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A 42-year-old Asian male presents for follow-up of elevated blood pressure. He has no additional chronic medical problems and is otherwise asymptomatic. An examination is significant for a blood pressure of 162/95 mm Hg but is otherwise unremarkable. all the labs are normal. (Claire's notes, ily) According to the American College of Cardiology/American Heart Association 2017 guidelines, which one of the following would be the most appropriate medication to initiate at this time? A) Clonidine (Catapres), 0.1 mg twice daily B) Hydralazine, 25 mg three times daily C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily D) Metoprolol tartrate (Lopressor), 25 mg twice daily
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A 42-year-old Asian male presents for follow-up of elevated blood pressure. He has no additional chronic medical problems and is otherwise asymptomatic. An examination is significant for a blood pressure of 162/95 mm Hg but is otherwise unremarkable. all the labs are normal. (Claire's notes, ily) According to the American College of Cardiology/American Heart Association 2017 guidelines, which one of the following would be the most appropriate medication to initiate at this time? A) Clonidine (Catapres), 0.1 mg twice daily B) Hydralazine, 25 mg three times daily C) Lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily D) Metoprolol tartrate (Lopressor), 25 mg twice daily
E) Triamterene (Dyrenium), 50 mg daily - ANS C During rounds at the nursing home, you are informed that there are two residents on the unit with laboratory-confirmed influenza. According to CDC guidelines, who should receive chemoprophylaxis for influenza? A) Only symptomatic residents on the same unit B) Only symptomatic residents in the entire facility C) All asymptomatic residents on the same unit D) All residents of the facility regardless of symptoms E) All staff regardless of symptoms - ANS C A 24-year-old female presents with a 2-day history of mild to moderate pelvic pain. She has had two male sex partners in the last 6 months and uses oral contraceptives and sometimes condoms. A physical examination reveals a temperature of 36.4°C (97.5°F) and moderate cervical motion and uterine tenderness. Urine hCG and a urinalysis are negative. Vaginal microscopy shows only WBCs. The initiation of antibiotics for treatment of pelvic inflammatory disease in this patient A) is appropriate at this time B) requires an elevated temperature, WBC count, or C-reactive protein level C) should be based on the results of gonorrhea and Chlamydia testing D) should be based on the results of pelvic ultrasonography - ANS A
A 24-year-old patient wants to start the process of transitioning from female to male. He has been working with a psychiatrist who has confirmed the diagnosis of gender dysphoria. Which one of the following would be the best initial treatment for this patient? A) ClomipheneB) Letrozole (Femara) C) Leuprolide (Eligard) D) Spironolactone (Aldactone) E) Testosterone - ANS E Based on American Cancer Society guidelines for cervical cancer screening, when should HPV DNA co-testing first be performed along with Papanicolaou testing? A) At the onset of sexual activity B) At age 21 C) At age 25 D) At age 30 E) At age 35 - ANS D Long-term proton pump inhibitor use is associated with an increased risk for A) Barrett's esophagus B) gout C) hypertension D) pneumonia E) type 2 diabetes - ANS D An 87-year-old female comes to your office for an annual health maintenance visit. She appears cachectic and tells you that for the past 6 months she has had a decreased appetite and generalized muscle weakness. The patient is alert and oriented to person and place. She has a 10% weight loss, dry mucous membranes, and tenting of the skin on the extensor surface of
her hands. While inflating the blood pressure cuff on her right arm you observe carpopedal spasms. Which one of the following is the most likely electrolyte disturbance? A) Hypercalcemia B) Hypocalcemia C) Hypokalemia D) Hypernatremia E) Hyponatremia - ANS B A 24-year old female presents to your office with a 3-month history of difficulty sleeping. She says that she struggles to fall asleep and wakes up multiple times at night at least three times a week. She tries to go to bed at 10:00 p.m. and wakes up at 6: a.m. to start her day. She lies awake for an hour in bed before falling asleep and spends up to 2 hours awake in the middle of the night trying to fall back asleep. Lately she has been feeling fatigued and having difficulty concentrating at work. You conduct a full history and physical examination and tell her to return in 2 weeks with a sleep diary. At this follow-up visit you see from her diary that she is sleeping an average of 51⁄2 hours per night. Which one of the following would be the most appropriate recommendation? A) Set her alarm for 5:30 a.m. B) Add a mid-afternoon nap C) Move her bedtime to 9:00 p.m. D) Move her bedtime to 12:30 a.m. E) Stay up for - ANS D
