Respiratory
A 62-year-old male sees you the day after returning from a 4-day cruise. He says he developed a fever and a productive cough on the day before the ship returned to Los Angeles following a trip down the coast of Baja California. He tells you that several other passengers had similar symptoms. The examination is remarkable for tachypnea and you hear crackles in both lungs. This patient’s history should raise concerns about infection with which one of the following pathogens?
A) Asian avian influenza A virus
B) Coxiella burnetii
C) Hantavirus
D) Histoplasma capsulatum
E) Legionella species
E) Legionella species
An 11-year-old female is brought to your office for a routine well child examination. The American Academy of Pediatrics recommends screening this patient for which one of the following?
A) Anemia
B) Diabetes mellitus
C) Dyslipidemia
D) HIV
C) Dyslipidemia
Which one of the following has the best evidence supporting its use for acute low back pain without radicular symptoms?
A) Acupuncture
B) Bed rest
C) Lumbar support
D) Oral corticosteroids
E) Cyclobenzaprine
E) Cyclobenzaprine
A 2-month-old male is brought to your office for a well child check. The parents tell you that he regurgitates with every meal, and they are getting very frustrated. He takes about 4–5 ounces of formula every 4 hours. With every feeding he will regurgitate a large amount of formula. They have tried frequent burping and elevating his head during and after feeding, but he continues to regurgitate. He does not appear to be uncomfortable and overall is a happy baby. He is growing well and a complete examination is normal. Which one of the following is the most appropriate management for this patient?
A) Reassurance
B) Metoclopramide (Reglan)
C) Omeprazole (Prilosec)
D) Ranitidine (Zantac)
E) Abdominal ultrasonography
A) Reassurance
Which one of the following outcomes is seen with intensive glycemic control in patients with type 2 diabetes mellitus?
A) Fewer hypoglycemic events
B) Improved blood pressure control
C) A delay in the development of macroalbuminuria
D) A reduced need for dialysis
E) Lower all-cause mortality rates
C) A delay in the development of macroalbuminuria
A 2-year-old female is brought to your office with an occasional barking cough that began late last night. The child has mild intercostal indrawing and no stridor at rest. Which one of the following would be most appropriate to help improve this child’s symptoms?
A) Humidification
B) A helium-oxygen mixture (heliox)
C) Oral dexamethasone
D) Nebulized albuterol
E) Nebulized budesonide (Pulmicort Respules)
C) Oral dexamethasone
A 65-year-old white female is diagnosed with hypertension. She has no significant past medical history. According to the JNC 8 panel, which one of the following would be an appropriate systolic blood pressure goal for this patient?
A) <120 mm Hg
B) <130 mm Hg
C) <140 mm Hg
D) <150 mm Hg
E) <160 mm Hg
D) <150 mm Hg
A 51-year-old female comes to your office for follow-up of fibromyalgia. She is currently taking amitriptyline, 10 mg at bedtime, and naproxen (Naprosyn), 500 mg twice daily, for her symptoms. A member of her fibromyalgia support group recommended fluoxetine (Prozac) to her and she asks you if it would be helpful. It would be appropriate to tell her that SSRIs for the treatment of fibromyalgia
A) do not affect depression scores
B) reduce fatigue
C) provide some pain reduction
D) help with sleep problems
E) are superior to tricyclics for pain control
C) provide some pain reduction
A 50-year-old female undergoes screening colonoscopy and a 1.2-cm polyp is discovered and removed. She is told that it is benign but she is concerned about her future risk for developing colon cancer. Which histologic type of colonic polyps >1.0 cm in size has the highest likelihood of becoming malignant?
A) Hamartomatous polyps
B) Hyperplastic polyps
C) Inflammatory polyps
D) Tubular adenomas
E) Villous adenomas
E) Villous adenomas
A 74-year-old female comes to the emergency department with the acute onset of severe pain in the middle to lower back after lifting a small piece of furniture. Imaging demonstrates an acute nondisplaced wedge compression fracture of the T12 vertebra. An examination confirms that there is no neurologic deficit. She is admitted to the hospital. In addition to pain management, which one of the following would you recommend?
