Cardio
Which one of the following medication classes reduces heart failure–related hospitalizations in patients without diabetes mellitus?
A) Calcium channel blockers
B) DPP-4 inhibitors
C) Insulin
D) SGLT2 inhibitors
E) Statins
ANSWER: D Adding an SGLT2 inhibitor to the medication regimen of patients with heart failure and without diabetes mellitus has been shown to reduce heart failure– related hospitalizations. Calcium channel blockers may have no effect or worsen heart failure. DPP-4 inhibitors can worsen the effects of heart failure. Insulin provides improved glucose control for patients with diabetes mellitus; however, it has not been independently shown to reduce heart failure–related hospitalizations. Statins are effective at reducing cholesterol levels but have not been shown to reduce heart failure–related hospitalizations.
A healthy 15-year-old female is brought to your office for a well adolescent visit. She does not have any health concerns or preexisting medical conditions. Based on the guidelines from the U.S. Preventive Services Task Force, which one of the following would be most appropriate for this patient?
A) A vision examination
B) Depression screening
C) A CBC
D) A lipid panel
E) HPV testing
ANSWER: B The U.S. Preventive Services Task Force (USPSTF) recommends depression screening for adolescents beginning at age 12 (B recommendation). The American Academy of Pediatrics (AAP) recommends routine vision screening from 12 months to 5 years of age and only risk-based vision screening in adolescents as vision conditions are less likely to begin in older children. The USPSTF recommends vision screening at least once in all children ages 3–5 (B recommendation). Iron deficiency screening is not recommended in adolescents; however, the AAP recommends universal hemoglobin or hematocrit screening at 12 months of age while the USPSTF states that there is insufficient evidence (I recommendation). While the AAP recommends dyslipidemia screening in children ages 9–11, the USPSTF currently states there is insufficient evidence for screening for ≤20 years of age (I recommendation). The USPSTF recommends against cervical cancer screening before age 21
A 78-year-old male with a history of hypertension, type 2 diabetes, ongoing tobacco use, and carotid endarterectomy presents to the emergency department with bloody diarrhea and severe lower abdominal pain. Which one of the following is the most likely diagnosis?
A) Angiodysplasia
B) Arteriovenous malformation
C) Colon cancer
D) Irritable bowel syndrome
E) Ischemic colitis
ANSWER: E The differential diagnosis for the painful rectal bleeding in this patient includes inflammatory bowel disease, infectious colitis, hemorrhoids, and ischemic colitis. The patient's multiple risk factors for vascular disease place him at higher risk for ischemic colitis. The differential diagnosis for painless rectal bleeding includes angiodysplasia, arteriovenous malformation, colon cancer, diverticular bleeding, and post-polypectomy bleeding. Irritable bowel syndrome does not cause rectal bleeding.
***BONUS QUESTION***
A 44-year-old male presents for evaluation of left shoulder pain and stiffness that has developed
gradually over the past few months after a fall while skiing. He describes a dull, deep, poorly
localized ache. On examination he has impaired active and passive range of motion in all planes. Radiography of the shoulder is unremarkable. Which one of the following is most likely to lead to symptom resolution?
A) Wearing a sling on the left arm for 4–6 weeks
B) Extracorporeal shock wave therapy
C) Biceps tendon sheath injection and physical therapy
D) Glenohumeral corticosteroid injection and physical therapy
E) Surgical repair
ANSWER: D This patient presents with adhesive capsulitis, manifested as the typical cardinal symptoms of pain, stiffness, and dysfunction of the affected shoulder. A combination of glenohumeral or subacromial corticosteroid injection and physical therapy is most likely to produce early and sustained improvement in symptoms and joint functioning. Prolonged use of a sling would worsen the condition. Referral for surgery may be indicated after a 3-month trial of conservative treatment fails. While extracorporeal shock wave therapy has shown benefit for frozen shoulder, its current role is as an adjunct to other primary therapies.
***BONUS QUESTION***
Most elder abuse is perpetrated by
A) family members
B) friends
C) nurses
D) paid caregivers
E) physicians
ANSWER: A. Most elder abuse occurs in the home and is perpetrated by family members (90% of all cases). A small proportion of older adults live in nursing homes, with only 4% of abuse perpetrated by paid caregivers. Risk factors for elder abuse include shared living arrangements, increased age, decreased physical health, cognitive impairment, disruptive behaviors, alcohol misuse, and social isolation.
A 39-year-old female presents with a sudden onset of palpitations. Her vital signs include a blood pressure of 114/68 mm Hg and a pulse rate of 166 beats/min. She is cooperative and alert. An EKG shows regular narrow complex tachycardia with normal intervals. She has tried vagal maneuvers with no improvement. Which one of the following would be the most appropriate treatment at this time?