A 45-year-old female presents to the emergency department with a 1-week history of facial swelling and progressive dyspnea with exertion. She was diagnosed 1 week ago with non- Hodgkin's lymphoma but her medical history is otherwise unremarkable. A chest radiograph is shown below. After hospital admission, which one of the following would be the most appropriate next step in the management of this condition? A) Intravenous antibiotics B) Urgent chemotherapy and radiation C) Urgent chemotherapy and plasmapheresis D) Urgent echocardiography E) Urgent bronchoscopy - ANS B A nonverbal 22-year-old male with intellectual disability is brought to your office by the staff of the group home where he lives. They report that the patient has been functioning at his baseline until this morning when he was found to have loud breathing. No other history is available at the time of this visit. On examination he has a temperature of 37.3°C (99.1°F), a blood pressure of 124/82 mm Hg, a pulse rate of 100 beats/min, and a respiratory rate of 16/min. The patient appears to be in mild distress and a high-pitched whistling, crowing sound on inspiration is heard as you walk in the room. Which one of the following would be the most appropriate next step for this patient? A) Oral antibiotics B) Oral corticosteroids C) Nebulized albuterol D) Nebulized epinephrine E) Urgent evaluation in the emergency department - ANS E
A 16-year-old female presents with chronic acne on her nose, forehead, and chin consisting of a few comedones and a few mildly inflamed papules and pustules. She says it is minimally improved after 12 weeks of daily adapalene 0.1% gel. There are no scars or cysts. The patient would like to try to achieve better control. Which one of the following would you recommend at this time? A) Continue adapalene 0.1% gel for 12 more weeks B) Add clindamycin (Cleocin T) 1% gel for up to 12 weeks C) Add clindamycin 1% gel for maintenance D) Stop adapalene 0.1% gel and start clindamycin 1% gel for maintenance E) Stop adapalene 0.1% gel and start erythromycin 2% gel for maintenance - ANS B A 32-year-old female who is one of your longtime patients calls you because of a 24-hour history of painful urination with urinary frequency and urgency. She is otherwise healthy and does not have any fever, chills, back pain, or vaginal discharge. She uses an oral contraceptive pill and states that her last menstrual period was normal and occurred last week. Which one of the following would be most appropriate at this time? A) Empiric antibiotic treatment B) A urinalysis C) A urine culture D) Plain abdominal radiographs E) Pelvic ultrasonography - ANS A
A 70-year-old female develops thrombocytopenia during a prolonged hospitalization for endocarditis. Her current medications include scheduled unfractionated heparin injections for venous thromboembolism prophylaxis. You suspect heparin- induced thrombocytopenia (HIT). Assuming that her thrombocytopenia is caused by HIT, which one of the following is the most likely complication? A) Anaphylaxis B) Disseminated intravascular coagulation C) Hemorrhage D) Sepsis E) Thrombosis - ANS E You are asked for your advice as part of a committee formed by your local health system to focus on fall prevention. Based on U.S. Preventive Services Task Force recommendations, which one of the following interventions has the strongest evidence for preventing falls in community- dwelling older adults at increased risk for falls? A) Calcium supplementation B) Vitamin D supplementation C) Supportive footwear D) Exercise classes E) Cognitive-behavioral therapy - ANS D A 42-year-old male presents with a 10-day history of hoarseness. He also has a 2-month history of reflux symptoms and has been taking antacids as needed. He does not take any other medications. There is no history of fever, weight loss, night sweats, or appetite changes. You note that the patient is hoarse, and a physical examination is normal, including
HEENT, cardiovascular, and pulmonary examinations. He is a member of a community choir that rehearses twice a week. In addition to voice rest, which one of the following would be most appropriate at this time? A) Supportive care only B) Azithromycin (Zithromax) C) Omeprazole (Prilosec) D) A course of prednisone - ANS C A 57-year-old male with a history of heart failure sees you for follow-up. He describes symptoms of mild dyspnea on exertion with ordinary activities such as shopping or yard work. An echocardiogram shows an ejection fraction of 37%. According to the New York Heart Association criteria, this patient's heart failure would be classified as which one of the following? A) Class I B) Class II C) Class III D) Class IV - ANS B A 40-year-old runner presents with pain in the left leg. He is training for a marathon and has been increasing his running distance in recent weeks. He reports localized pain and swelling at the midpoint of the shin over the past 4 weeks that begins after a run and lasts for a few days, but now the swelling and tenderness have lasted for several days and there is severe pain when he tries to run. You suspect a tibial stress fracture. Which one of the following imaging modalities would be indicated initially? A) A plain film
