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100
A 43-year-old female smoker has type 2 diabetes mellitus, morbid obesity, and a recent diagnosis of symptomatic peripheral arterial disease. You have started her on atorvastatin (Lipitor), offered a supervised exercise program, and discussed smoking cessation and interventions. Which one of the following should be recommended to prevent cardiovascular events in this patient? A) Aspirin B) Cilostazol (Pletal) C) Enoxaparin (Lovenox) D) Pentoxifylline E) Warfarin (Coumadin)
ANSWER: A Patients with symptomatic peripheral arterial disease should be started on a daily dose of either aspirin or clopidogrel to prevent cardiovascular events such as acute myocardial infarction or stroke (SOR B). Cilostazol is a phosphodiesterase inhibitor with both antiplatelet and arterial vasodilatory activity. It has been shown to improve claudication symptoms by 50% compared to placebo. Likewise, pentoxifylline is also used in the treatment of claudication symptoms but is less effective than cilostazol and is reserved as a second-line agent. Neither agent has been shown to decrease cardiovascular events in patients with symptomatic peripheral artery disease. Neither enoxaparin nor warfarin is indicated for symptomatic peripheral artery disease.
100
A study finds that the positive predictive value of a new test for breast cancer is 75%, which means that A) among patients with known breast cancer who had the test, 75% had a positive test B) among patients with no breast cancer who had the test, 75% had a negative test C) 75% of patients who tested positive actually had breast cancer D) 75% of patients who tested negative did not have breast cancer
ANSWER: C Positive predictive value refers to the percentage of patients with a positive test for a disease who actually have the disease. The negative predictive value of a test is the proportion of patients with negative test results who do not have the disorder. The percentage of patients with a disorder who have a positive test for that disorder is a test’s sensitivity. The percentage of patients without a disorder who have a negative test for that disorder is a test’s specificity.
100
A 64-year-old male comes to your office for evaluation of a persistent rash affecting his groin. It is itchy but not painful and does not affect his daily activities. He has tried over-the-counter antifungal creams without relief. On examination you find well-demarcated, dark red patches in the inguinal region bilaterally. When examined with a Wood’s light the area fluoresces coral-red. The most effective treatment for this condition is topical A) ketoconazole (Nizoral) B) erythromycin C) hydrocortisone D) mupirocin (Bactroban) E) terbinafine (Lamisil)
ANSWER: B Coral-red fluorescence on Wood’s light examination is typical of infection with Corynebacterium minutissimum, a condition known as erythrasma. This organism commonly complicates intertrigo, often in the groin or interdigital spaces. Erythromycin is the most effective treatment for this bacterial infection.
100
While performing a routine annual physical on a 42 year-old woman, you find 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
NSWER: C 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.
100
An 86-year-old female nursing-home resident has type 2 diabetes mellitus, chronic diastolic heart failure, chronic kidney disease, advanced osteoarthritis, hypertension, Alzheimer’s disease, and other comorbidities. She requires assistance with dressing, bathing, and feeding. For this patient, the American Geriatrics Society recommends a hemoglobin A1c goal of A) <7.0% B) <8.0% C) <8.5% D) <9.0% E) <9.5%
ANSWER: C The American Geriatrics Society consensus report for considering treatment goals for glycemia recommends a hemoglobin A1c goal of <8.5% for individuals with very complex health problems or poor health. This includes individuals in long-term care and those with end-stage chronic illnesses, moderate to severe cognitive impairment, or more than two activity of daily living (ADL) dependencies. A hemoglobin A1c <8.5% equates to an estimated average glucose level of approximately 200 mg/dL. Looser glycemic targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.
200
You are the medical director of a long-term-care facility that has 60 residents. Several patients experience fever, cough, and upper respiratory symptoms. Two of these patients test positive for influenza A (H1N1) virus. Which one of the following is recommended by the Centers for Disease Control and Prevention (CDC) for this situation? A) Chemoprophylaxis with appropriate medications for all residents B) Treatment initiated on an individual basis once testing confirms that a resident has influenza C) Prophylaxis only for staff who have had direct patient contact with a resident with laboratory-confirmed infection D) No chemoprophylaxis for staff or residents who have been appropriately vaccinated
ANSWER: A The occurrence of two or more laboratory-confirmed cases of influenza A is considered an outbreak in a long-term care facility. The CDC has specific recommendations for managing an outbreak, which include chemoprophylaxis with an appropriate medication for all residents who are asymptomatic and treatment for all residents who are symptomatic, regardless of laboratory confirmation of infection or vaccination status. All staff should be considered for chemoprophylaxis regardless of whether they have had direct patient contact with an infected resident or have received the vaccine. Requesting restriction of visitation is recommended; however, it cannot be strictly enforced due to residents’ rights.
