Cardiology
Which of the following indicates a hypertensive emergency?
A. Diastolic blood pressure ≥ 100 mm Hg only
B. Diastolic blood pressure ≥ 90 mm Hg and proteinuria
C. Systolic blood pressure ≥ 170 mm Hg only
D. Systolic blood pressure ≥ 180 mm Hg and rales
D
Patients with elevated blood pressure (systolic blood pressure ≥ 180 mm Hg or diastolic blood pressure ≥ 110 mm Hg) and signs or symptoms of ongoing acute damage to the brain, heart, or kidney (papilledema, chest pain, rales, or proteinuria) are classified as having a hypertensive emergency.
A 28-year-old G1P0 woman presents to the clinic at eight weeks of gestation for her first prenatal appointment. She denies any past medical history. She is a nonsmoker and is taking a daily prenatal vitamin. She plans to breastfeed her new baby. Laboratory findings reveal that she is rubella non-immune. Which of the following is the best recommendation regarding rubella immunization in this patient?
A. Administer rubella vaccine in the third trimester
B. Administer rubella vaccine now
C. Administer rubella vaccine postpartum
D. Administer rubella vaccine postpartum and when no longer breastfeeding
C
The American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention recommend that seronegative women should receive the rubella vaccine postpartum in the form of the measles, mumps, and rubella (MMR) vaccine. This live-attenuated virus vaccine can theoretically cross the placenta and infect the fetus. Therefore, a contraindication to the MMR vaccine is pregnancy. However, breastfeeding is not a contraindication.
A 37-year-old man presents to the clinic to establish care. He feels well and prioritizes eating a healthy diet and exercising at least 30 minutes 5 days per week. He is sexually active with one partner. He was recently at a health fair, where he had a screening blood pressure measurement, random glucose check, and spot HIV test. He brings a card in from the health fair that shows a blood pressure of 100/70 mm Hg, random glucose of 92 mg/dL, and negative HIV test result. He also received his influenza vaccine at the fair. His vital signs in the clinic are a BP of 102/74 mm Hg, HR of 75 bpm, RR of 16/min, and BMI of 20 kg/m2. He wants to know whether he should have any other tests or vaccines done at this time. Which of the following is appropriate for health maintenance for the patient at this visit?
A. Screening for anemia
B. Screening for colon cancer
C. Screening for diabetes
D. Screening for hepatitis C
E. Screening for HIV
D
The USPSTF recommends screening for hepatitis C virus (HCV) infection in all adults aged 18 to 79 years.
A 13-year-old obese boy presents to the clinic with a four-month history of worsening nonradiating left hip pain. He denies trauma or inciting event and states the pain is associated with activity and is relieved with rest. Physical examination reveals an antalgic gait, with simultaneous external rotation and abduction of the left hip during flexion. Plain radiographs reveal a posterior displacement of the left femoral epiphysis which has the appearance of “ice-cream slipping off a cone.” Which of the following is the most likely diagnosis?
A. Legg-Calve-Perthes
B. Septic arthritis
C. Slipped capital femoral epiphysis
D. Transient synovitis
C
Slipped capital femoral epiphysis is one of the most common hip disorders in adolescence which typically presents around the age of 12 years in girls and 13.5 years in boys. Obesity is a significant risk factor and the majority of cases are unilateral. Clinical manifestations include dull, aching pain of the hip, groin, thigh, or knee without a history of preceding trauma. The pain is nonradiating and is exacerbated by physical activity and relieved with rest. Most commonly, the presentation is of a chronic nature with most individuals reporting pain > 3 weeks in duration.
Diagnosis is made by noting a posterior displacement of the femoral epiphysis on plain radiographs which appears as “ice cream slipping off a cone.” Treatment is operative stabilization.
Which of the following is recommended as first-line pharmacotherapy in the treatment of generalized anxiety disorder in adults?
