Don't choose "C"
•Which of the following classes of antihypertensive drugs is most likely to cause angioedema?
•A. ACE inhibitors
•B. alpha blockers
•C. beta blockers
•D. calcium channel blockers
•E. thiazide diuretics
•A
•Out of all the choices, ACE inhibitors are most strongly associated with angioneurotic edema
•Which of the following mechanisms is most likely responsible for the increase in B-type natriuretic peptide seen in congestive heart failure?
•A. decreased left ventricular volume
•B. increased afterload affecting the kidneys
•C. increased preload affecting the kidneys
•D. right atrial contraction
•E. ventricular myocyte stretch
•E
•Ventricular myocyte stretch is known to cause increase in circulating B-type natriuretic peptide, as B-type natriuretic peptide is stored in ventricular myocytes. Decreased left ventricular volume does not cause increased stretch of myocytes and would not increase levels of BNP. Increased afterload affecting the kidneys does increase BNP but not through renal mechanisms. Similarly, increased preload affecting the kidneys can increase BNP but not through renal mechanisms. BNP is only released in situations of increased ventricular strain; atrial natriuretic peptide is released in response to atrial strain. Therefore, right atrial contraction is incorrect.
•Which of the following statements is correct regarding patients going through alcohol withdrawal?
•A. they are at risk for hyperglycemia
•B. they will develop delirium tremens
•C. they should always receive thiamine and a multivitamin
•D. propranolol can decrease the likelihood of withdrawal seizures and hallucinations
•E. they should receive magnesium sulfate for seizure prophylaxis
•C
•Thiamine and other vitamin deficiencies are common in alcoholism, and their deficiency can cause potentially permanent neurological sequelae if not treated promptly. Delirium tremens is a severe form of alcohol withdrawal, but is not always present. It carries a 5-15% mortality rate. Hyperglycemia is not typically associated with alcohol withdrawal itself. Low-potency benzodiazepines are the treatment of choice for seizure treatment and autonomic dysfunction. Propranolol is not associated with withdrawal seizures or hallucination in alcohol withdrawal. Magnesium sulfate is not routinely given for seizure prophylaxis in alcohol withdrawal.
•A 25 year old male presents with a 2 hour history of acute shortness of breath and severe right upper quadrant pain on inspiration. He smokes cigarettes and has a 7 pack year history. He has no additional medical history. On examination he is in noticeable distress. Pulse oximetry reveals an oxygen saturation of 88% on room air. The most likely diagnosis is
•A. asthma exacerbation
•B. bronchitis
•C. pneumonia
•D. pulmonary embolism
•E. spontaneous pneumothorax
•E
•Pneumothorax, or accumulation of air in the pleural space, is classified as spontaneous or traumatic. Primary spontaneous pneumothorax occurs in the absence of an underlying lung disease, whereas secondary spontaneous pneumothorax is a complication of preexisting pulmonary disease. Primary pneumothorax effects mainly tall, thin boys and men aged 10 to 30 years. The patient has acute onset of ipsilateral chest pain. It is thought to occur from rupture of subpleural apical blebs in response to high negative intrapleural pressures. Family history and cigarette smoking may also be important factors.
•A 68 year old male presents with a 1 week history of cough and a temperature of 38.5C (101.3F). Chest radiograph reveals a right middle lobe infiltrate. The most likely cause is
•A. Chlamydophila pneumoniae
•B. Haemophilus influenzae
•C. Mycoplasma pneumoniae
•D. Streptococcus pneumoniae
•E. Legionella species
•D
•Streptococcus pneumoniae is the most common cause of community acquired pneumonia.
•A 65 year old male presents with a history of smoking and hypertension. Family history is significant for coronary artery disease. Ultrasound of the abdomen reveals a 4 cm abdominal aortic aneurysm. The most appropriate next step is
•A. MRA of the abdomen
•B. MRI of the abdomen
•C. noncontrast CT scan of the abdomen
•D. observation
E. surgical consultation
•D
•For asymptomatic aneurysms, abdominal aortic aneurysm repair is indicated if the diameter is greater than 5.5 cm.
•The most appropriate initial screening test for an abdominal aortic aneurysm is
•A. angiogram
•B. CT scan with contrast
•C. CT scan without contrast
•D. MRI
•E. ultrasound
•E
•Ultrasonography has a sensitivity of 95% and specificity of 100% for the detection of an abdominal aortic aneurysm: additionally, it is a noninvasive, inexpensive study that does not expose the patient to radiation or risk of contrast side effects.