200
The specificity of a screening test is best described as the proportion of persons A) with the condition who test positive B) with the condition who test negative C) with the condition who test positive, compared to the total number screened D) without the condition who test positive E) without the condition who test negative
ANSWER: E A screening test’s specificity is the proportion of persons without the condition who test negative for that condition. In other words, it is a measure of the test’s ability to properly identify those who do not have the disease. Conversely, the sensitivity of a screening test is the proportion of those with the condition who test positive. The other options listed describe false-negatives, false-positives, and prevalence.
200
Which one of the following is most appropriate in the management of frostbite? A) Complete surgical debridement of hemorrhagic blisters B) Rapid rewarming with dry heat and warm blankets C) Withholding analgesics to ensure accurate assessment D) Vigorously rubbing affected tissues to restore circulation E) Leaving simple, non-tense areas of clear blistering intact
ANSWER: E Because of an increased risk of infection, simple non-tense areas of clear blistering in a frostbitten patient are best left intact. Tense or hemorrhagic blisters may be carefully aspirated, but only under sterile conditions. Rapid rewarming of affected areas is best done in a whirlpool bath containing a mild antiseptic at 40°C–41°C. Freezing injuries are extremely painful and analgesics are indicated. Vigorous rubbing of affected tissue is contraindicated, as it may lead to further tissue loss.
200
A 50-year-old female sees you for follow-up of uncontrolled hypertension. Her recent blood pressure measurements average >175/105 mm Hg. The patient has diabetes mellitus and a BMI of 32.3 kg/m2. Physical findings are otherwise noncontributory. Recent laboratory studies include three different potassium levels <3.5 mEq/L (N 3.5–5.0) despite increasing dosages of oral potassium supplements, with the dosage now at 100 mEq daily. Which one of the following would be most appropriate at this point? A) Measurement of peripheral aldosterone concentration and peripheral renin activity B) CT of the abdomen C) Renal CT angiography D) An aldosterone suppression test
ANSWER: A Hyperaldosteronism, usually caused by a hyperaldosterone-secreting adrenal mass, has to be considered in a middle-aged patient with resistant hypertension and hypokalemia. Peripheral aldosterone concentration (PAC) and peripheral renin activity (PRA), preferably after being upright for 2 hours, are the preferred screening tests for hyperaldosteronism. A PAC >15 ng/dL and a PAC/PRA ratio >20 suggest an adrenal cause. Abdominal CT may miss adrenal hyperplasia or a microadenoma. Renal CT angiography is useful for detecting renal artery stenosis. If the PAC/PRA is abnormal, an aldosterone suppression test should be ordered.
200
In a patient with symptoms of thyrotoxicosis and elevated free T4, the presence of thyroid TSH receptor site antibodies would indicate which one of the following as the cause of thyroid gland enlargement? A) Toxic multinodular goiter B) Toxic adenoma C) Hashimoto’s (lymphadenoid) thyroiditis D) Subacute (giant cell) thyroiditis E) Graves disease
ANSWER: E When there is a question about the cause of goiter and thyrotoxicosis, the presence of TSH receptor immunoglobulins indicates Graves disease. The prevalence of specific forms of TSH receptor site antibodies can distinguish Graves disease from Hashimoto’s disease. Both are autoimmune diseases, but in Graves disease there is a predominance of TSH receptor antibodies. In Hashimoto’s disease TSH receptor–blocking antibodies are more predominant. These immunoglobulins tend to disappear with therapy.
300
Which one of the following is associated with treatment of COPD with inhaled corticosteroids? A) An increased risk of monilial vaginitis B) An increased risk of bruising C) Consistent improvement in FEV1 D) A decreased risk of pneumonia E) Decreased mortality
ANSWER: B Inhaled corticosteroids increase the risk of bruising, candidal infection of the oropharynx, and pneumonia. They also have the potential for increasing bone loss and fractures. They decrease the risk of COPD exacerbations but have no benefit on mortality and do not improve FEV1 on a consistent basis.
