it's going tibia ok
102. A 67-year-old male presents to your office with a 1-month history of fever with edema and erythema of his right foot. His medical history is significant for peripheral artery disease and poorly controlled type 2 diabetes with diabetic neuropathy. Significant vital signs include a temperature of 38.6°C (101.5°F), a blood pressure of 155/90 mm Hg, and a pulse rate of 85 beats/min. A physical examination is most notable for a draining ulcer on the ball of his right foot. The edema and erythema are limited to his right foot and he has no calf tenderness. Dorsalis pedis and posterior tibial artery pulses are present but diminished at the right ankle. Sensation to monofilament testing of his right foot is diffusely diminished, which is consistent with his baseline. The best initial imaging test of the foot ulcer would be
A) radiography
B) ultrasonography
C) CT
D) MRI
E) technetium 99m bone scintigraphy
A) radiography
19. The American Academy of Pediatrics recommends obtaining a blood pressure reading at well child checks beginning at what age?
A) 18 months
B) 2 years
C) 3 years
D) 4 years
E) 5 years
C) 3 years
104. Which one of the following is true regarding acute gastroenteritis in children?
A) Handwashing and general hygiene alone can prevent rotavirus infection
B) Daily probiotics are recommended
C) The majority of cases are caused by bacteria
D) Oral rehydration is as effective as intravenous rehydration in mild to moderate dehydration
E) Promethazine is the antiemetic of choice in patients with moderate dehydration and nausea
D) Oral rehydration is as effective as intravenous rehydration in mild to moderate dehydration
164. A 40-year-old female presents with a low back strain that occurred when moving furniture over the weekend. She rates her pain as mild to moderate. She initially tried acetaminophen, 1 g every 8 hours, and when this was ineffective, she switched to ibuprofen, 600 mg every 6–8 hours without relief. She is in good health otherwise and does not take any other medications. Which one of the following would be the most appropriate pharmacologic therapy to recommend next?
A) A combination of acetaminophen, 500 mg, and ibuprofen, 600 mg, every 8 hours
B) CBD oil applied to the low back up to four times daily
C) Diclofenac topical (Voltaren Arthritis Pain) applied to the low back every 6 hours
D) Hydrocodone/acetaminophen (Norco), 5/325 mg every 6 hours
E) Oxycodone (Roxicodone), 5 mg, every 4–6 hours
A) A combination of acetaminophen, 500 mg, and ibuprofen, 600 mg, every 8 hours
174. A 25-year-old female presents to your office for an annual health maintenance visit. You note a BMI of 17 kg/m2 , a heart rate of 66 beats/min, and a blood pressure of 110/64 mm Hg. The patient reports exercising for 2 hours each day, incorporating cardio and light weights. The patient presents a detailed food diary and asks for advice about how to adjust her nutrition to lose weight. In order to provide the best care for this patient, which one of the following would you order?
A) A fecal calprotectin level
B) Stool cultures
C) A DEXA scan
D) Chest radiography
E) Thyroid ultrasonography
C) A DEXA scan
181. Which one of the following is the recommended duration of anticoagulation for a first episode of a provoked proximal deep vein thrombosis of the leg?
A) 6 weeks
B) 3 months
C) 9 months
D) 1 year
E) Lifelong
B) 3 months
145. A 17-year-old male with a history of type 2 diabetes sees you because of fatigue and a 15-lb weight loss in the past month. The patient reports excessive and frequent urination, thirst, and nausea. His only medication has been metformin, but he states that he stopped taking it 6 months ago. His current weight in your office is 93 kg (205 lb), which confirms the reported weight loss. His blood pressure is 130/78 mm Hg, his pulse rate is 90 beats/min, and his temperature is 37.0°C (98.6°F). A physical examination is otherwise unremarkable. A capillary blood glucose level is 348 mg/dL, a hemoglobin A1c is 11.5%, serum ketones are negative, and a urinalysis shows 3+ glucosuria with concentrated urine but is otherwise normal. Which one of the following would be the most appropriate treatment?