B) Ultrasonography C) CT D) MRI E) Bone scintigraphy - ANS A A 24-year-old female presents with progressively worsening vulvar pain for 3 days. On examination a 3×3-cm tender, fluctuant mass is noted on the right labia minora. She had a similar episode of this problem last year. Which one of the following would be the most appropriate management? A) Expectant management B) Fine-needle aspiration C) Incision and drainage D) Marsupialization E) Excision under general anesthesia - ANS D Which one of the following should NOT be consumed during pregnancy due to a potentially high mercury content? A) Catfish B) Crawfish, shrimp, and lobster C) Flounder and haddock D) Salmon and trout E) Shark and swordfish - ANS E An 18-month-old female is brought to your office by her mother for evaluation of a cough. The patient has had low-grade fevers and a runny nose for 2 days. She now has a cough that is worse at night. On examination she has a temperature of 37.5°C (99.5°F), a pulse rate of 120 beats/min, a respiratory rate of 30/min, and an oxygen saturation of 92% on room air. She is
noted to have hoarseness, mild inspiratory stridor, and a barking cough. She does not have drooling or a muffled voice. Which one of the following should be ordered to confirm the diagnosis? A) No further testing B) ACBC C) A viral culture D) Rapid antigen testing E) A radiograph of the neck - ANS A A 25-year-old male presents with a 4-month history of crampy abdominal pain, diarrhea, and fatigue. His symptoms began gradually but have become more severe and he is now experiencing rectal bleeding. He says that his abdominal pain seems to temporarily improve after eating. He has smoked five cigarettes per day for the past 8 years. He is surprised to learn that he has lost 7 kg (15 lb) when he is weighed today. His vital signs include a blood pressure of 116/70 mm Hg, a heart rate of 76 beats/min, a respiratory rate of 12/min, and a temperature of 37.7°C (99.9°F). A physical examination reveals abdominal tenderness and mild distention. An anorectal examination is significant for a perianal fistula. A laboratory evaluation is notable for mild anemia. His kidney and liver function are normal. Which one of the following is the most likely diagnosis? A) Celiac disease B) Chronic pancreatitis C) Crohn's disease D) Irr - ANS C
A 34-year-old female at 32 weeks gestation presents with a right-sided, pounding headache that began 8 hours ago and is similar to headaches she has had in the past. She is sensitive to light and sound, and has vomited several times since the onset of pain. She has taken acetaminophen without relief. She takes prenatal vitamins but no other routine medications. On examination her blood pressure is normal. Which one of the following would be the most appropriate treatment for this patient? A) Dihydroergotamine B) Metoclopramide (Reglan) C) Naproxen D) Oxycodone (OxyContin) E) Sumatriptan (Imitrex) - ANS B Which one of the following U-100 insulin products has the longest duration of action? A) Degludec (Tresiba) B) Glargine (Lantus) C) Isophane NPH (Humulin N) D) Lispro (Humalog) E) Regular (Humulin R) - ANS A When performing a geriatric assessment, which one of the following is an instrumental activity of daily living? A) Bathing B) Dressing C) Transferring between the bed and a chair D) Using the telephone E) Using the toilet - ANS D
A 21-year-old female sees you for a medical evaluation prior to admission to a treatment program for anorexia nervosa. The effects of anorexia on the hypothalamic-pituitary axis can cause which one of the following? A) Bone loss B) Elevated testosterone C) Hyperglycemia D) Hypothyroidism E) Menorrhagia - ANS A A 9-year-old male with a history of moderate persistent asthma is brought to the emergency department with an acute exacerbation. His symptoms began with a runny nose and nasal congestion 2 days ago. His parents state that he has not had any fevers or chills and he was eating and drinking well until a few hours ago when his breathing started to appear more labored. After multiple treatments with inhaled albuterol (Proventil, Ventolin) and oral prednisolone he remains tachypneic and wheezy. Which one of the following intravenous medications should be added to the patient's current treatment to reduce the likelihood of hospital admission? A) Ketorolac B) Magnesium sulfate C) Methylprednisolone D) Omalizumab (Xolair) E) Theophylline - ANS B A 10-year-old female is brought to your office for a sports preparticipation examination. You note thoracic rib asymmetry
during the Adams forward bend test. Radiographs confirm rightward thoracolumbar scoliosis with a Cobb angle of 32°. Which one of the following would be most appropriate at this time? A) Genetic testing (ScoliScore) B) MRI of the thoracic and lumbar spine without contrast C) Scoliosis radiography in 1 year D) Referral to physical therapy E) Referral to a pediatric orthopedist - ANS E An 85-year-old nursing home patient with dementia who has bilateral hearing aids has been slightly more confused over the past 2 weeks according to the staff. He is also speaking at a louder volume than normal. He does not have any pain, but an examination shows impacted cerumen in both ears. Which one of the following would be most appropriate in the management of this patient? A) No therapy B) Irrigation of the ears with cold water C) Use of olive oil drops D) Removal of the cerumen using peroxide E) Restraining the patient and attempting manual removal of the cerumen - ANS D A previously healthy 18-year-old female presents with finger pain. About 5 days ago she started to have mild burning of her left distal index finger. Two days later she developed worsening pain and redness of her fingertip. She does not remember injuring her finger or having a similar problem previously.