300
A new serum marker has been developed for the diagnosis of pulmonary embolism. The test has a likelihood ratio of 1. Which one of the following conclusions can be made from this information? A) The test can confirm pulmonary embolism B) The test rules out pulmonary embolism C) The test can neither confirm nor rule out pulmonary embolism D) The likelihood ratio does not determine how well a test performs
ANSWER: C The likelihood ratio (LR) is the ratio of the probability of a specific test result in people who have a particular disease to the probability in people who do not. LRs correspond to the clinical impression of how well a test rules in or rules out a given disease. A test with an LR of 1.0 indicates that it does not change the probability of disease. The higher above 1 the LR is, the more likely it is that the disease is present (an LR >10 is considered good). Conversely, the lower the LR is below 1, the more likely it is that the disease is not present (an LR <0.1 is considered good). Likelihood ratios are alternative statistics for summarizing diagnostic accuracy, and have several particularly powerful properties that make them more useful clinically than other statistics.
300
A mother brings in her 10-year-old son because of a swollen area in his neck that she first noticed yesterday. He has also had symptoms of an upper respiratory infection. On examination the child has a runny nose but otherwise appears well. Palpation reveals a soft, 1.5-cm, slightly tender mass, inferior to the angle of the mandible and anterior to the sternocleidomastoid muscle. The most likely diagnosis is A) thyroglossal duct cyst B) dermoid cyst C) branchial cleft cyst D) thyroid tumor
ANSWER: C In children, neck masses usually fall into one of three categories: developmental, inflammatory/reactive, or neoplastic. The history and physical examination can help narrow the diagnosis, with location of the mass being particularly helpful. Branchial cleft cysts make up approximately 20% of neck masses in children. They commonly present in late childhood or adulthood, when a previously unrecognized cyst becomes infected. They are most frequently found anterior to the sternocleidomastoid muscle, but can also be preauricular. Thyroglossal duct cysts are located in the midline over the hyoid bone. Frequently, they elevate when the patient swallows. Dermoid cysts are usually mobile, moving with the overlying skin. They can be located in the submental or midline region. Thyroid tumors are also usually located in the midline. Malignant masses are usually hard, irregular, nontender, and fixed.
300
A 70-year-old male with hypertension, benign prostatic hyperplasia, depression, and well-controlled diabetes mellitus sees you because of increasing fatigue. His medical history also includes stent placement for coronary artery disease. A physical examination is unremarkable except for decreased peripheral pulses. A CBC, basic metabolic profile, hemoglobin A1c level, free T4 level, and TSH level are all normal, except for a serum sodium level of 125 mEq/L (N 135–145). His serum osmolality is 268 mOsm/kg (N 275–290). His urine sodium level is 50 mEq/L (N <20) and his urine osmolality is 300 mOsm/kg. Which one of the patient’s medications is most likely to cause this problem? A) Losartan (Cozaar) B) Tamsulosin (Flomax) C) Metformin (Glucophage) D) Atorvastatin (Lipitor) E) Sertraline (Zoloft)
ANSWER: E In patients who are euvolemic but have hyponatremia, decreased serum osmolality, and elevated urine osmolality, the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is likely. Other causes to rule out include thyroid disorders, adrenal insufficiency, and diuretic use. Renal function has to be normal as well. Common drugs that cause SIADH include SSRIs (particularly in patients over 65), chlorpropamide, barbiturates, carbamazepine, opioids, tolbutamide, vincristine, diuretics, and NSAIDs. Treatment of the problem consists of discontinuing the offending drug. Temporary fluid restriction may also be required.
300
A 45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now has anterior neck tenderness and swelling, with pain radiating up to her ears. Your examination reveals a tender goiter. Which one of the following would support a diagnosis of subacute granulomatous thyroiditis? A) Pretibial myxedema B) Exophthalmos C) Multiple nodules on ultrasonography D) Low radioactive iodine uptake (<5%)
ANSWER: D Subacute granulomatous thyroiditis is the most common cause of thyroid pain. Free T4 is elevated early in the disease, as it is in Graves disease; however, later in the disease T4 becomes depressed and then returns to normal as the disease resolves. Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be found in Graves disease, but are not associated with subacute granulomatous thyroiditis. Multiple nodules on ultrasonography suggests multinodular goiter rather than subacute granulomatous thyroiditis. Patients with subacute granulomatous thyroiditis will have a low radioactive iodine uptake (RAIU) at 24 hours, but patients with Graves disease will have an elevated RAIU (SOR C).