A) Resuming oral metformin
B) Starting oral empagliflozin (Jardiance)
C) Starting subcutaneous insulin
D) Starting subcutaneous liraglutide (Victoza)
E) Hospitalization for continuous intravenous insulin
C) Starting subcutaneous insulin
176. A 4-year-old male is brought to your office by his mother because of fevers, irritability, runny nose, and cough for the past week. On examination he is noted to have bilateral conjunctivitis; dry cracked lips; a maculopapular rash; edema and erythema of his palms and soles bilaterally; and a nontender, enlarged, right anterior cervical lymph node. Which one of the following should be included in the evaluation of this patient’s condition?
A) Chest radiography
B) Neck ultrasonography
C) Echocardiography
D) Neck CT
E) Cardiac MRI
C) Echocardiography
170. A 61-year-old male is found to have a 2-cm right adrenal incidentaloma on CT. He has no history of hypertension, electrolyte abnormalities, headaches, flushing, or sweating. Which one of the following studies should be performed in patients found to have an adrenal incidentaloma?
A) An ACTH stimulation test
B) A dexamethasone suppression test
C) Paired serum aldosterone and plasma renin activity
D) Serum or urine metanephrines
E) A PET scan
B) A dexamethasone suppression test
120. A 4-month-old female is brought to your clinic for a routine well child visit. She has not been seen by a physician since 2 weeks of age due to parental concerns about seeking care during the COVID-19 pandemic. Her growth and development appear to be normal. Which one of the following vaccines is CONTRAINDICATED today?
A) Haemophilus influenzae type b
B) Hepatitis B
C) Inactivated poliovirus
D) 13-valent pneumococcal conjugate (PCV13, Prevnar 13)
E) Rotavirus
E) Rotavirus
12. A 37-year-old female presents to your clinic with a long-standing history of abnormal menstrual cycles, often occurring irregularly more than 40 days apart. She has ongoing struggles with weight gain, acne, and facial hair growth. She states that she is not currently sexually active. Her last Papanicolaou smear 2 years ago was normal. Her vital signs and a physical examination are unremarkable other than a BMI of 36 kg/m2 . An office urine pregnancy test is negative. Laboratory evaluation reveals a hemoglobin A1c of 6.2%, and normal TSH, prolactin, and 17-hydroxyprogesterone levels. Which one of the following is required to confirm the most likely diagnosis?
A) No additional evaluation
B) A serum C-peptide test
C) A dexamethasone suppression test
D) Ultrasonography of the pelvis
E) CT of the abdomen and pelvis
A) No additional evaluation
65. A 34-year-old gravida 2 para 2 presents for a postpartum examination 6 weeks after an uncomplicated vaginal delivery. Both the mother and infant are doing well. Her only complication during the pregnancy was an abnormal 3-hour glucose tolerance test. She managed her blood glucose with a combination of diet and exercise and delivered at 39 weeks gestation. The patient’s vital signs and a physical examination are normal today. Which one of the following should you recommend for this patient based on her history of gestational diabetes?
A) No glucose testing today, and initiation of metformin to prevent diabetes
B) No glucose testing today, and annual screening with a fasting plasma glucose level starting 1 year after delivery
C) No further glucose testing unless she becomes pregnant again
D) A 2-hour plasma glucose level using a 75-g oral glucose load
D) A 2-hour plasma glucose level using a 75-g oral glucose load
58. A 53-year-old female sees you for a routine health maintenance visit. The patient reports that she is newly menopausal and asks you about osteoporosis screening. Her past medical history includes morbid obesity, and her family history includes type 2 diabetes in her mother and hypertension in her father. The patient is a nonsmoker and rarely consumes alcohol. Her only medication is loratadine (Claritin), 10 mg daily. Which one of the following would you recommend regarding osteoporosis screening for this patient?
