Cardiology
A 63-year-old female with a history of obesity and hypertension sees you for evaluation of shortness of breath on exertion and lower extremity edema. Echocardiography shows grade 2 diastolic dysfunction and an ejection fraction of 50%. You diagnose heart failure with preserved ejection fraction. Which one of the following medications has the best evidence to reduce hospitalization due to heart failure or cardiovascular death in patients such as this?
A) Carvedilol (Coreg)
B) Empagliflozin (Jardiance)
C) Lisinopril (Zestril)
D) Sacubitril/valsartan (Entresto)
E) Spironolactone (Aldactone)
What is Empaglifozin (Jardiance)?
A 55-year-old male sees you because of heartburn and dysphagia. Esophagogastroduodenoscopy shows moderately severe esophagitis. Which one of the following is the most appropriate long-term pharmacologic management for this condition?
A) Famotidine (Pepcid), 10 mg daily
B) Metoclopramide (Reglan), 10 mg before meals
C) Omeprazole, 40 mg daily
D) Sucralfate (Carafate), 1 g twice daily
What is omeprazole, 40 mg daily?
A 63-year-old female presents with pain in her right hand. She states that for 3 months she has experienced a catching sensation and her ring finger occasionally locks into a claw-like form. On examination a nodule is palpated and her pain is localized to the volar surface of the metacarpophalangeal joint on her ring finger. When instructed to clench her fist and subsequently release, her ring finger remains in a flexed position. Which one of the following is considered first-line treatment for this condition?
A) Buddy taping
B) Transcutaneous electrical nerve stimulation (TENS) unit therapy
C) Corticosteroid injection
D) Physical therapy
E) Surgical release
What is a corticosteroid injection?
According to the American Diabetes Association, which one of the following hemoglobin A1c measurements fits the criteria for prediabetes?
A) 5%
B) 5.5%
C) 6%
D) 6.5%
What is 6%?
A Black female presents with multiple insect bites on her arms and legs. This patient is at risk for developing which one of the following conditions?
A) Acanthosis nigricans
B) Acne keloidalis nuchae
C) Dermatosis papulosa nigra
D) Melasma
E) Postinflammatory hyperpigmentation
What is Postinflammatory hyperpigmentation
For patients with atrial fibrillation requiring anticoagulation, which one of the following concomitant conditions would indicate a need for treatment with warfarin instead of a direct oral anticoagulant?
A) Congestive heart failure
B) Diabetes mellitus
C) A history of stroke
D) Hypertension
E) Severe mitral stenosis
What is severe mitral stenosis?
A 25-year-old male presents for a pretravel consultation prior to embarking on a 10-day mission trip to Central America with his church. His past medical history includes GERD, irritable bowel syndrome, and generalized anxiety disorder. The last time he traveled internationally he experienced a prolonged bout of traveler’s diarrhea, despite his best efforts at practicing good hand hygiene and careful food and drink selection. He asks if there are any medications that he can take to prevent a similar experience this time. Which one of the following is most appropriate for prophylactic use in this situation?
A) Bismuth subsalicylate (Pepto-Bismol)
B) Calcium carbonate (Tums)
C) Ciprofloxacin (Cipro)
D) Omeprazole
E) A probiotic containing Lactobacillus acidophilus
What is Bismuth subsalicylate (Pepto-Bismol)?
A 20-year-old college student comes to your office on Monday morning after injuring his right arm during a rugby match 2 days earlier. He is not certain of the mechanism of injury but was struck forcefully on the lower posterior part of his upper arm above the elbow. He describes paresthesias on the extensor side of his forearm and the back of his hand. His upper arm is bruised and mildly swollen at the described location. In addition to the paresthesias on the extensor forearm and the back of the hand, which one of the following motor findings would you expect?
A) An inability to maintain all fingers fanned out under resistance
B) Weakness of elbow flexion with the hand in a prone position
C) Weakness of finger and wrist extension under resistance
D) Weakness of flexion of the fourth and fifth fingers
E) Weakness of thumb apposition
What is weakness of finer and wrist extension under resistance?
Which one of the following endocrine conditions is most commonly associated with long-term opioid therapy?
A) Hyperprolactinemia
B) Hypocortisolism
C) Hypogonadism
D) Hypoparathyroidism
E) Hypothyroidism
What is hypogonadism?
Newborn screening for critical congenital heart disease with pulse oximetry is recommended for
A) all infants within the first 6 hours of life
B) all infants before 24 hours of life
C) all infants 24 hours or more after birth
D) only infants with clinical signs of hypoxemia
E) only infants with a heart murmur
What is all infants 24 hours or more after birth?