On examination you note erythema of the medial palmar tip of her affected finger, with several vesicles that have opaque fluid in them. The distal digital pulp is soft but tender. Which one of the following is the most appropriate treatment for this condition? A) Warm water soaks B) Pain control and dressings C) Antibiotics D) Antifungals E) Incision and drainage - ANS B A 52-year-old gravida 4 para 4 presents with bothersome incontinence, predominantly with coughing and straining. In addition to a physical examination, urinalysis, and measurement of postvoid residual volume, which one of the following tests is recommended as part of the initial evaluation? A) Cough stress testing B) Urodynamic testing C) Pelvic ultrasonography with a vaginal probe D) Cystoscopy - ANS A The mother of a 1-year-old child wants to know how useful influenza vaccine is for preventing influenza in young children. The influenza season is typically significant in your area and the child attends day care. You answer her question by explaining how many children need to be vaccinated in order to prevent one case of influenza. This statistic is referred to as the A) absolute risk reduction B) relative risk reduction C) number needed to treat
D) number needed to harm E) prevalence - ANS C A 45-year-old male comes to your office for a routine health maintenance examination. His medical history is significant for sarcoidosis, which was diagnosed 5 years ago during a workup for hilar adenopathy seen on a routine chest radiograph. He has been entirely asymptomatic for the past 2 years and has never required any treatment. Which one of the following annual screenings would be most appropriate? A) Bone density screening B) Echocardiography C) High-resolution CT of the chest D) An ophthalmologic examination E) A urinalysis - ANS D A 34-year-old female has a "bump" on her middle finger (shown below). She thinks it has been there approximately a month but says that it only recently began to bother her. She has not tried to treat it. This lesion is most likely a A) basal cell carcinoma B) dermatofibroma C) keratoacanthoma D) mucous cyst E) wart - ANS D A 73-year-old female sees you for the first time for a health maintenance visit. Her medical history includes hyperlipidemia, GERD, insomnia, and osteoarthritis, but she is otherwise
healthy. Her estimated 10-year risk of atherosclerotic cardiovascular disease is 14%. She lives independently. She has a past history of alcohol abuse but has not used alcohol in 20 years, and is a lifetime nonsmoker. Her current medication regimen includes aspirin, 81 mg once daily; melatonin, 3 mg at bedtime; acetaminophen, 500 mg three times daily; atorvastatin (Lipitor), 20 mg once daily; and famotidine (Pepcid), 20 mg once daily. Today her blood pressure is 130/70 mm Hg, pulse rate 72 beats/min, and oxygen saturation 95% on room air. Which one of the following changes to her current medication regimen would improve the likelihood of benefit and reduce the likelihood of harm? A) Stopping aspirin B) Stopping melatonin C) Stopping acet - ANS A A 14-year-old female is brought to your office as a new patient for a routine well child examination. She has had very little medical care since the pre-kindergarten evaluation. She feels well and does not take any medications. Her past medical, surgical, family, and social histories are unremarkable. A review of systems is notable for no history of menstruation. An examination is notable for a height at the first percentile and a lack of any breast development. Laboratory studies reveal an elevated FSH level. Which one of the following would be the most appropriate next step? A) Follow-up every 3-6 months for assessment of pubertal development B) A corticotropin stimulation test
C) Karyotyping D) Radiography of the hand for bone age E) MRI of the brain and pituitary - ANS C A 42-year-old male sees you for follow-up after his third episode of pneumonia. He has no other significant medical history. He has never smoked, drinks alcohol occasionally, and has no other drug use or known exposures. A physical examination is normal. Pulmonary function tests demonstrate an FEV1 of 72% of predicted and an FEV1/FVC ratio of 0.68, which does not normalize with bronchodilator administration. A chest radiograph shows hyperinflation but no other significant findings. Laboratory Findings Platelets 102,000/mm3 (N150,000-450,000) Creatinine 0.7mg/dL(N0.6-1.2) AST 56U/L(N8-48) ALT 43U/L(N7-55) Albumin 3.3g/dL(N3.5-5.0)Which one of the following conditions best explains this patient's abnormal findings? A) 1-Antitrypsin deficiency B) Cystic fibrosis C) Goodpasture syndrome D) Hereditary hemochromatosis E) Sarcoidosis - ANS A Which one of the following is most likely to cause a false- positive urine drug screen for amphetamines? A) Amlodipine (Norvasc) B) Bupropion (Wellbutrin) C) Levofloxacin (Levaquin) D) Pantoprazole (Protonix) E) Sertraline (Zoloft) - ANS B