A) No screening now or in the future, and calcium supplementation only
B) No screening now or in the future, and calcium and vitamin D supplementation
C) Radiography of her hip and lumbar spine now
D) A DEXA scan now
E) A DEXA scan at age 65
E) A DEXA scan at age 65
142. A 35-year-old female with rheumatoid arthritis currently being treated with adalimumab (Humira) injections sees you for evaluation after developing a red, swollen, warm, and painful right knee. Arthrocentesis is performed, and the synovial fluid analysis is concerning for septic arthritis. Which one of the following organisms is the most likely cause of her infection?
A) Candida albicans
B) Escherichia coli
C) Mycobacterium tuberculosis
D) Staphylococcus aureus
E) Streptococcus pyogenes
D) Staphylococcus aureus
190. Which one of the following oral conditions shows the most significant response to oral antivirals?
A) Behçet’s syndrome
B) Hand-foot-and-mouth disease
C) Herpangina
D) Herpes gingivostomatitis
E) Vincent’s angina
D) Herpes gingivostomatitis
84. A 55-year-old female with a BMI of 50 kg/m2 and recently diagnosed severe obstructive sleep apnea (OSA) presents for follow-up after a sleep study. She was unable to tolerate positive pressure therapy. Her OSA could be most effectively addressed by which one of the following interventions?
A) Use of a nasal dilator device
B) A positional sleep alarm to avoid the supine position
C) Clonidine, 0.1 mg orally before bedtime
D) Uvulopalatopharyngoplasty
E) Bariatric surgery
E) Bariatric surgery
192. A 20-year-old pregnant female presents to your clinic to discuss the possibility of delivering her baby at her home. A few of her friends have had their babies at home and she asks for your advice about her delivery. Which one of the following presents the greatest risk with an out-of-hospital birth?
A) Nulliparity
B) Maternal age <25
C) Prior vaginal delivery
D) Single gestation
E) Cephalic presentation
A) Nulliparity
63. A 32-year-old female comes to your office because of chronic diarrhea, abdominal cramping, and bloating. She has had these symptoms for many years but has never discussed them in depth with a physician. A thorough history and physical examination are most consistent with irritable bowel syndrome (IBS). You order IgA tissue transglutaminase (tTG) antibody and fecal calprotectin testing to rule out other conditions and both are negative. She has expressed an interest in nonpharmacologic measures as initial management of her IBS. Which one of the following should you recommend initially, given that it has the best evidence of benefit for her condition?
A) A gluten-free diet
B) A low-FODMAP diet
C) Soluble fiber
D) Prebiotics
E) Probiotics
C) Soluble fiber
77. A 67-year-old male with a history of hypertension comes to your clinic for a follow-up visit. He has had two myocardial infarctions in the past 5 years and has undergone stent placement. He is currently asymptomatic. His vital signs are stable and his blood pressure is well controlled. Laboratory studies reveal a normal hemoglobin A1c and lipid profile. In addition to high-dose statin therapy, his current medication regimen includes the following:
Aspirin
Carvedilol (Coreg)
Chlorthalidone
Clopidogrel (Plavix)
Lisinopril (Zestril)
Adding which one of the following would help to provide secondary prevention of cardiovascular events in this patient?
A) Azithromycin (Zithromax)
B) Colchicine (Colcrys)
C) DHA
D) Niacin
E) Omega-3 supplements
B) Colchicine (Colcrys)
157. A 20-year-old female comes to your office for routine follow-up after recently finishing neck irradiation treatment for Hodgkin’s lymphoma. Her past medical history is otherwise significant for allergic rhinitis and GERD. She feels generally well after treatment. A physical examination is unremarkable. Which one of the following should be performed to monitor for complications from radiation?