A. Buspirone
B. Escitalopram
C. Hydroxyzine
D. Lorazepam
B
The mainstay of treatment is cognitive-behavioral therapy, pharmacotherapy, or both. First-line medication includes a serotonin reuptake inhibitor (e.g., escitalopram) or a serotonin-norepinephrine reuptake inhibitor.
A 56-year-old woman with a history of hypertension presents to the emergency department with a blood pressure of 220/160 mm Hg and a mean arterial pressure of 180 mm Hg. Physical examination is normal. Laboratory results reveal hematuria, and an elevated blood urea nitrogen and creatinine. Which of the following would be an appropriate target for blood pressure lowering in this patient?
A. 120/80 mm Hg (mean arterial pressure of 93 mm Hg) over one hour
B. 120/80 mm Hg (mean arterial pressure of 93 mm Hg) over the next 24 hours
C. 200/114 mm Hg (mean arterial pressure of 144 mm Hg) over one hour
D. No active lowering of blood pressure should be performed in this patient
C
For most hypertensive emergencies, mean arterial pressure should be reduced by approximately 10 to 20 percent in the first hour and then gradually during the next 23 hours so that the final pressure is reduced by approximately 25 percent compared with baseline (in the first 24 hours).
Which of the following is the best modality to evaluate a solitary pulmonary nodule for likelihood of malignancy?
A. Chest X-ray
B. CT of the chest with contrast
C. CT of the chest without contrast
D. MRI of the chest
C
Low-dose CT of the chest without contrast is the imaging modality of choice to evaluate solitary pulmonary nodules for likelihood of malignancy. Neither intravenous nor oral contrast is necessary to evaluate a pulmonary nodule.
Which of the following individuals should receive the quadrivalent meningococcal conjugate vaccine?
A. 1-year-old healthy boy
B. 10-year-old boy with asthma
C. 12-year-old healthy girl
D. 24-year-old man attending his senior year in college and living in a dormitory as a residential advisor
C
The Advisory Committee on Immunization Practices recommends administration of the quadrivalent meningococcal vaccine for all individuals between 11–18 years of age, preferably at 11 to 12 years of age with a booster at 16 years of age. Vaccination is also recommended for those adults and children less than 10 years of age who are at increased risk for meningococcal disease (e.g., functional asplenia, complement deficiencies, travel to endemic areas, during a community outbreak).
A 30-year-old woman with a history of obstructive sleep apnea presents to the clinic with right shoulder pain. She is holding her right arm with her left arm and reports she injured her shoulder while swinging from one bar to the next during a gymnastics session five hours ago. On physical exam, you note a shoulder dimple inferior to the acromion, and further workup with radiography confirms your suspicion of anterior glenohumeral dislocation. Which of the following clinical interventions is most appropriate?
A. Attempt reduction with intra-articular pain control
B. Attempt reduction with intravenous pain control
C. Attempt reduction without pain control
D. Place the patient’s arm in a sling
A
A 5-year-old boy presents to the clinic for follow-up on possible attention-deficit/hyperactivity disorder. You look at the assessments the family has brought from home and from school, along with the criteria from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. You determine that a diagnosis of attention-deficit/hyperactivity disorder is appropriate in this child. Which of the following is the best next step in treatment?
A. Atomoxetine
B. Behavioral therapy
C. Guanfacine
D. Methylphenidate
B
For children younger than 6 years who are diagnosed with attention-deficit/hyperactivity disorder (ADHD), behavioral therapy is the initial treatment of choice, with medications reserved for children who respond poorly to behavioral therapy or have moderate to severe symptoms.
Which of the following medications is most essential to the treatment and prolonged survival of stage C heart failure with ejection fraction ≤ 35%?
A. Amlodipine
B. Diltiazem
C. Hydrochlorothiazide
D. Spironolactone
D
A 54-year-old woman with a 30 pack-year smoking history reports a chronic cough productive of a small amount of phlegm and shortness of breath with strenuous activity. Physical examination shows hyperresonance in the lung fields. Spirometry shows a pre- and post-bronchodilator FEV1/FVC ratio of 0.60 and FEV1 85% of predicted. Which of the following agents would be the best initial pharmacologic treatment according to the most recently updated guidelines?