400
Which one of the following classes of diabetes medications increases the risk of genitourinary infections by blocking glucose reabsorption by the kidneys? A) SGLT2 inhibitors such as canagliflozin (Invokana) B) GLP-1 receptor agonists such as exenatide (Byetta) C) DPP-4 inhibitors such as sitagliptin (Januvia) D) Meglitinides such as repaglinide (Prandin) E) 4-Glucosidase inhibitors such as acarbose (Precose)
ANSWER: A SGLT2 inhibitors inhibit SGLT2 in the proximal nephron. This blocks glucose reabsorption by the kidney, increasing glucosuria. The advantages of this medication include no hypoglycemia, decreased weight, decreased blood pressure, and effectiveness at all stages of type 2 diabetes mellitus. Disadvantages are that it increases the risk of genitourinary infections, polyuria, and volume depletion and increases LDL-cholesterol and creatinine levels. GLP-1 receptor agonists work by activating the GLP-1 receptors, causing an increase in insulin secretion, a decrease in glucagon secretion, slowing of gastric emptying, and increasing satiety. DPP-4 inhibitors inhibit DPP-4 activity, which increases postprandial active incretin concentration. This increases insulin secretion and decreases glucagon secretion. Meglitinides act by closing the ATP-sensitive K+ channels on the B-cell plasma membranes, which increases insulin secretion. 4-Glucosidase inhibitors inhibit intestinal 4-glucosidase, which slows intestinal carbohydrate digestion and absorption.
400
A new home urine test is designed to detect a particular type of cancer. The gold standard test for this cancer is a biopsy, but a biopsy is more costly than the urine test, is invasive, and is associated with a number of adverse side effects. To test the effectiveness of the home urine test, 104 people took the test and then agreed to a biopsy. When the study was concluded, 77 people tested negative and 27 tested positive on the urine test. Biopsies were positive in 18 individuals, 8 of whom tested negative on the urine test. What is the negative predictive value of the home urine test, rounded to a whole number? A) 20% B) 37% C) 56% D) 80% E) 90%
ANSWER: E The results of this urine test were that 10 people had the disease and tested positive (true positives); 8 people had the disease but tested negative (false negatives); 17 people did not have the disease (27 – 10) but tested positive (false positive); 69 people did not have the disease (77 – 8) and tested negative (true negative). The negative predictive value is determined by dividing the true negatives (69) by the total number who tested negative (true plus false negatives = 77). The result is 89.6%, which rounded to a whole number is 90%.
400
A 55-year-old female receives a gynecologic and breast examination from a nurse practitioner, who also orders a routine mammogram. Who is legally responsible for ensuring that the patient is notified of the results of the mammogram? A) The nurse practitioner B) The supervising physician C) The facility performing the mammogram D) The patient
ANSWER: C While it is certainly appropriate for the nurse practitioner or physician who ordered the test to notify the patient of mammography results, the facility performing the test is legally responsible. This is specified by the federal Mammography Quality Standards Act, first passed by Congress in 1992.
400
Complications of hypoparathyroidism include A) somnolence B) low vitamin D C) muscle flaccidity D) hyperkalemia E) refractory heart failure
ANSWER: E The classic symptoms of hypoparathyroidism are those of insufficient calcium. Typically these include refractory heart failure, tetany, seizures, altered mental status, and stridor. Refractory heart failure is related to the low calcium interfering with the normal contractility of myocytes. Low vitamin D can cause hypocalcemia but is not caused by it. Patients are not at risk for hyperkalemia if they have hypoparathyroidism. Seizures, not somnolence, and muscle twitching, not flaccidity, are symptoms of low calcium.
400
A 56-year-old male with diabetes mellitus, hypertension, and chronic renal insufficiency presents for follow-up of his chronic medical conditions. Results of his most recent metabolic panel included an estimated glomerular filtration rate of 30 mL/min/1.73 m2 (N >60) and a calcium level of 10.4 mg/dL (N 8.5–10.2). Medication reconciliation reveals he is not taking the sevelamer (Renagel, Renvela) prescribed by the consulting nephrologist. You explain to the patient that he should be taking sevelamer to lower his serum calcium. The drug accomplishes this by A) blocking the effect of parathyroid hormone B) blocking excessive vitamin D levels, thus decreasing intestinal calcium absorption and increasing renal calcium excretion C) blocking intestinal absorption of phosphate, which lowers parathyroid hormone secretion D) directly blocking excessive calcium absorption in the intestines E) directly increasing the renal excretion of both calcium and phosphate
ANSWER: C This patient has secondary hyperparathyroidism, a common cause of hypercalcemia in patients with chronic renal insufficiency. Sevelamer is a newer synthetic agent in the therapeutic class of phosphate binders, which includes calcium acetate. Decreasing serum phosphate lowers the feedback stimulation of parathyroid hormone secretion by the parathyroid gland, which is often excessive in chronic renal insufficiency. Normalizing parathyroid levels improves serum calcium levels.