•A 40 year old male presents to the emergency department for evaluation of tachycardia, elevated blood pressure, tremors and hallucinations. He reports that he has not consumed any alcohol in three days but has been drinking “for years.” This patient’s alcohol addiction and withdrawal symptoms are an example of
•A. alcohol abuse syndrome
•B. episodic alcohol use
•C. intermittent alcohol use
•D. physical dependence
•E. psychological dependence
•D
•Physical dependence is demonstrated by the presence of withdrawal symptoms when the substance, in this case, alcohol, is not used for a period of time. While the patient may indeed have alcohol abuse syndrome due to years of use.
A 40 year old male presents with the abrupt onset of unilateral flank pain and nausea. Physical examination reveals positive costovertebral angle tenderness. After obtaining a urinalysis, the most definitive and cost effective test to evaluate this patient’s condition is which of the following?
A.helical noncontrast CT scan
B.Intravenous urography
C.MRI
D.Plain film radiography of the abdomen
E.Renal ultrasonography
•A
Noncontrast CT scanning is the best radiologic test. It may also give information concerning the type of stone de to stone characteristics.
•A 78 year old male nursing home resident is brought in to the emergency department with a productive cough, fever and tachypnea. History reveals that he has received his annual flu shot and pneumococcal immunization. Chest radiograph reveals consolidated pneumonia. The most like organism to cause this patient’s bacterial pneumonia is
•A. adenovirus
•B. Haemophilus influenzae
•C. Mycoplasma pneumoniae
•D. Mycoplasma tuberculosis
•E. Streptococcus pneumoniae
•E
•The most common causative organism in nursing home associated pneumonia is Streptococcus pneumoniae. This is isolated in approximately 48% of culture isolates.
•A 68 year old male presents with the complain of excess thirst and urination, fatigue and gradual onset of impotency of the past six months. His skin has a dark color that also appeared over the past year. Physical examination is positive for atrophic testes, hepatomegaly, and a firm, freely moveable thyroid. Laboratory studies reveal a fasting glucose of 274 mg/dL. The most likely diagnosis is
•A. Addison disease
•B. hemochromatosis
•C. pituitary adenoma
•D. Sipple syndrome
•E. Werner syndrome
•B
•This patient’s symptoms are consistent with diabetes mellitus. The additional findings of skin discoloration, hepatomegaly, and hypogonadism should raise suspicion for hemochromatosis. The most common presenting complaints of hemochromatosis are lethargy, arthralgias and hypogonadism. Liver abnormalities are common in this condition. Diagnostic testing would include ferritin and transferrin saturation.
•A 26 year old male presents with unremitting back pain at the thoracolumbar junction, which has been treated repeatedly with physical therapy and osteopathic manipulation with little to no relief. He also notes loose bowel movements that are often bloody but not painful. He denies traveling, recent antibiotic use or fever. The most likely diagnosis is
•A. celiac sprue
•B. erosive gastritis
•C. hemorrhoids
•D. infectious colitis
•E. ulcerative colitis
•E
•Ulcerative colitis is the correct answer, based on the patient’s symptoms of nonpainful, bloody stools with back pain, this is a result of facilitated segments at levels T10-L2, which most specifically target the descending colon and rectosigmoid colon. These are the portions of the colon most frequently implicated in ulcerative colitis.
•Which of the following factors allows you to code at a higher complexity visit based on counseling or coordination of care?
•A. complexity of care
•B. presence of a psychiatric condition complicating care
•C. number of tests ordered
•D. number of referral made
•E. time
•E
•The correct answer is time. Documentation of time spent in counseling and coordination of care can be used to support billing at a higher level if greater than 50% of the visit is dedicated to such counseling. A complex patient does not necessarily require a higher level of coding if all the patient’s issues are stable, however, if the physician can document the amount of time spent counseling and coordinating the patient’s care, the physician may be able to code at a higher level.
•A 38 year old African American male presents with a four month history of a progressively worsening cough that occurs throughout the day and keeps him awake at night. History reveals that he was diagnosed with HIV seven years ago. The most appropriate initial step in the workup of this patient is
•A. bronchoalveolar lavage
•B. CD4 count
•C. CT scan of the chest
•D. pulmonary function testing
•E. upper endoscopy
•B
•A CD4 count of less than 200 cells/mcL is indicative of AIDS and therefore increases the probability of opportunistic infections and malignancies in this patient with history of cough and positive HIV status.