A. A long-acting antimuscarinic antagonist and long-acting beta-2 agonist
B. A long-acting beta-2 agonist
C. A short-acting beta-2 agonist
D. An inhaled corticosteroid
B
GOLD group A is characterized by ≤ 1 exacerbations per year and a modified Medical Research Council score of 0 or 1. A score of 1 is assigned to this patient based on her report that she is only bothered by dyspnea during strenuous activity. Initial recommended therapy for GOLD group A is a long-acting beta-2 agonist or a long-acting muscarinic antagonist.
A 40-year-old woman presents to the clinic for her annual wellness visit. Her past medical history is unremarkable. Her mother was diagnosed with colon cancer at 53 years of age. The patient reports no changes in bowel habits, rectal bleeding, or unexplained weight loss. Which of the following is the correct recommendation for colon cancer screening in this patient?
A. Order a carcinoembryonic antigen (CEA) level and screening colonoscopy at this visit
B. Order a screening colonoscopy at this visit
C. Plan on a screening colonoscopy at 43 years of age
D. Plan on a screening colonoscopy at 50 years of age
B
Patients with a first-degree relative with advanced adenoma or colorectal cancer diagnosed before the age of 60 years should have a screening colonoscopy at 40 years of age or 10 years younger than the earliest diagnosis in their family (whichever comes first).
A 35-year-old woman who works in business presents to the clinic with gradual onset of mild pain in her left big toe and reports no recent trauma. She wears high heels and narrow-toed shoes most of the day. Examination reveals lateral deviation of the hallux on the first metatarsal with erythema but no tenderness of the first metatarsophalangeal joint. Which of the following is the most likely diagnosis?
A.Gout
B. Hallux valgus
C. Sesamoiditis
D. osteoarthritis
B
Hallux valgus or bunion deformity is lateral deviation of the hallux on the first metatarsal. Restrictive shoes are the main risk factor for hallux valgus, which is more prevalent in women. Symptoms may range from no pain to severe pain. The diagnosis is made by clinical examination, although radiographs can reveal osteoarthritis. Wearing shoes with a wide toe box or stretching previously owned shoes relieves compression of the valgus deformity.
A 62-year-old man presents to the emergency department with anxiety, tachycardia, hypertension, and tremors. He becomes increasingly confused and is unable to report when his last substance use occurred. Toxicology screens, including acetaminophen, salicylate, blood alcohol, and urine drug screen are within normal limits, other than a positive screening test for marijuana. As he is monitored, he becomes increasingly agitated, confused, and combative, and his heart rate range is 120–130 beats per minute and blood pressure 160–170/100–110 mm Hg. Which of the following is the next best step in treatment of his symptoms?
A. Chlordiazepoxide
B. Lorazepam
C. Methadone
D. Naltrexone
A
Chlordiazepoxide is a long-acting benzodiazepine helpful in slowing tapering alcohol withdrawal. For comparison, chlordiazepoxide is dosed hourly, as compared to every 5–10 minutes for diazepam and every 15–20 minutes for lorazepam.
A 75-year-old woman presents to your clinic with concerns of reduced exercise capacity over the past month. She states that she gets lightheaded shortly after starting to exercise, but is otherwise in good health and takes no medications. She has a history of a TIA. Electrocardiography evaluation reveals persistent atrial fibrillation. She does not want to take long term medications and elects to have cardioversion. Which of the following is the most appropriate next step for this patient prior to cardioversion?
