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100
Which one of the following is true regarding respiratory syncytial virus (RSV) infection? A. Most infections in the United States occur between August and December, B. Corticosteroids should be a routine part of treatment, C. The diagnosis is usually based on positive serology, D. It is rarely associated with bacterial co-infection
What is D. It is rarely associated with bacterial co-infection Respiratory syncytial virus (RSV) is a common cause of respiratory tract infections in children. The infections are usually self-limited and are rarely associated with bacterial co-infection, but in very young infants, prematurely born infants, or those with pre-existing heart/lung conditions, the infection can be severe. In North America, RSV season is November to April. Treatment is primarily supportive, including a trial of bronchodilators, with continued use only if there is an immediate response. Corticosteroids and antibiotics are not routinely indicated (SOR B). Routine laboratory and radiologic studies should not be used in making the diagnosis, as it is based on the history and physical examination (SOR C).
100
A 67-year-old male with moderate macrocytosis complains of paresthesias of his feet. If the patient has a borderline low vitamin B12 level, elevated levels of which one of the following would suggest vitamin B12 deficiency? A. Serum gastrin, B. Reticulocytes, C. Methylmalonic acid, D. Serum ferritin, E. Serum folate
What is C. Methylmalonic acid Neurologic symptoms may develop with low-normal vitamin B12 levels in serum. In true vitamin B12 deficiency, methylmalonic acid and homocysteine levels are typically quite elevated, and these return to normal with treatment
100
A healthy 68-year-old male is seen in December for a routine examination. A review of his immunizations indicates that he received a standard dose of inactivated influenza vaccine at the health clinic in September. He received 23-valent pneumococcal vaccine (Pneumovax 23) at age 65. He should now receive which one of the following? A. High-dose influenza vaccine, B. 13-valent pneumococcal conjugate vaccine (Prevnar 13), C. 23-valent pneumococcal vaccine, D. No vaccines at this time
What is B. 13-valent pneumococcal conjugate vaccine (Prevnar 13) The Advisory Committee on Immunization Practices advises that the 13-valent pneumococcal vaccine be given in addition to the 23-valent vaccine, preferably before the 23-valent vaccine. Only one dose of influenza vaccine is recommended per season. A single dose of 23-valent pneumococcal vaccine is all that is required
100
A 50-year-old male presents to your office with a 1-hour history of an intense retro-orbital headache. This started while he was jogging and eased somewhat when he stopped, but has persisted along with some pain in his neck. Other than a blood pressure of 165/100 mm Hg, his examination is unremarkable. Noncontrast CT of the head is also unremarkable. His pain has persisted after 2 hours in the emergency department. Which one of the following would be most appropriate at this time? A. MRI of the head, B. Angiography, C. Nifedipine (Procardia) sublingually, D. Sumatriptan (Imitrex) subcutaneously, E. A lumbar puncture
What is E. A lumbar puncture Early diagnosis of a nontraumatic subarachnoid emorrhage is paramount for achieving a good outcome when a patient presents with a headache that is unusually severe and feels different than other headaches. Risk factors include smoking, hypertension, heavy alcohol use, and a family history of aneurysm or hemorrhagic stroke. The initial evaluation should consist of noncontrast CT of the head (SOR C). If it is negative or equivocal the next step would be to perform a lumbar puncture to determine whether or not the cerebrospinal fluid is xanthochromic. The absence of xanthochromia rules out subarachnoid hemorrhage (SOR C).
100
YOU CAN'T SIT WITH US!
What is Mean Girls
200
A 4-week-old white male is brought to your office with a 2-week history of increasing dyspnea, cough, and poor feeding. The child appears nontoxic and is afebrile. On examination you note conjunctivitis, and a chest examination reveals tachypnea and crackles. A chest film shows hyperinflation and diffuse interstitial infiltrates and a WBC count reveals eosinophilia. A. Staphylococcus species, B. Chlamydia trachomatis, C. Respiratory syncytial virus, D. Parainfluenza virus
What is B. Chlamydia trachomatis Chlamydial pneumonia is usually seen in infants 3–16 weeks of age, and these patients frequently have been sick for several weeks. The infant appears nontoxic and is afebrile, conjunctivitis is present in about 50% of cases. A chest film will show hyperinflation and diffuse interstitial or patchyinfiltrates.