A 63-year-old male presents to your office because of intermittent chest pain with exertion. He has been building a new deck and noted the onset of chest pain following particularly intense workdays. He reports that the pain always resolves with rest, and he has not noticed any lower extremity edema or difficulty breathing. His past medical history is notable only for hypertension and coronary artery disease diagnosed 3 years ago. His current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Zestril), 10 mg daily; and aspirin, 81 mg daily. His vital signs include a weight of 80 kg (176 lb), a height of 178 cm (70 in), a blood pressure of 138/78 mm Hg, a pulse rate of 80 beats/min, a respiratory rate of 12/min, and an oxygen saturation of 96% on room air. A physical examination is normal. An EKG reveals normal sinus rhythm without ST-segment, T-wave, or Q-wave abnormalities. In addition to prescribing as-needed, immediate-release nitroglycerin, which one of the following would be the most appropriate pharmacotherapy at this time?
A) Diltiazem (Cardizem LA), 180 mg daily
B) Ezetimibe (Zetia), 10 mg daily
C) Isosorbide mononitrate, 30 mg daily
D) Metoprolol succinate (Toprol-XL), 100 mg daily
E) Ranolazine (Ranexa), 500 mg twice daily
A 55-year-old male presents with intermittent epigastric pain, early satiety, and bloating. His symptoms have been present for years with minimal change. You suspect a diagnosis of functional dyspepsia. Which one of the following additional findings would constitute an alarm symptom and warrant further workup?
A) Epigastric tenderness
B) Increased abdominal pain when the abdominal wall muscles are tensed
C) Lymphadenopathy
D) Nausea
E) Weight gain
What is lymphadenopathy?
A local corticosteroid injection is most likely to result in sustained improvement when offered early in the course of which one of the following conditions?
A) Adhesive capsulitis
B) De Quervain tenosynovitis
C) Lateral epicondylitis
D) Osteoarthritis of the knee
E) Subacromial impingement syndrome
What is De Quervain tenosynovitis?
A 35-year-old female with previously regular menses presents with a 3-month history of amenorrhea, hot flashes, and increased irritability. A pregnancy test is negative, an estrogen level is low, and an FSH level is markedly elevated. There is no change in repeat testing 1 month later and you make a diagnosis of primary ovarian insufficiency. Further testing does not reveal a cause for her condition. She does not desire more children. Which one of the following should you recommend to this patient for hormone replacement therapy?
A) No treatment
B) Transdermal estradiol without progestogen
C) Continuous oral estradiol without progestogen
D) Continuous oral estradiol and cyclic progestogen
E) Continuous oral estradiol and a levonorgestrel IUD (Mirena)
What is continuous oral estradiol and levonorgestrel IUD (Mirena)?
A 53-year-old female sees you because she would like treatment for hot flashes that she finds quite bothersome. Her last menstrual period was 8 months ago. She has a history of unprovoked deep vein thrombosis and a history of depression that is treated with venlafaxine (Effexor XR). In addition to optimizing the dosage of her venlafaxine, which one of the following would be most effective for treatment of her hot flashes?
A) Black cohosh
B) Clonidine
C) Gabapentin (Neurontin)
D) Oral progesterone
E) Topiramate (Topamax)
What is gabapentin (Neurontin)
A 25-year-old male with no significant past medical history comes to your office to establish care. A physical examination reveals a cardiac murmur that has not been documented previously. Which one of the following findings would be most concerning for hypertrophic cardiomyopathy as the cause of his murmur?
A) A diastolic murmur that increases in the left lateral decubitus position
B) A systolic murmur that increases with an isometric handgrip
C) A systolic murmur that increases when moving from squatting to standing
D) A systolic murmur that decreases with the Valsalva maneuver
E) A fixed split of the second heart sound
What is a systolic murmur that increases when moving from squatting to standing?
A 45-year-old male sees you for a routine health maintenance examination. You screen him for hepatitis C. A hepatitis IgG antibody is positive but on reflex testing there is no detectable viral RNA. When discussing the test results with him, he reports past use of injected opioids and intermittent use of cocaine. To his knowledge he has never been diagnosed with viral hepatitis. Regarding hepatitis C, the patient’s history and test results indicate
A) current infection with need for treatment
B) exposure less than 2 weeks prior to screening
C) a false-positive result
D) previous infection with immunity to future infection
E) previous infection with susceptibility to future infection
What is previous infection with susceptibility to future infection?
A 70-year-old male presents with an acutely painful, swollen right knee that developed over 2–3 days without any known cause. There is no other joint pain. He has had similar, less severe episodes off and on in the past. He feels well otherwise and has not had any fever, chills, or rash. Examination of other joints is negative except for some degenerative changes of the distal interphalangeal joints of the fingers. Examination of the right knee is notable for warmth, redness, diffuse tenderness, and swelling. There is no evidence of knee instability, meniscal injury, or trauma. A knee x-ray shows soft-tissue swelling and chondrocalcinosis (calcification of the cartilage). Knee aspiration is performed and a synovial fluid Gram stain is negative for bacteria with other results pending. Which one of the following is the most likely explanation for these knee findings? A) Calcium pyrophosphate deposition disease (pseudogout)
B) Gout
C) Osteoarthritis
D) Psoriatic arthritis
E) Septic arthritis
What is calcium pyrophosphate deposition disease (pseudogout)?