A) Adenosine
B) Atropine
C) Diltiazem (Cardizem)
D) Metoprolol
E) Synchronized cardioversion
ANSWER: A If vagal maneuvers are not effective in the management of stable supraventricular tachycardia (SVT), the most appropriate next step is treatment with intravenous adenosine at an initial dose of 6 mg. Atropine is a treatment option for bradycardia, particularly in the setting of heart block. Diltiazem or metoprolol may be used acutely in atrial fibrillation or in the prevention of SVT. Synchronized cardioversion is indicated in patients with SVT who become hypotensive or unresponsive.
***BONUS QUESTION***
A 6-year-old male is brought to your office by his parents for follow-up after being seen in the emergency department (ED) for an unprovoked, nonfebrile seizure. He does not have any prior seizure history and his past medical history is unremarkable. An EEG in the ED was normal. The parents are concerned about his risk for recurrent seizure and ask about treatment with anti-epileptic drug (AED) therapy. Which one of the following should you recommend?
A) Starting AED monotherapy only if he has a second seizure
B) Starting AED monotherapy now
C) Starting combination AED therapy only if he has a second seizure
D) Starting combination AED therapy now
ANSWER: A In the absence of risk factors such as abnormal EEG results, the presence of a predisposition to seizures, or an etiology such as severe head trauma or cerebral palsy, anti-epileptic drug (AED) therapy is not indicated after a first unprovoked childhood seizure. There is no significant difference in 1- to 2-year seizure remission rates between starting AED therapy after the first or second seizure, and there are significant risks associated with AED treatment. AED monotherapy should be attempted before starting AED combination therapy.
POP CULTURE: Which song was longest-running #1 song on the Billboard Hot 100 in 2009?
A. "I Gotta Feeling" - The Black Eyed Peas
B. "Boom Boom Pow" - The Black Eyed Peas
C. "Poker Face" - Lady Gaga
D. "Right Round" - Flo Rida
"I Gotta Feeling" - The Black Eyed Peas: 14 weeks (began July 11, 2009).
A right hand–dominant 9-year-old male is brought to your office by his parents after falling from a piece of playground equipment and landing on his left hand. He is in significant pain and there is visible swelling of the distal left forearm. An examination reveals intact distal sensation and capillary refill. He is given oral NSAIDs. X-rays reveal a unicortical irregularity at the distal radial metaphysis without displacement. You diagnose a buckle fracture. Which one of the following would be most appropriate at this time?
A) No treatment
B) Immobilization in a prefabricated removable splint for 2–3 weeks
C) Immobilization in a short arm cast for 6 weeks
D) Immobilization in a long arm cast for 6 weeks
E) Referral to an orthopedic surgeon
ANSWER: B This patient has a buckle fracture, or an incomplete compression fracture. These fractures are common in younger children due to the relative elasticity of their bones. Increasing evidence supports a shorter period of immobilization and follow-up is often not necessary if symptoms are improving. Removable splints are acceptable and may be better tolerated and more convenient in younger patients.
Which one of the following is present in polycythemia vera?
A) An α-1 antitrypsin deficiency
B) An elevated α-fetoprotein level
C) An elevated erythropoietin level
D) Antimitochondrial antibodies
E) A Janus kinase 2 mutation
ANSWER: E The World Health Organization’s major diagnostic criteria for polycythemia vera include an elevated hemoglobin or hematocrit level, abnormal bone marrow biopsy results, and the presence of the Janus kinase 2 (JAK2) genetic mutation, found in 98% of cases. The only minor criterion is a subnormal erythropoietin level, which helps distinguish polycythemia vera from common causes of secondary erythrocytosis such as smoking, sleep apnea, and testosterone use.
Which one of the following conditions is most associated with an increased risk for venous thromboembolism?
A) Active cancer
B) COPD
C) Poorly controlled type 2 diabetes
D) Severe intermittent asthma
E) Stage 3 chronic kidney disease
ANSWER: A Patients with venous thromboembolism (VTE) should receive anticoagulant therapy for at least 3 months to reduce the risk for further embolization. In patients with persistent provoking factors such as active cancer or antiphospholipid syndrome, or who have had previous episodes of unprovoked VTE, the long-term risk for recurrence is high and indefinite anticoagulation therapy is recommended. The risk for VTE is much higher with active cancer compared to COPD, poorly controlled type 2 diabetes, severe intermittent asthma, and stage 3 chronic kidney disease.