200
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the severity of anorexia nervosa is based on which one of the following? A. Refusal to eat, B. The frequency of episodes of binge eating or purging behavior, C. Body mass index (BMI), D. The presence or absence of amenorrhea, E. Orthostatic changes in pulse or blood pressure
What is C. Body mass index (BMI) According to the DSM-5, the level of severity of anorexia nervosa is based on the patient’s body mass index (BMI). Mild is a BMI >17.0 kg/m2, moderate is a BMI of 16.0–16.99 kg/m2, severe is a BMI of 15.0–15.9 kg/m2, and extreme is a BMI <15.0 kg/m2. Recurrent episodes of binge eating or purging behavior help differentiate restricting type from binge-eating/purging type, but do not indicate severity. Orthostatic changes in pulse or blood pressure and refusal to eat are criteria for inpatient hospitalization, but are not part of the classification of severity according to the DSM-5.
200
36-year-old obese female presents to your office with a chief complaint of amenorrhea. On examination you note hirsutism and body acne. She is on no medications and a pregnancy test is negative. Serum testosterone is at the upper limits of normal and TSH is within normal limits. In addition to weight loss and exercise, which one of the following would be the most appropriate initial management? A. High-dose combined oral contraceptives, B. Progestin-only contraceptives, C. Metformin, Glucophage), D. Levothyroxine (Synthroid)
What is C. Metformin (Glucophage) This patient has polycystic ovary syndrome, which is characterized by hyperandrogenism on clinical and laboratory evaluations, polycystic ovaries on pelvic ultrasonography, and ovulatory dysfunction. Hyperandrogenism and either polycystic ovaries or ovulatory dysfunction are necessary to make the diagnosis. The first-line recommendation in obese patients is lifestyle modification, but metformin may improve abnormal menstruation (SOR A).
200
Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum levels of: A. cortisol, B. creatine phosphokinase, C. creatinine, D. LDH, E. TSH
What is E. TSH Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a patient on amiodarone have baseline thyroid function tests (free T4, TSH) with follow-up testing every 6 months to monitor for these conditions.
200
Mom the meatloaf!!
What is Wedding Crashers
300
A mother brings her 2-year-old daughter to your office because the child is not using her left arm. Earlier in the day the mother left the toddler under the supervision of her 12-year-old sister while she went to the store. When she returned the toddler was playing with toys using only her right arm, and was holding the left arm slightly pronated, flexed, and close to her body. The older daughter was unaware of any injury to the girl’s arm, and the child does not seem distressed or traumatized. Physical examination of the child’s clavicle, shoulder, wrist, and hand do not elicit any signs of pain or change in function. She does seem to have some tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow. A. Plain radiographs of the affected elbow, B. Ultrasonography of the affected elbow, C. Evaluation by an orthopedic surgeon within 24 hours, D. Attempted reduction of the subluxed radial head, E. Placement in a splint and follow-up in the office if there is no improvement in the next 1–2 weeks
What is D. Attempted reduction of the subluxed radial head Radial head subluxation, or nursemaid’s elbow, is the most common orthopedic condition of the elbow in children 1–4 years of age, although it can be encountered before 1 year of age and in children as old as 9 years of age. The mechanism of injury is partial displacement of the radial head when the child’s arm undergoes axial traction while in a pronated and fully extended position. The classic history includes a caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is recalled.
300
A factory worker sustains a forced flexion injury of the distal interphalangeal (DIP) joint, resulting in a small bone fragment at the dorsal surface of the proximal distal phalanx (mallet fracture). Which one of the following is the most appropriate management strategy? A. Buddy taping and early range of motion, B. Splinting the DIP joint in extension, C. Splinting the DIP joint in flexion, D. Referral for surgical repair
What is B. Splinting the DIP joint in extension The recommended treatment for a mallet fracture is splinting the distal interphalangeal (DIP) joint in extension (SOR B). The usual duration of splinting is 8 weeks. It is important that extension be maintained throughout the duration of treatment because flexion can affect healing and prolong the time needed for treatment. If the finger fracture involves >30% of the intra-articular surface, referral to a hand or orthopedic surgeon can be considered. However, conservative therapy appears to have outcomes similar to those of surgical treatment and therefore is generally preferred.