A) No routine follow-up surveillance
B) Parathyroid hormone levels
C) Swallow studies
D) Carotid artery ultrasonography
E) Neck CT
D) Carotid artery ultrasonography
97. A 62-year-old male presents with a 2-day history of a painful abscess in his perianal area. He has a history of well controlled type 2 diabetes and hypertension and he currently takes metformin and lisinopril (Zestril). He also has a history of recurrent skin abscesses, which have responded well to oral sulfamethoxazole/trimethoprim (Bactrim). He has occasional chills but has not had a fever. On examination his vital signs are normal and you note the presence of a 2.5×2.5-cm perianal abscess. A point-of-care glucose level is 172 mg/dL and the results of a CBC are pending. Which one of the following would be the most appropriate next step?
A) Continue current management and follow up in 48 hours
B) Perform incision and drainage, obtain a culture, and start sulfamethoxazole/trimethoprim only
C) Perform incision and drainage, obtain a culture, and start oral linezolid (Zyvox)
D) Perform incision and drainage, obtain a culture, and start sulfamethoxazole/trimethoprim plus amoxicillin/clavulanate (Augmentin)
D) Perform incision and drainage, obtain a culture, and start sulfamethoxazole/trimethoprim plus amoxicillin/clavulanate (Augmentin)
152. A 25-year-old primigravida presents at 28 weeks gestation for a routine prenatal visit. She is undecided about breastfeeding versus bottle feeding and asks if breastfeeding provides any benefits for her own health. You advise her that breastfeeding would decrease her risk of later developing
A) colon cancer
B) diabetes mellitus
C) lung cancer
D) osteoarthritis
E) recurrent respiratory infections
B) diabetes mellitus
148. An 18-month-old male is brought to your office by his parents for a well child check. The child was born at 28 weeks gestation and had a month-long NICU stay but has remained healthy and out of the hospital since that time. He is up to date on vaccines and his growth and development are appropriate. He was on omeprazole (Prilosec) for GERD but the parents have recently stopped the medication and he is doing well. He received palivizumab (Synagis) monthly last year during respiratory syncytial virus (RSV) season and never developed a respiratory infection. His parents are hoping that he can receive palivizumab again this year to prevent complications if he develops RSV. He recently started attending day care and they are worried about his exposure risk. Which one of the following would you recommend this year for chemoprophylaxis against RSV in this patient?
A) No chemoprophylaxis
B) A single dose of palivizumab only if RSV exposure is confirmed
C) A single dose of palivizumab prior to RSV season
D) Monthly administration of palivizumab during RSV season
A) No chemoprophylaxis
151. A 17-year-old female sees you for a preparticipation evaluation for cross country running. She has not had any falls or other injuries and estimates that she runs 40 miles per week. Menarche occurred at age 12 but over the past year her periods have become irregular, with her last menses occurring about 4 months prior to presentation. She is not sexually active and a urine pregnancy test is negative. She and her parents tell you that she eats a healthy diet, although she does report an inadvertent weight loss of 15 lb as she has increased her running mileage over the past year. She takes a multivitamin and occasional acetaminophen for pain but does not take any chronic medications. A physical examination reveals a thin female who does not show any signs of acute distress. Her vital signs include a weight of 52 kg (115 lb), a height of 173 cm (68 in), a BMI of 18 kg/m2 , a heart rate of 50 beats/min, and a blood pressure of 85/44 mm Hg. Which one of the following is the most likely underlying cause of her condition?
A) Anemia
B) Anorexia nervosa
C) Low circulating estrogen levels
D) Low energy availability relative to needs
E) Vitamin D deficiency
D) Low energy availability relative to needs
154. A 55-year-old female presents for a telehealth visit because of a 2-month history of right lateral hip pain. Her symptoms began shortly after she started jogging. The pain worsened a week ago after a long car trip. She reports that the pain has been interfering with her sleep quality, particularly if she rests on her right side. You ask her to walk away from her video camera so you can observe her ambulation. You note a Trendelenburg gait with her body shifting to the right side. Which one of the following is the most likely diagnosis?
A) Femoroacetabular impingement
B) Greater trochanteric pain syndrome
C) A hamstring strain
D) A labral tear
E) Sacroiliac joint dysfunction
B) Greater trochanteric pain syndrome