A 3-year-old male is brought to your office by his parents for a routine well child visit. He is up to date on vaccines and the parents have no concerns to discuss today. According to the U.S. Preventive Services Task Force, this child should be screened for which one of the following conditions?
A) Amblyopia
B) Anemia
C) Autism spectrum disorder
D) Dental caries
E) Hearing loss
ANSWER: A USPSTF recommends vision screening at least once in all children 3–5 years of age to detect amblyopia or its risk factors (B recommendation). Anemia screening is recommended for all children at 1 year of age by the American Academy of Pediatrics (AAP), but this approach was found to have insufficient evidence of benefit by the USPSTF (I recommendation). Screening for autism spectrum disorder is recommended by the AAP at 18 and 24 months of age, but the USPSTF found insufficient evidence that universal screening results in improved care in families without concerns about their child's development (I recommendation). The USPSTF found insufficient evidence of benefit of screening for dental caries in children <5 years of age (I recommendation).Universal hearing screening is recommended for newborns, but screening at this age is not recommended.
Which one of the following conditions is most likely to impair swallowing of both solids and liquids?
A) Achalasia
B) Eosinophilic esophagitis
C) Esophageal cancer
D) Esophageal stricture
E) Schatzki ring
ANSWER: A Achalasia is a smooth muscle motility disorder that impairs swallowing of both solids and liquids. In contrast, anatomic causes of dysphagia that impede the lumen of the esophagus through mass effect or inflammation, such as eosinophilic esophagitis, esophageal cancer, esophageal stricture, and Schatzki rings, typically impair swallowing of solids but not liquids.
A 55-year-old female sees you because of weakness in the left leg. She has a history of hypertension, type 2 diabetes, osteoarthritis of the knees, and degenerative disk disease of the cervical and lumbar spines. An examination is notable for focal weakness on dorsiflexion of her left foot and extension of her toes, and a neurologic examination is otherwise normal. Which one of the following is the most likely explanation for these findings?
A) Cervical myelopathy
B) Diabetic neuropathy
C) L4 nerve root impingement
D) Peroneal nerve compression
E) Tarsal tunnel syndrome
ANSWER: D The most common cause of foot drop is a compression neuropathy of the peroneal (also known as common fibular) nerve, most often at the fibular head just distal to the lateral knee. Tight-fitting braces and casts as well as prolonged leg crossing can cause this neuropathy. Cervical myelopathy may cause lower extremity weakness, but it may also cause numbness and upper motor neuron findings such as hyperreflexia. Diabetic neuropathy is typically bilateral and symmetric and rarely causes motor weakness. L5, but not L4, nerve root impingement can also cause foot drop. Tibial nerve compression at the tarsal tunnel causes pain into the lateral midfoot, but it does not lead to foot drop.
POP CULTURE: Which of the following is NOT a real Taylor Swift song?
A. I Can Do It With A Broken Heart
B. Enchanted
C. Getaway Car
D. You And Me
E. Cancelled!
D. You And Me
A 36-year-old female presents with a medical history of hypertension, hyperlipidemia, obesity, and 3 miscarriages. She is not currently pregnant. She was recently discharged from the hospital with her second deep vein thrombosis (DVT) in the past several years. A workup for the underlying cause of her thrombophilia is positive for antiphospholipid antibodies. Which one of the following medications would be most appropriate for the long-term treatment of this patient’s DVT?
A) Apixaban (Eliquis)
B) Aspirin
C) Clopidogrel (Plavix)
D) Enoxaparin (Lovenox)
E) Warfarin
ANSWER: E The correct treatment of a deep vein thrombosis (DVT) in a patient with antiphospholipid syndrome is warfarin. Most DVTs can be treated with a direct oral anticoagulant (DOAC). DOACs may be acceptable in low-risk patients with a single previous DVT, but they are not preferred for patients with antiphospholipid antibody syndrome due to the risk for increased arterial thrombotic events. Aspirin is clearly not appropriate in a patient with recurrent DVTs. Clopidogrel would never be indicated for the treatment of a DVT. If this patient were pregnant, enoxaparin would be preferred.
YOUR TURN IS SKIPPED!!
A 73-year-old female presents with chronic diarrhea. You suspect microscopic colitis and order colonoscopy. Based on the suspected diagnosis, you should expect which one of the following colonoscopy findings?
A) Granulomas
B) Normal mucosa
C) Patchy ulcerations
D) Pseudomembranes
ANSWER: B In a patient with microscopic colitis, the most common finding on colonoscopy is normal mucosa. Because the mucosa appears normal, microscopic colitis needs to be diagnosed with biopsy. Granulomas may be found in patients with Crohn disease. Ulcerations are found in ulcerative colitis. Pseudomembranes are found in Clostridioides difficile infection. Granulomatous changes and pseudomembranes may also require biopsy for diagnosis.