300
A 30-year-old ill-appearing male presents with right hand and arm pain and a rapidly expanding area of redness. On examination he has a temperature of 38.9°C (102.0°F), a pulse rate of 120 beats/min, and a blood pressure of 116/74 mm Hg. He also has erythema from the dorsal hand to the elbow, violaceous bullae on the dorsal hand and wrist, and severe pain with dorsiflexion of the wrist or fingers. Which one of the following is the most appropriate initial step in the management of this patient? A. Oral dicloxacillin and outpatient follow-up within the next 24 hours, B. Intravenous metronidazole, C. Consultation with an infectious disease specialist for antibiotic management, D. Immediate surgical consultation for operative debridement, E. Incision and drainage with wound cultures in the emergency department
What is D. Immediate surgical consultation for operative debridement This patient has physical findings consistent with a necrotizing skin and soft-tissue infection, or necrotizing fasciitis. Severe pain and skin changes outside the realm of cellulitis, including bullae and deeper discoloration, are strong indications of necrotizing fasciitis. Antimicrobial therapy is essential but is not sufficient by itself; aggressive surgical debridement within 12 hours reduces the risk of amputation and death.
300
Which one of the following drugs is NOT effective for maintenance therapy in bipolar disorders? A. Haloperidol, B. Lamotrigine (Lamictal), C. Lithium, D. Quetiapine (Seroquel), E. Valproate sodium (Depacon)
What is A. Haloperidol Lithium, valproate, lamotrigine, and some antipsychotics (including quetiapine) are effective treatments for both acute depression and maintenance therapy of bipolar disorders. Haloperidol is an effective treatment for acute mania in bipolar disorders, but not for maintenance therapy or acute depression.
300
Show me the money!
What is Jerry MacGuire
400
You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with her appearance and possible future disability, and request that she be treated. You recommend which one of the following? A. Observation, B. Medial shoe wedges, C. Torque heels, D. Sleeping in a Denis Browne splint for 6 months, E. Derotational osteotomy of the femur
What is A. Observation There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8–10 years of age who still have cosmetically unacceptable, dysfunctional gaits.
400
An 80-year-old female is seen for progressive weakness over the past 8 weeks. She says she now has difficulty with normal activities such as getting out of a chair and brushing her teeth. Her medical problems include hypertension, diabetes mellitus, and hyperlipidemia. Her medications include glipizide (Glucotrol), simvastatin (Zocor), and lisinopril (Prinivil, Zestril). Findings on examination are within normal limits except for diffuse proximal muscle weakness and normal deep tendon reflexes. A CBC, urinalysis, erythrocyte sedimentation rate, TSH level, and serum electrolyte levels are normal. Her blood glucose level is 155 mg/dL and her creatine kinase level is 1200 U/L (N 40–150). Which one of the following is the most likely diagnosis? A. Statin-induced myopathy, B. Polymyalgia rheumatica, C. Guillain-Barre syndrome, D. Diabetic ketoacidosis
What is A. Statin-induced myopathy This patient is most likely suffering from a drug-induced myopathy caused by simvastatin, which is associated with elevated creatine kinase. Polymyalgia rheumatica is usually associated with an elevated erythrocyte sedimentation rate. Guillain-Barré syndrome is associated with depressed deep tendon reflexes.
400
While performing a routine physical examination on a 42-year-old female you discover an apparent nodule in the left lobe of the thyroid measuring approximately 1 cm in diameter, which is confirmed on ultrasonography. The most appropriate next step in the evaluation of this finding is a: A. serum calcitonin level, B. serum free T3 level, C. serum TSH level, D. serum thyroglobulin level, E. radionuclide thyroid scan
What is C. serum TSH level Thyroid nodules >1 cm that are discovered incidentally on examination or imaging studies merit further evaluation. Nodules <1 cm should also be fully evaluated when found in patients with a family history of thyroid cancer, a personal history of head and neck irradiation, or a finding of cervical node enlargement. Reasonable first steps include measurement of TSH or ultrasound examination. The American Thyroid Association’s guidelines recommend that TSH be the initial evaluation (SOR A) and that this be followed by a radionuclide thyroid scan if results are abnormal. Diagnostic ultrasonography is recommended for all patients with a suspected thyroid nodule, a nodular goiter, or a nodule found incidentally on another imaging study (SOR A). Routine measurement of serum thyroglobulin or calcitonin levels is not currently recommended.