500
38. Azithromycin (Zithromax) is prescribed for a 65-year-old male with coronary artery disease. This drug should be used with caution in this patient due to an increased risk for A) an adverse effect on left ventricular function B) peripheral edema C) elevation of systolic blood pressure D) fatal arrhythmias
ANSWER: D In March of 2013 the FDA issued a safety warning regarding azithromycin and its potential to lead to serious and even fatal arrhythmias, particularly in at-risk patients. Risk factors include hypokalemia, hypomagnesemia, a prolonged QT interval, and the use of certain medications to treat abnormal heart rhythms. The mechanism of action is prolongation of the QT interval, leading to torsades de pointes (level of evidence 2, SOR A). The FDA recommends that physicians consider the risk of torsades de pointes and fatal heart rhythms associated with azithromycin when considering antibiotic treatment options, particularly in patients who are already at risk for cardiovascular events.
500
A 55y/o G0 postmenopausal woman presents for routine f/u. She states that last month she had 2 episodes of vaginal spotting that self resolved. She has no other sx. You order a TVUS. At what endometrial thickness is an endometrial biopsy indicated?
>4 mm (per ACOG) >5 mm (per radiological society)
500
Which one of the following vaccines is CONTRAINDICATED in immunocompromised adults? A) Herpes zoster B) Human papillomavirus C) Meningococcal D) Pneumococcal polysaccharide E) Tdap
The herpes zoster vaccine is the only live-attenuated virus vaccine listed, and is therefore the one contraindicated in immunodeficient patients. Human papillomavirus, Tdap, meningococcal, and pneumococcal polysaccharide vaccines are not live or live-attenuated vaccines, and may be given to immunocompromised patients.
500
A 69-year-old female is unable to obtain adequate calcium from dietary sources. She is on long-term therapy with pantoprazole (Protonix) for peptic ulcer disease. Which one of the following would be the most appropriate calcium supplement for this patient? A) Oyster shell calcium B) Calcium carbonate C) Calcium lactate D) Calcium gluconate E) Calcium citrate
ANSWER: E Women over the age of 50 require at least 1200 mg of calcium a day. Inadequate calcium intake is common, particularly in older women, and is associated with increased bone loss and an increased fracture risk. Supplements should be considered when dietary intake is inadequate. Calcium carbonate is the least expensive and most commonly used supplement, but it is constipating and stomach acid improves its absorption. Calcium gluconate and calcium lactate are rarely used for fracture prevention or calcium supplementation. Bone meal and oyster shell calcium are primarily composed of calcium carbonate but may contain lead or other contaminants since they are derived from natural sources. In addition, their absorption without stomach acid is erratic. Calcium citrate is less dependent on stomach acidity for absorption and it may be used with long-term gastric acid suppression agents. It may be taken without regard to food or meals.
500
Which one of the following metabolic abnormalities is most likely to be seen in patients with stage 4 kidney disease? A) Hyperaldosteronism B) Hyperparathyroidism C) Hypothyroidism D) Hypogonadism E) Type 2 diabetes mellitus
ANSWER: E Hyperparathyroidism is usually caused by a single adenoma of one of the four parathyroid glands. A minority of cases (10%–15%) are associated with four-gland hyperplasia. Studies that localize the glands, such as a technetium scan or ultrasonography, help surgeons who are familiar with this condition achieve a cure rate of 95%–98%, with an estimated complication rate of 1%–3%. For patients <50 years old or symptomatic patients, such as those with a frANSWER: B Hyperparathyroidism is present in more than half of patients who have a glomerular filtration rate <60 mL/min, and is independently associated with increased mortality and an increased prevalence of cardiovascular disease. In patients with stage 4 chronic kidney disease, current guidelines recommend monitoring of serum calcium and phosphate levels every 3–6 months and bone-specific alkaline phosphatase activity every 6–12 months with the goal of normalizing these values. The other metabolic abnormalities listed are less common than hyperparathyroidism.