A 35-year-old female presents with a swollen right index finger after accidentally slamming the car door on the finger yesterday. She has constant pain of the distal finger but no throbbing under her fingernail. On examination the end of the right index finger is swollen, and she has a small subungual hematoma. She is able to flex and extend the distal interphalangeal (DIP) joint with some pain, but has normal strength. An x-ray shows a transverse fracture across the distal phalanx that does not involve the joint. Which one of the following is the optimal treatment plan for this patient?
A) Ice, NSAIDs, and DIP flexion as tolerated
B) Draining the subungual hematoma and bandaging the finger
C) Buddy taping the finger for 3–4 weeks
D) Splinting the DIP joint in full extension for 4–6 weeks
E) Referral to an orthopedic surgeon
ANSWER: D A distal phalanx fracture can occur after a crush injury or direct force to the end of the finger. The affected finger will have swelling, bruising, and often a subungual hematoma. Simple fractures can be managed with splinting in extension for 4–6 weeks with a finger guard or U-shaped aluminum splint. Hematomas that are more than 50% of the nail bed surface can be drained with a hot needle or instrument. Buddy taping is used for minimally angled middle or proximal phalanx fractures that do not involve the joints. A patient who is unable to flex or extend the distal interphalangeal (DIP) joint, has decreased sensation, or has a complex fracture extending into the joint should be referred to an orthopedic surgeon.
A 65-year-old female is found to have a T-score of –3.3 on a DEXA scan that is performed as part of her Welcome to Medicare evaluation. She has a 30-pack-year smoking history but quit smoking 5 years ago. An examination reveals a thin female but is otherwise unremarkable. A CBC, a comprehensive metabolic panel, and thyroid studies are unremarkable. X-rays reveal evidence of an old compression fracture of the thoracic spine. Which one of the following would be the most appropriate initial treatment?
A) Oral alendronate (Fosamax)
B) Oral raloxifene (Evista)
C) Subcutaneous denosumab (Prolia)
D) Subcutaneous teriparatide (Forteo)
E) Intravenous zoledronic acid (Reclast)
ANSWER: D The diagnosis of osteoporosis can be made with a prior fracture of the hip or spine, or a T-score ≤–2.5. A FRAX score ≥3% for hip fracture or ≥20% for major osteoporotic fracture is also diagnostic. The usual first-line treatment is an oral bisphosphonate such as alendronate or intravenous zoledronic acid. Denosumab would be preferred if the creatinine clearance were less than 30–35 mL/min/1.73 m². Patients such as this one would be considered at very high fracture risk. Diagnostic criteria for this risk category include a T-score <–3.0, a FRAX score ≥4.5% for hip fracture or ≥30% for major osteoporotic fracture, multiple fractures, fracture within 12 months, or fracture during treatment for osteoporosis. The initial treatment recommendation would be a parathyroid hormone analogue such as teriparatide daily for 2 years. Raloxifene is indicated for the prevention of vertebral fractures only.
A 69-year-old male with a history of coronary artery disease sees you for follow-up after hospitalization for new-onset atrial fibrillation. After some difficulty with low blood pressure with other rate control agents, he was discharged on amiodarone. This patient should be monitored for amiodarone toxicity with which one of the following?
A) An amiodarone plasma level
B) A blood glucose level
C) A CBC with differential
D) Pulmonary function testing
E) Urinalysis
ANSWER: D Patients treated with amiodarone should be monitored with pulmonary function testing at baseline and if clinical suspicion of pulmonary toxicity develops. Amiodarone is commonly used to manage ventricular arrhythmias, and for rate and rhythm control in atrial fibrillation. Amiodarone is associated with pulmonary fibrosis, and baseline assessment with pulmonary function tests including measurement of diffusing capacity of the lungs for carbon monoxide (DLCO) and chest x-ray is recommended. Amiodarone is also associated with hypothyroidism and less commonly with hyperthyroidism, liver inflammation, peripheral neuropathies, optic neuritis and corneal microdeposits, and bluish skin discoloration.
A 12-year-old female is brought to your clinic for a sports preparticipation evaluation for volleyball. Her family history is significant for a paternal grandfather with cardiovascular disease. In early childhood, she was diagnosed with atopic dermatitis and mild intermittent asthma that is controlled with a short-acting bronchodilator. The review of systems is unremarkable except for occasional shortness of breath when she is exposed to cats. On examination in a supine position, a systolic nonradiating murmur is best heard over the left upper sternal border. The murmur decreases with the Valsalva maneuver. Which one of the following is the most likely diagnosis?