400
Effective treatments for obsessive-compulsive disorder include (check one). A. Freudian analysis, B. benzodiazepines, C. amphetamine salts, D. atypical antipsychotics, E. repetitive exposure to fearful stimuli
What is E. repetitive exposure to fearful stimuli In obsessive-compulsive disorder (OCD), intrusive thoughts cause anxiety, which patients suppress with recurring behaviors. Various types of psychotherapy have been tried, but repeated exposure to fearful stimuli has been the best. Repeated and prolonged exposure to stimuli that elicit fear, combined with strict avoidance of any compulsive behaviors, seems to be the most effective method for controlling the obsessive-compulsive behaviors. Tricyclic antidepressants and SSRIs are also effective for treating OCD.
400
A census taker once tried to test me. I ate his liver with some fava beans and a nice Chianti.
What is The Silence of the Lambs
500
The most common source of chest pain in children is: A. pulmonary, B. cardiac, C. musculoskeletal, D. gastroesophageal, E. psychogenic
What is C. musculoskeletal The most common cause of chest pain in children is musculoskeletal (50%–60%) followed by psychogenic (10%–30%) and respiratory causes (3%–12%). Cardiac conditions account for 0%–5% of cases of chest pain in children. Red flags that suggest a cardiac etiology include a patient history of palpitations with the chest pain, an abnormal cardiac physical examination (rubs or gallops), exertional chest pain without another more likely etiology such as asthma, and a positive family history.
500
A 30-year-old female stepped off a curb earlier today and twisted her left ankle. She was able to bear weight immediately following the injury and tried to continue her normal routine, but the pain in her ankle and foot increased over the next few hours. She comes to your office and your examination reveals swelling of the ankle and bruising of the lateral foot. Tenderness to palpation is present over the distal aspect of the fibula and lateral malleolus and to a lesser degree over the proximal fifth metatarsal. No bony tenderness is present along the medial aspect of the ankle or foot. List the Ottawa Ankle Rules, then which one of the following would be most appropriate at this point? A. Radiographs of the ankle and foot, B. Radiographs of the foot only, C. Radiographs of the ankle only, D. No radiographs
What is Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR An inability to bear weight both immediately and in the emergency department for four steps. OR Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR Bone tenderness at the navicular bone (for foot injuries) A. Radiographs of the ankle and foot
500
A 45-year-old male with diabetes mellitus returns to your office for follow-up. He is on metformin (Glucophage), 1000 mg/day, as well as atorvastatin (Lipitor), 40 mg daily for hyperlipidemia. There is no diagnosis of hypertension, and his blood pressure at today’s visit is 120/70 mm Hg. Laboratory results include a hemoglobin A1c of 6.4% and an LDL-cholesterol level of 105 mg/dL. His urine albumin/creatinine ratio is in the microalbuminuric range for the first time. Which one of the following would be most appropriate at this point? A. Renal ultrasonography, B. A repeat urine albumin/creatinine ratio, C. 24-hour urine for microalbumin, D. Increasing the atorvastatin dosage, E. Stopping metformin
What is B. A repeat urine albumin/creatinine ratio This normotensive diabetic patient, appropriately screened for microalbuminuria, should have this finding confirmed on at least one of two additional spot tests, since emporary factors other than nephropathy can also result in microalbuminuria. Once a diagnosis of chronic kidney disease is confirmed, renal ultrasonography should be ordered to detect potentially reversible causes. A 24-hour urine is not necessary since the urine microalbumin/creatinine ratio correlates well with a 24-hour urine for albumin. Metformin is not ontraindicated in the presence of microalbuminuria alone without a decline in the glomerular filtration rate
500
A 77-year-old male presents with significant postherpetic neuralgia in a chest wall distribution. Which one of the following is most likely to be effective in diminishing his discomfort? A. Oral valacyclovir (Valtrex), B. Topical lidocaine (Xylocaine) patches, C. Steroids, D. Herpes zoster vaccine E. Acupuncture
What is B. Topical lidocaine (Xylocaine) patches Antiviral drugs are useful for treatment of acute herpes zoster but not for treatment of postherpetic neuralgia. Herpes zoster vaccine can prevent postherpetic neuralgia by reducing the incidence of herpes zoster but it has no role in the treatment of neuralgia. Neither acupuncture nor epidural corticosteroid injections are helpful in treating postherpetic neuralgia. Topical agents such as lidocaine patches and capsaicin cream or patches have been shown to reduce symptoms of postherpetic neuralgia, as have the oral agents gabapentin, pregabalin, and amitriptyline.
500
I'm gonna make him an offer he can't refuse.
What is The Godfather