A) Early mobilization as tolerated
B) Bed rest until a back brace is obtained
C) Evaluation for kyphoplasty
D) Evaluation for vertebroplasty
E) A neurosurgical evaluation
A) Early mobilization as tolerated
A 2-year-old female is brought to your office with a 3-day history of rhinorrhea, fever, cough, and increasing dyspnea. Her past medical history is unremarkable and she is up to date on her immunizations. She has a respiratory rate of 40/min, a pulse rate of 120 beats/min, a temperature of 37.8°C (100.0°F), and an oxygen saturation of 93% on room air. She is alert and irritable, and has clear rhinorrhea and expiratory wheezing, but good airflow overall. The remainder of the examination is normal. Which one of the following would be most appropriate at this time?
A) Supportive treatment only
B) Nebulized racemic epinephrine (Asthmanefrin)
C) Nebulized albuterol
D) A single dose of dexamethasone
E) A 5-day course of methylprednisolone (Medrol)
A) Supportive treatment only
A 53-year-old male sees you for follow-up of his hypertension. His medical history includes prediabetes and gout, and he is currently taking lisinopril (Prinivil, Zestril), 40 mg daily, to control his blood pressure. His blood pressure after resting is 148/86 mm Hg. Laboratory findings include a serum creatinine level of 0.8 mg/dL (N 0.6–1.2) and a serum potassium level of 4.5 mEq/L (N 3.5–5.1). Which one of the following would be the most appropriate management of this patient’s hypertension?
A) No change in medication
B) Add amlodipine (Norvasc)
C) Add hydrochlorothiazide
D) Add losartan (Cozaar)
E) Add metoprolol succinate (Toprol-XL)
B) Add amlodipine (Norvasc)
A 46-year-old runner presents with left heel pain. The pain has been occurring mostly with running, but more recently it is painful with walking. On examination there is tenderness and a palpable nodule on the midsubstance of the left Achilles tendon. Which one of the following therapeutic options is most likely to be effective for long-term recovery?
A) Oral NSAIDs
B) Eccentric calf-strengthening exercises
C) Corticosteroid injection of the Achilles tendon sheath
D) Surgical debridement or excision of the tendon nodule
E) Fixation in a walking boot
B) Eccentric calf-strengthening exercises
A 60-year-old female sees you because she has recently lost 20 lb without trying and is having trouble swallowing. Her other medical problems include obesity, tobacco abuse, and GERD. Which one of the following is the most appropriate diagnostic test in this situation?
A) A barium swallow
B) Endoscopic esophageal ultrasonography
C) Chest CT
D) Upper endoscopy
D) Upper endoscopy
Which one of the following can falsely elevate hemoglobin A1c?
A) Antiretroviral treatment for HIV infection
B) Chronic liver disease
C) Hemolytic anemia
D) Iron deficiency anemia
E) Pregnancy
D) Iron deficiency anemia
A 12-year-old male has a 1-week history of fever, headache, sore throat, and a mildly productive cough. He also began having ear pain yesterday. On examination he does not appear to be toxic. He has a temperature of 37.8°C (100.0°F). Examination of his ears shows a bulla on the right tympanic membrane, as well as mild to moderate erythema of the posterior pharynx. The neck is supple. The lungs have a few scattered crackles. The remainder of the examination is unremarkable. A chest radiograph reveals thickened bronchial shadows, as well as interstitial infiltrates in the lower lobes. The most appropriate treatment at this time would be
A) amoxicillin
B) azithromycin (Zithromax)
C) ceftriaxone (Rocephin)
D) cefuroxime (Zinacef)
E) vancomycin
B) azithromycin (Zithromax)
A 72-year-old male has newly diagnosed systolic heart failure due to hypertensive cardiomyopathy. The patient has an estimated left ventricular ejection fraction of 30% and was dyspneic at rest and with minimal exertion at the time of diagnosis. Which one of the following drugs is indicated to reduce mortality in this patient?