A. Four weeks of anticoagulation with warfarin
B. Heparin bolus followed by immediate cardioversion
C. Screening transesophageal echocardiography to detect thrombi
D. Three weeks of anticoagulation with a non-vitamin K oral anticoagulant
D
Spontaneous or intended conversion of atrial fibrillation to sinus rhythm is associated with an increased risk of thromboembolism. Patients undergoing cardioversion of atrial fibrillation that has lasted more than 48 hours represent a particularly high-risk group.
The most common source of stroke associated with cardioversion in these patients is embolism of a thrombus from the left atrial appendage. The embolism may be present at the time of conversion or develop post-conversion as a result of left atrial mechanical dysfunction. Patients with atrial fibrillation of more than 48 hours duration should receive at least three weeks of anticoagulation with a non-vitamin K oral anticoagulant (NOAC) prior to an attempt at cardioversion.
In which one of the following groups does the Centers for Disease Control recommend a tuberculin skin test rather than an interferon-gamma release assay?
A. Children younger than 5 years
B. Homeless persons
C. Illicit drug users
D. Recent contacts of someone with active tuberculosis
A
In children younger than 5 years, the tuberculin skin test is preferred because of decreased sensitivity of interferon-gamma release assay testing in this age group.
Which of the following is the most common form of anthrax?
A. Cutaneous anthrax
B. Gastrointestinal anthrax
C. Inhalation anthrax
D. Injection anthrax
A
Cutaneous anthrax is the most common form, with the development of symptoms typically occurring between five to seven days after exposure to the spores. Lesions most often occur on exposed skin such as the face and arms, beginning as a small, painless, usually pruritic papule that enlarges rapidly and forms a central bulla, followed by erosion and the development of a necrotic ulcer with black eschar.
Tx: fluoroquinolone
A 57-year-old woman presents to the urgent care clinic with severe pain and tenderness in the right leg. She says she has experienced similar episodes during the past 6 months. About 10 months ago, she sustained an open fracture of the right femur during a ski trip. She has a past medical history of type 2 diabetes mellitus and hyperlipidemia. Her temperature is 99.5°F (37.5°C). Physical examination of the right leg shows erythema, tenderness, swelling, and a draining sinus tract. Laboratory studies reveal an elevated erythrocyte sedimentation rate and an elevated C-reactive protein. Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis
B. Chronic osteomyelitis
C. Osteonecrosis
D. Osteoarthritis
B
Chronic osteomyelitis most commonly results from open fractures, bacteremia, or contiguous soft tissue infection. Patients usually present with a history of intermittent flares of pain, erythema, and tenderness over a bony prominence. The presence of a draining sinus tract is a classic finding associated with chronic osteomyelitis. Laboratory studies can show an elevated erythrocyte sedimentation rate and C-reactive protein. Risk factors include diabetes mellitus, peripheral vascular disease, and history of trauma. Treatment typically consists of antimicrobial therapy with activity against methicillin-resistant Staphylococcus aureus and gram-negative organisms, such as vancomycin.
A 39-year-old woman has had persistent bipolar disorder refractory to lamotrigine in the last few years. Her primary clinician has recommended another mood stabilizer. It is excreted through the kidneys, and it acts by stimulating inhibitory neurotransmitters and inhibiting excitatory neurotransmitters. It is available in a generic formulation and treats hypomania, mania, and depression that can be associated with bipolar disorder. Which of the following would most likely occur from treatment with this drug?
A. Depolarization abnormalities
B. Hypocalcemia
C. Hypothyroidism
D. Lithium toxicity with low-dose aspirin
C
A 16-year-old boy suddenly collapses while he is out jogging with his family one afternoon. He has no remarkable medical history. His family history includes an uncle who died unexpectedly at the age of 20 years. An echocardiography is performed and reveals left ventricular hypertrophy that is most significant in the interventricular septum. No valvular abnormalities are noted. Which of the following criterion is essential for an implantable cardioverter defibrillator placement?
