bleeding or bruising.
Prior to his STEMI the patient was taking lisinopril (Prinivil, Zestril), 10 mg daily; warfarin
(Coumadin), 2.5 mg daily; and metoprolol succinate (Toprol-XL), 25 mg daily. Upon
discharge he was instructed to continue all of those medications and to add clopidogrel
(Plavix), 75 mg daily, and aspirin, 81 mg daily.
The patient’s vital signs and physical examination are normal except for an irregularly
irregular rhythm on the cardiovascular examination. His INR is 2.5.
Which one of the following would be most appropriate at this time?
A) Continue the current regimen
B) Discontinue aspirin
C) Discontinue clopidogrel
D) Discontinue warfarin
E) Decrease warfarin with a goal INR of 1.5–2.0
ANSWER: A
Current guidelines recommend that patients with an ST-elevation myocardial infarction (STEMI) who also
have atrial fibrillation take dual antiplatelet therapy such as aspirin plus clopidogrel and a vitamin K
antagonist, with a goal INR of 2.0–3.0. If a patient was already taking a direct-acting oral anticoagulant
(DOAC) instead of warfarin for atrial fibrillation, the patient should continue with the DOAC in addition
to dual antiplatelet therapy. The duration of triple therapy should be as short as possible, and aspirin can
often be discontinued after 1–3 months. However, this patient’s STEMI occurred less than 2 weeks ago
and he should continue triple therapy.
When evaluating a patient with menorrhagia, which one of the following laboratory findings
would be most consistent with von Willebrand disease?
A) An isolated prolonged prothrombin time
B) An isolated prolonged partial thromboplastin time
C) A low serum iron level
D) A low platelet count
E) A low fibrinogen level
ANSWER: B
Von Willebrand disease (vWD) is a common coagulation disorder generally due to a hereditary reduction
in the quality or quantity of a protein complex required for platelet adhesion, known as von Willebrand
factor (vWF). The extent of deficiency varies greatly, resulting in vWD subtypes ranging from
asymptomatic to serious. A common problem associated with vWD is menorrhagia, and the diagnosis
should always be entertained in women who experience excessive menstrual blood loss. Although tests
measuring vWF are easily obtained, interpretation of the results can be challenging since vWF levels can
be affected by blood type, inflammation, infection, trauma, and emotional stress. Confirmation of vWD
often requires the expertise of a hematologist. Although the results for all laboratory tests listed can fall
within their reference ranges in a patient with vWD, the finding most suggestive of this diagnosis is an
isolated prolonged partial thromboplastin time.
A 16-year-old female is brought to your office by her mother, who is concerned that her
daughter has seemed tired lately. The patient denies any specific health concerns or recent
illnesses. She is taking an oral contraceptive and reports that her menstrual bleeding is light
in flow. Recent laboratory findings include a TSH level of 1.44 :U/mL (N 0.5–5.0), a
hematocrit level of 38% (N 36–46), a mean corpuscular volume of 71 :m3
(N 78–102), an
RBC count of 5.7 million/mm3
(N 4.10–5.10), and ovalocytes on a peripheral smear.
Which one of the following is most likely to explain this patient’s initial laboratory
abnormalities and lead to a diagnosis?
A) A vitamin B12 level
B) A ferritin level
C) A free T4 level
D) Hemoglobin electrophoresis
E) A fluorescent spot test
ANSWER: D
This presentation is consistent with alpha-thalassemia minor trait in a generally asymptomatic patient.
Hemoglobin electrophoresis will be abnormal, with HbA2 increased and HbA decreased. The free T4 level
is likely to be normal in a patient with a normal TSH level. A ferritin level is also likely to be normal given
the normal levels of hemoglobin and hematocrit. A fluorescent spot test is used to screen for G-6-PD
deficiency, which would be associated with bite cells and Heinz bodies. A vitamin B12 level would be useful
for evaluating macrocytosis, which is not present in this patient.