•A 78 year old female presents to the office with a 24 hour history of acute lower abdominal pain. On examination he appears uncomfortable and has an oral temperature of 38.0 (100.4F). Abdominal palpation reveals involuntary guarding throughout his lower abdomen and discrete tenderness is elicited over the tip of the 12th rib on the right. Which of the following is correct regarding this condition in elderly patients?
•A. CT scan is widely used as the imaging of choice
•B. laparoscopic appendectomy is less beneficial than traditional open appendectomy
•C. more likely to present for evaluation soon after the onset of symptoms
•D. perforation and abscess formation are uncommon operative findings
•E. typically exhibit symptoms of fever and right lower quadrant abdominal pain
•A
•Elderly patients do not classically exhibit symptoms for acute appendicitis, so suspicion should be raised if they have low grade fevers, long standing pain before admission and a neutrophil left shift greater than 76%. CT scanning is the imaging modality of choice for this presentation.
•An 85 year old female is noted to have calcium level of 11.8 mg/dL. Which of the following ECG changes is most likely due to this patient’s electrolyte imbalance?
•A. third degree heart block
•B. peaked T waves
•C. prominent U waves
•D. QT interval shortening
•E. torsades de pointes
•D
•QT interval shortening is a common ECG finding indicative of hypercalcemia. A third degree heart block is typically secondary to degenerative changes in the conduction system in elderly persons as well as digitais toxicity; it can be a transient finding with an acute inferior myocardial infarction. Peaked T waves are most frequently due to hyperkalemia. Prominent U waves are commonly observed in the elderly and those with increased vagal tone. Normal U waves are positive; if negative, they can indicate left anterior descending artery occlusion. Torsades de pointes can be related to severe hypocalcemia.
•Multidrug resistant tuberculosis refers to a disease that is resistant to
•A. ethambutol and isoniazid
•B. isoniazid and pyrazinamide
•C. isoniazid and rifampin
•D. pyrazinamide and ethambutol
•E. rifampin and pyrazinamide
•C
•Multidrug resistant tuberculosis is caused by an organism that is resistant to at least both isoniazid and rifampin, the 2 most potent tuberculosis drugs. Theses drugs are used to treat all persons with tuberculosis disease.
•A 38 year old male with a history of alcoholism presents with nausea, vomiting and diffuse abdominal pain that radiates to his back. Which of the following laboratory values is most suggestive of a poor prognosis in this patient?
•A. anion gap of 10 mEq/L
•B. diastolic blood pressure greater than 90 mmHg
•C. elevated serum amylase
•D. elevated serum lipase
•E. leukocyte count of 20,000/mcL
•E
•The patient is evaluated for morbidity risk with acute pancreatitis using the Ranson criteria at admission and again at 48 hours. The initial criteria include: age greater than 55 years, leukocyte count greater than 16,000/mcL, blood glucose greater than 11 mmol/L, lactate dehydrogenase greater than 350 IU/L and aspartate aminotransferase greater than 250 U/L. At 48 hours the reassessment includes: packed cell volume decrease of greater than 10%, BUN increase of greater than 1.8 mmol/L, calcium of less than 2 mmol/L, base deficit of greater than 4 mmol/L and a partial oxygen pressure of less than 60 mmHg.
•A 27 year old trauma victim is transferred to the intensive care unit after sustaining multiple fractures in a motorcycle accident. He is stabilized and has received 2 units of packed red blood cells. Vital signs reveal a blood pressure of 100/60 mmHg, a heart rate of 120/min, and a respiratory rate of 15/min. Laboratory studies reveal a hemoglobin of 10.1 g/dL and a creatinine of 2.3 mg/dL. The remaining laboratory studies are unremarkable. The most appropriate treatment for this patient’s acute kidney injury is to
•A. administer dobutabamine 2 mcg/min drip
•B. administer fluid bolus with 1 L normal saline
•C. administer intravenous furosemide 40 mg followed by saline flush
•D. initiated total parenteral nutrition
•E. transfuse 1 additional unit of packed red blood cells
•B
•Administration of 1 L normal saline is correct because this patient has experience a sudden volume loss from hemorrhage associated with trauma. The effective circulating volume was reduced, causing hypoperfusion and a subsequent rise in serum creatinine. The kidney will perfuse when volume is restored.