A. Documented atrial tachycardia
B. Family history of myocardial infarction
C. Interventricular septal thickness > 10 mm
D.Right ventricular systolic dysfunction
E. Syncope
E
The American College of Cardiology Foundation/American Heart Association guidelines focus on clinical factors in deciding whether an ICD is appropriate. These clinical factors include documented ventricular tachycardia, family history of sudden cardiac death, interventricular septal thickness > 30 mm, left ventricular systolic dysfunction, and syncope.
A 48-year-old man presents to your clinic with illness lasting for the past three weeks. His initial symptoms included nasal congestion and drainage with a sore throat. He later developed a cough, which has progressively worsened. He says sometimes when he coughs, it is difficult to stop, and occasionally he has experienced shortness of breath. He has had a low-grade fever with a maximum temperature of 101°F. His wife started out with similar symptoms, but they seemed to be limited to the upper respiratory tract and have significantly improved. You question the patient regarding his and his wife’s vaccine history, and he says he has not received any vaccines since childhood, except an annual influenza vaccine which he received one month ago. He remembers that his wife was given a vaccine when she cut her hand on a metal can while cooking Thanksgiving dinner last year. Which of the following would be the most appropriate empiric therapy while waiting for laboratory test results?
A. Amoxicillin
B. Clarithromycin
C. Doxycycline
D. Levofloxacin
B
Bordetella pertussis is the causative agent of whooping cough, also known as pertussis.
Macrolides, such as azithromycin and clarithromycin, are the preferred treatment, with erythromycin being less favored because of difficult dosing intervals and significant gastrointestinal side effects.
A 65-year-old woman presents to the clinic for a maintenance visit. She is up to date on cancer screenings but expresses concern to the physician about ovarian cancer. She hands the physician a newspaper clipping with a headline about the link between baby powder and ovarian cancer. To help counsel and educate the patient, the physician pulls up a research article on this topic. The research article describes a case-control study that reports the odds of perineal baby powder use were 50% greater among patients with ovarian cancer compared to healthy controls (odds ratio = 1.5, P value = 0.01). Controls were recruited from the same clinic population as cases. Exposure history was classified by study participants’ self-reports via a self-administered questionnaire. Cases were classified by medical chart review, using standardized billing and coding definitions for disease classification. Which of the following might limit the study’s interpretation based on the described study design?
A. Chance error
B. Nondifferential misclassification
C. Recall bias
D. Selection bias
C
Recall bias creates an apparent association between exposure and disease, when in reality no such association exists.
A 32-year-old woman presents with intermittent fever and joint aches for the past several weeks, as well as a facial rash that started after exposure to sunlight. On examination, the erythematosus, scaly rash involves the lateral cheeks and bridge of the nose but spares the nasolabial folds. Which of the following is a 2019 European League Against Rheumatism/American College of Rheumatology obligatory entry criterion for the diagnosis of systemic lupus erythematosus?
A. ANA titer ≥ 1:40
B. ANA titer ≥ 1:80
C. Anti-Smith antibodies
D. Lupus anticoagulant
B
The newer 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus has a higher sensitivity than the previous criteria and includes a positive ANA with a titer ≥ 1:80 at least once as an obligatory entry criterion. A persistently negative ANA result typically rules out SLE.
The diagnosis is established by then accumulating ≥ 10 points on weighted groups in seven clinical domains (constitutional, hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, renal) and three immunologic domains (antiphospholipid antibodies, complement proteins, SLE‐specific antibodies).
A 19-year-old woman presents to the clinic for follow-up of bulimia nervosa. She was diagnosed six months ago and is currently being managed with nutritional rehabilitation and cognitive behavioral therapy. She reports that she continues to binge eat and uses laxatives to try to prevent weight gain. Which of the following is the next best step in management?
A. Bupropion
B. Fluoxetine
C. Fluvoxamine
D. Sertraline
B
Fluoxetine is a selective serotonin reuptake inhibitor and is recommended as first-line treatment in the management of bulimia nervosa because of its efficacy and tolerability. A target dose of 60 mg daily is recommended.