A 19-year-old female comes to your office with lower abdominal pain that has increased over
the past 2 days. Her last menstrual period was 4 days ago. She has been nauseated and has
been vomiting. The physical examination reveals a temperature of 38.0°C (100.4°F) and
lower abdominal tenderness with mild rebound. She has a mucopurulent cervical discharge,
tenderness with cervical motion, a normal-size uterus, and left adnexal fullness. A serum
hCG is negative.
Which one of the following is the most appropriate management?
A) Ceftriaxone (Rocephin), 250 mg intramuscularly
B) Hospitalization for intravenous antibiotics
C) Surgical consultation for immediate appendectomy
D) Laparoscopy
ANSWER: B
This patient has signs and symptoms of acute salpingitis. This condition is commonly confused with
appendicitis, ectopic pregnancy, and other pelvic pathology. In this case the findings are clearly pelvic in
origin. Endocervical inflammation with a mucopurulent discharge is noted in almost every case of acute
salpingitis. The acute nature of this presentation and the adnexal fullness suggest gonorrhea rather than
chlamydial infection, although the antibiotic regimen should probably cover Chlamydia as well. Admission
to the hospital and treatment with parenteral antibiotics is most appropriate in this case because of the
severity of the illness, the desire to maintain reproductive function, and the adnexal fullness.
Routine laparoscopy for every case of salpingitis is considered too costly and dangerous. The choice of
intravenous antibiotic may vary, but usually consists of a $-lactam antibiotic (cefoxitin or ceftriaxone) plus
doxycycline, or gentamicin and clindamycin. Ceftriaxone, 250 mg intramuscularly, is appropriate for
uncomplicated gonococcal infection.
An 82-year-old female sees you for follow-up 6 weeks after fracturing her hip when she
tripped on a hose and fell in her garden. She underwent surgical repair and acute inpatient
rehabilitation. She has successfully recovered, is participating in an outpatient physical
therapy program, and is now walking with a cane. She reports gastroesophageal reflux
controlled with over-the-counter ranitidine (Zantac) as her only chronic medical condition.
She recalls having been told that she had only mild bone loss on a bone density test last year.
She has been taking a calcium and vitamin D supplement since then. She is concerned about
sustaining another fracture.
Which one of the following should you do now to reduce her risk of recurrent fracture?
A) Prescribe alendronate, 70 mg weekly
B) Prescribe raloxifene (Evista), 60 mg daily
C) Prescribe teriparatide (Forteo), 20 :g daily
D) Discontinue ranitidine
ANSWER: A
Undertreatment of osteoporosis occurs frequently after a hip fracture. Unless a contraindication exists,
patients should be treated with a bisphosphonate after a hip fracture, regardless of bone mineral density
(SOR C). Controlled gastroesophageal reflux is not a contraindication to bisphosphonate therapy. Proton
pump inhibitor use, but not H2-blocker use, is also a modifiable risk factor for osteoporosis. Raloxifene and
teriparatide are not bisphosphonates or first-line therapy for prevention of recurrent hip fracture. Raloxifene
has not been shown to reduce the rate of nonvertebral fractures.
A 25-year-old gravida 1 para 0 presents for follow-up of gestational diabetes mellitus. She
had a positive screening test at her 24-week visit last week and has been checking her blood
glucose at home twice daily since that time. She is not currently on any diabetes medications
and has a nutrition visit scheduled for later today. She is currently unclear on what her
glucose level should be at various times throughout the day.
Which one of the following is the goal fasting blood glucose in this patient?
A) ≤ 75 mg/dL
B) ≤ 95 mg/dL
C) ≤ 120 mg/dL
D) ≤ 140 mg/dL
E) ≤ 180 mg/dL
ANSWER: B
Clinicians who care for pregnant women need to be familiar with the diagnosis and monitoring parameters
for gestational diabetes mellitus, as these help to determine the need for management strategies outside of
diet and exercise. The goal is d95 mg/dL for fasting blood glucose, d140 mg/dL for 1-hour postprandial
glucose, and d120 mg/dL for 2-hour postprandial glucose.