A) Atenolol (Tenormin)
B) Digoxin
C) Furosemide (Lasix)
D) Lisinopril (Prinivil, Zestril)
E) Nifedipine (Procardia)
D) Lisinopril (Prinivil, Zestril)
You are called by the parents of a 6-year-old male because he has a 2-week history of awakening at night with severe back pain. You request an immediate evaluation in your office.
A likely cause of this pain is
A) rheumatoid arthritis
B) lumbar sprain
C) compression fracture
D) discitis
E) scoliosis
D) discitis
An 80-year-old male presents with a 4-hour history of generalized abdominal pain, vomiting, and fever to 101°F. On examination you note normal cardiovascular findings, generalized moderate abdominal tenderness, absent bowel sounds, and a normal rectal examination. The diagnostic abdominal film shown on the following page suggests
A) a leaking abdominal aortic aneurysm
B) toxic megacolon
C) small bowel obstruction
D) diverticulitis
E) a perforated viscus
C) small bowel obstruction
A school nurse calls you for recommendations about a healthy 6-year-old female who was found to have head lice yesterday and was treated with permethrin 1% shampoo last night. The nurse reports that on examination today the child appeared well, weighed 30 kg (66 lb), and had 6 nits on her scalp. In addition to home eradication measures and regular nit combing, you recommend which one of the following for this child?
A) Oral ivermectin (Stromectol) and return to class today
B) Topical lindane and return to class today
C) Topical benzyl alcohol (Ulesfia) and return to class as soon as she is nit free
D) Return to class today and retreatment with permethrin 1% shampoo in 6 days
E) Retreatment with permethrin 1% shampoo in 6 days and return to class as soon as she is nit free
D) Return to class today and retreatment with permethrin 1% shampoo in 6 days
A 60-year-old male with COPD returns for a follow-up visit. He has been treated twice for pneumonia in the past year and is using his albuterol metered-dose inhaler (Proventil, Ventolin) several times a day. His FEV1 is 60% of predicted. To reduce symptoms and prevent hospitalization, which one of the following would be the most appropriate medication to add to this patient’s treatment regimen at this time?
A) Roflumilast (Daliresp)
B) A long-acting 2-agonist bronchodilator
C) A long-acting 2-agonist and an inhaled corticosteroid
D) A long-acting anticholinergic inhaler
E) Long-acting theophylline
D) A long-acting anticholinergic inhaler
An 82-year-old male presents to the emergency department with severe generalized abdominal pain. He has a history of paroxysmal atrial fibrillation and stopped taking rivaroxaban (Xarelto) 2 months ago because of the cost. The physical examination reveals generalized abdominal tenderness and an epigastric bruit. You suspect mesenteric ischemia. Which one of the following is the recommended imaging study?
A) Ultrasonography
B) Endoscopy
C) Catheter angiography
D) CT angiography
E) MR angiography
D) CT angiography
A 13-year-old baseball pitcher develops pain in the upper arm at the shoulder when throwing and is diagnosed with Little League shoulder. This entity is actually a
A) coracoclavicular ligament sprain
B) sprain or tear of the acromioclavicular ligament
C) deltoid muscle strain
D) proximal humeral epiphysitis
E) labral tear on the acromion
D) proximal humeral epiphysitis
Which one of the following therapies is most likely to reduce abdominal cramping in a patient with irritable bowel syndrome?
A) Peppermint oil
B) Polyethylene glycol (MiraLAX)
C) Probiotics
D)Wheat bran
A) Peppermint oil
A 35-year-old female who is approximately 90 kg (200 lb) above her ideal body weight comes to you for weight loss recommendations. Her mother, who had a BMI of 37.0 kg/m2, recently suffered a fatal heart attack and the patient would like to avoid this. She has no other medical problems except for well-controlled hypertension. Her medication list includes lisinopril (Prinivil, Zestril), 20 mg daily, and an etonogestrel subdermal (Nexplanon) implant for contraception. Which one of the following strategies would be most effective for reducing her cardiac risk?
A) A low-fat diet
B) A high-protein diet
C) Orlistat (Xenical), 120 mg 3 times daily with meals
D) Phentermine (Suprenza), 30 mg daily
E) Referral for bariatric surgery
E) Referral for bariatric surgery