A 45-year-old female presents with a 1-week history of pain at the base of her anterior neck radiating to her right jaw. Prior to the onset of pain she had a sore throat, fever, and body aches. These symptoms resolved and the neck pain started. She now reports palpitations and excessive sweating. Her vital signs include a pulse rate of 110 beats/min, a blood pressure of 140/83 mm Hg, and a normal temperature. On examination she appears uncomfortable and diaphoretic. An HEENT examination is unremarkable and you note no cervical lymphadenopathy. Her thyroid is tender and mildly enlarged. A cardiac examination shows tachycardia with no murmurs. Laboratory studies reveal a normal CBC, an erythrocyte sedimentation rate of 55 mm/hr (N 0–29), and a TSH level of 0.21 U/mL (N 0.5–5.0). Total T3 and free T4 levels are within the normal range. You order a radioactive iodine uptake scan, which shows diffusely low iodine uptake in her thyroid. In addition to a -blocker, which one of the following would be most appropriate at this point?
A) Ibuprofen, 800 mg three times daily
B) Levothyroxine (Synthroid), 50 g daily
C) Methimazole, 5 mg three times daily
D) Prednisone, 40 mg daily
E) Vancomycin, 20 mg/kg intravenously every 12 hours
What is Ibuprofen, 800 mg three times daily?
A 12-year-old female with Down syndrome is brought to your office by her parents to establish care after recently moving to the area. Which one of the following laboratory studies should you routinely check on an annual basis?
A) A TSH level only
B) A lipid panel only
C) A CBC with differential and a lipid panel
D) A CBC with differential, and TSH and IgA tissue transglutaminase (tTG) levels
E) A CBC with differential, and serum iron, total iron-binding capacity, and TSH levels
What is a CBC, serum iron, TIBC, and TSH?
A 74-year-old patient presents to your office for medical clearance for an upcoming surgery. In addition to basic laboratory studies requested by the surgeon, you obtain an EKG (see PPT). The EKG is most consistent with which one of the following?
A) Left bundle branch block
B) Right bundle branch block
C) Right ventricular hypertrophy
D) Paced rhythm
E) Wolff-Parkinson-White syndrome
What is right bundle branch block?
A 48-year-old male presents to the emergency department for an initial episode of acute gallstone pancreatitis with a lipase level of 700 U/L (N 10–140). A right upper quadrant ultrasound shows gallstones within the gallbladder but is otherwise normal. He is treated with intravenous fluids and medications to control pain and nausea, and is admitted to a regular medical floor bed. The next morning he reports that his symptoms are improving with oral medications. A physical examination is notable for normal vital signs and mild epigastric tenderness. A comprehensive metabolic panel shows improving leukocytosis and stable parameters including a normal bilirubin level. Which one of the following management options is most appropriate in this situation?
A) Rechecking a serum lipase level and starting oral feeding if the result is normal
B) Initiating enteral feeding through a nasojejunal tube
C) Initiating parenteral feeding through an intravenous line
D) Consulting a gastroenterologist for endoscopic retrograde cholangiopancreatography (ERCP)
E) Consulting a general surgeon for cholecystectomy during this admission
What is consulting a general surgeon for cholecystectomy during this admission?
A 72-year-old male presents to your office because of right hip pain and difficulty walking. He notes that the pain is relieved by activity and is worse at night. You obtain a plain film of the hip (See PPT). An elevation in which one of the following laboratory results would confirm the diagnosis?
A) Alkaline phosphatase
B) Calciferol
C) Creatine phosphokinase
D) Gamma-glutamyl transpeptidase
E) Phosphorus
What is alkaline phosphatase?
A previously healthy 58-year-old female sees you for evaluation of increased hair growth on her face and a weight gain of 18 kg (40 lb) over the past year. An examination is significant for a blood pressure of 155/98 mm Hg, a BMI of 34 kg/m2 with a truncal obesity pattern, striae on the sides of the torso and lower abdomen, marked hirsutism, and a rounded, swollen facial appearance. A urine pregnancy test is negative. Liver and renal function tests are normal, as are TSH, electrolyte, testosterone, and DHEA levels. A hemoglobin A1c is 6.2%. Which one of the following would be most useful to diagnose the condition suggested by this patient’s presentation?
A) A 24-hour urinary free cortisol level
B) 24-hour urinary metanephrines
C) ACTH stimulation testing
D) FSH and LH levels
E) Plasma renin activity testing and an aldosterone level
What is a 24-hour urinary free cortisol level?
A randomized, controlled study of 300 participants tested the effectiveness of a new medication to reduce breast cancer–related deaths. Within 2 years of treatment, 15 out of 150 participants with breast cancer in the treatment group died, while 60 out of the 150 participants in the control group died. Based on this study, what is the number needed to treat to prevent one breast cancer–related death?
A) 2
B) 3
C) 5
D) 10
E) 15
What is 3?