•A 78 year old male presents with a 3 day history of gradually worsening nausea and midabdominal pain. He denies rectal bleeding or weight loss. He has a temperature of 38.0C (100.4F). Physical examination reveals mild constipation in associating with left lower quadrant pain. Laboratory studies reveal a leukocyte count of 11,200/mcL. The most likely diagnosis is
•A. acute cholecystitis
•B. acute diverticulitis
•C. acute pancreatitis
•D. small bowel obstruction
•E. irritable bowel syndrome
•B
•Acute diverticulitis can present with a lower left quadrant pain that is often relieved by defecation, the location of pain may be anywhere in the lower abdomen due to the redundancy of the sigmoid colon. Diverticulitis can cause muscle spasms, guarding and rebound tenderness predominantly affecting the lower left quadrant. A white blood count reveals leukocytosis and stool may be heme positive due to bleeding at sites of perforation.
•A 72 year old male presents for evaluation of a tremor in both his arms that has been progressively worsening over the last 6 months. The tremor initially began in the left arm and four months ago began in the right. The tremor only occurs while he is at rest. He reports that he has been moving slower and has to take much smaller steps. He is taking no new medications. The most appropriate next step to confirm the diagnosis is
•A. complete history and physical examination
•B. CT scan of the head with IV contrast
•C. lumbar puncture
•D. MRI of the brain
•E. electroencephalogram
•A
The diagnosis of Parkinson disease is made primarily by a thorough clinical evaluation. There are no specific tests that are used to diagnose Parkinson disease. In this case, the patient’s progressive resting tremor and the slowing movement are consistent with Parkinson disease.
•Which of the following treatments has been shown to alter the long term rate of decline in lung function in patients with chronic obstructive pulmonary disease?
•A. inhaled fluticasone (Flovent)
•B. inhaled ipratropium bromide (Atrovent)
•C. oral theophylline (Theo-Dur)
•D. oxygen therapy
•E. smoking cessation
•E
•Longitudinal studies have shown accelerated decline in FEV1 in a dose response relationship to the intensity of cigarette smoking, which is typically expressed as pack years.
•A 56 year old female is brought to the emergency department by her husband with the gradual onset of lethargy and confusion over the past few days. Initial laboratory studies reveal a normal complete blood count, a normal comprehensive metabolic profile and a calcium level of 14.5 mg/dL. Which of the following is the most appropriate initial management?
•A. volume expansion with saline and administration of salmon calcitonin and zoledronic acid
•B. subcutaneous synthetic parathyroid hormone and vitamin D in doses of 50,000 IU
•C. glucose in combination with insulin until serum calcium is below 10 mg/dL
•D. surgical removal of the parathyroid glands
•E. subcutaneous denosumab at 60 mg after admission to the intensive care unit
•A
•Volume expansion with saline and administration of salmon calcitonin and zoledronic acid is the preferred approach to severe hypercalcemia.
•A 37 year old female presents to the clinic for evaluation of dysuria, urinary frequency and mild flank pain. She reports that her symptoms have gradually worsened over the past few weeks. Past medical history reveals urinary tract infections but she reports that she has not been to a clinic for years. Vital signs are normal. Physical examination reveals flank pain on the right side. Urinalysis reveals erythrocytes, positive nitrites and a pH of 7.2. She is prescribed empirical antibiotics and asked to follow up in 2 weeks. Cultures come back showing Proteus mirabilis. On follow up evaluation, the patient reports that her symptoms have barely improved and she is still experiencing flank pain. A CT scan without contrast confirms the diagnosis. The most appropriate management for this patient is
•A. low sodium diet
•B. increased fluid intake and analgesics
•C. allopurinol
•D. hydrochlorothiazide
•E. surgical intervention
•E
•This patient suffers from a struvite stone, as evidenced by the recurrent urinary tract infections of a Proteus species. Definitive treatment for this type of stone is surgical removal.
•A spry 84 year old male with hypertension controlled by a low dose diuretic presents with his grandson. The grandson informs you that the elderly gentleman has fallen several times during the previous week. On questioning the patient denies having fallen, stating that he just lost his balance and slid to the floor. Vital signs are stable and physical examination is unremarkable aside from some bruising to the left hip and forearm. There is no significant bony tenderness. Which of the following is the most appropriate course of action?
•A. ECG and chemistry profile
•B. lumbosacral spine and pelvic radiographs
•C. prescription for a front-wheeled walker
•D. referral for aquatherapy and gait training
•E. referral to adult protective services to investigate possible abuse
•A
•For a person who has fallen, the evaluation should include a detailed history of the circumstances surrounding the fall, medications, medical problems and mobility; an examination of vision, gait, balance and lower extremity joint function; an examination of neurologic function, including muscle strength; and an examination of the cardiovascular system. Tests are needed only if the history and physical examination do not reveal the cause of falling. In this case, the patient is on a diuretic and the physical examination did not reveal the cause of this fall. Therefore it would be reasonable to order an ECG and chemistry profile.