A) An atrial septal defect
B) Hypertrophic obstructive cardiomyopathy
C) Mitral valve prolapse
D) A pulmonary flow murmur
E) Tricuspid stenosis
ANSWER: D A pulmonary flow murmur is an innocent systolic harsh murmur most commonly identified in adolescents and best heard at the left upper sternal border with minimal radiation. It is reduced when the Valsalva maneuver is performed. Atrial septal defects present as midsystolic murmurs best heard over the left upper sternal border. They radiate to the back and start softly then intensify in sound. Hypertrophic obstructive cardiomyopathy causes a midsystolic murmur heard over the left lower sternal border and apex. It is enhanced by the Valsalva maneuver. A mitral valve prolapse murmur is enhanced with the Valsalva maneuver in late systole, has a midsystolic click, and radiates to the apex. Tricuspid stenosis is a pathologic mid-diastolic murmur heard over the left lower sternal border. It increases with deep inspiration.
A 25-year-old primigravida at 30 weeks’ gestation presents with a 2-week history of intense pruritus of the palms and soles. The pregnancy has otherwise been uncomplicated. There are no skin lesions on examination. A CBC is unremarkable, but a metabolic panel is notable for the following: ALT 85 (nl 7-55), AST 75 (nl 8-48), alkaline phosphatase 140 (nl 45-114), bilirubin 1.8 (nl 0.1-1.2). Which one of the following tests is most likely to confirm the diagnosis?
A) An acute hepatitis profile
B) A bile acid level
C) A gamma-glutamyl transferase level
D) Ultrasonography of the liver
E) A punch biopsy of the skin
ANSWER: B Intrahepatic cholestasis of pregnancy can occur in up to 2% of pregnancies and is most frequent in the second or third trimester. The condition causes severe pruritus initially occurring on the palms and soles without skin lesions.. A diagnosis can be made clinically and by elevated serum bile acid levels. Hepatitis is a reasonable consideration, but this clinical picture is more compatible with intrahepatic cholestasis of pregnancy. A serum gamma-glutamyl transferase level would test for liver inflammation but would not add any useful information. Liver ultrasonography should be performed if obstruction is suspected. A skin biopsy may reveal excoriations but would not be diagnostic.
A 55-year-old female presents with lateral hip pain. You suspect greater trochanteric pain syndrome and prescribe anti-inflammatory medications and physical therapy. If her pain does not respond to these measures, which one of the following alternative diagnoses is most likely?
A) Femoroacetabular impingement
B) Gluteus medius tendon tear
C) Ischiofemoral impingement
D) Labral tear
E) Piriformis syndrome
ANSWER: B The most common cause of lateral hip pain is greater trochanteric pain syndrome , which can be caused by gluteus medius tendinopathy or tearing, or iliotibial band friction. A gluteus medius tendon tear should be considered in patients with greater trochanteric pain syndrome that does not respond to anti-inflammatory medications and physical therapy. Femoroacetabular impingement is a cause of intra-articular hip pain that usually presents with anterior pain. Ischiofemoral impingement is caused by impingement of the quadratus femoris muscle and nerve between the proximal femur at the level of the lesser trochanter and ischial tuberosity, resulting in deep buttock pain worsened by activities requiring a long stride. Labral tears are associated with anterior hip pain and may cause a popping, catching, or clicking sound with activities. Piriformis syndrome is caused by the piriformis entrapping the sciatic nerve, and causes hip and buttock pain as well as sciatica.
Which one of the following attention-deficit/hyperactivity disorder (ADHD) medications is
considered safest to take while breastfeeding?
A) Amphetamine (Evekeo)
B) Atomoxetine (Strattera)
C) Clonidine
D) Guanfacine
E) Methylphenidate (Ritalin)
ANSWER: E Racemic methylphenidate has been studied in breastfeeding mothers and drug levels in breast milk were found to be about 0.2% of the adult dose. Drug levels were undetectable in breastfed infants and the infants had no long-term growth or developmental issues. Methylphenidate can reduce serum prolactin levels, but this has not been shown to have any clinical impact on milk supply. Less is known about amphetamine in breastfeeding, but milk and infant serum levels are significantly higher than with methylphenidate. Atomoxetine and guanfacine have no reliable data in breastfeeding and should be avoided until more is known. Clonidine has been shown to be present in significant amounts in breast milk and serum from breastfed infants (up to 50% of the maternal serum levels). While no adverse effects have been shown, this high level of medication in the infant raises concerns, and experts recommend avoiding clonidine while breastfeeding.