The U.S. Preventive Services Task Force recommends screening for depression for A) all adults B) all women but not men C) only adults with a family history of depression D) only adults with a known personal history of depression E) only adults with a history of disability, medical illness, complicated grief, chronic sleep disturbance, and/or loneliness - ANS A A 62-year-old female sees you for a routine health maintenance examination. She has a history of breast cancer diagnosed 6 years ago that was treated with lumpectomy, radiation, and endocrine therapy. She is feeling well today and has no symptoms of concern. There is no family history of breast, ovarian, colon, or prostate cancers. In addition to mammography, which one of the following annual tests would improve this patient's chance of survival? A) No tests B) CT of the chest C) MRI of the breast D) Breast ultrasonography E) A bone scan - ANS A A 62-year-old male with hypertension presents to your office with substernal chest pain radiating into his left arm for the past 20 minutes. He also has diaphoresis and nausea. He has a blood pressure of 156/96 mm Hg, a pulse rate of 84 beats/min, and an oxygen saturation of 93% on room air. An EKG shows ST- segment elevations in leads V1 and V2. Your medical assistant
calls 911 for immediate transport to the local hospital's emergency department. While awaiting the ambulance's arrival you give the patient low-dose aspirin and sublingual nitroglycerin. Which one of the following would be most appropriate regarding oxygen therapy at this time? A) No oxygen therapy B) Oxygen via nasal cannula at 2 L/min C) Oxygen via nasal cannula at 6 L/min D) 100% oxygen with a regular mask E) 100% oxygen with a nonrebreathing mask - ANS A You see an 89-year-old female with advanced dementia who has stopped eating. The patient's daughter asks you about the role of tube feeding in this situation. You discuss the risks and benefits. In patients with advanced dementia who have a feeding tube placed, there is evidence of increased A) nutritional status B) healing of pressure ulcers C) quality of life D) survival E) emergency department visits - ANS E A 55-year-old male with a BMI of 32 kg/m2 presents to your office to discuss weight management. He has moderately well controlled type 2 diabetes and hypertension. He prefers not to modify his diet and would like to know if he can expect significant weight loss from exercising. He plans to walk briskly for 45 minutes daily. Which one of the following would be the best advice for this patient?
A) Moderate exercise alone is ineffective for weight loss B) Moderate exercise alone is superior to dietary changes for weight loss C) Moderate exercise alone is moderately beneficial for weight loss D) Adding moderate exercise to dietary changes substantially increases weight loss - ANS C A 67-year-old female patient began taking a bisphosphonate for treatment of osteoporosis 2 years ago after a DXA scan revealed a T-score of - 2.7. Her FRAX score showed a 10-year probability of hip fracture of 5%. You order a repeat DXA scan and her T- score is now - 2.3 and her FRAX score is 3.5%. Which one of the following should you recommend to this patient regarding the duration of treatment with a bisphosphonate? A) Stop taking it now B) Continue taking it for 1 more year C) Continue taking it for 3 more years D) Continue taking it for 7 more years E) Continue taking it indefinitely - ANS C A 43-year-old male presents to the emergency department with the acute onset of sharp, stabbing chest pain when inhaling and exhaling. The pain worsens with coughing and deep breathing. He has no significant previous medical history but recently returned from a work trip to Japan and has noted right leg swelling for the past week. He has no other symptoms. He is a smoker and has a family history of coronary artery disease in his paternal grandfather. On examination he appears uncomfortable, and his lungs are clear. A cardiac examination is notable for
tachycardia. He has a blood pressure of 110/70 mm Hg, a heart rate of 112 beats/min, a respiratory rate of 18/min, a temperature of 37.7°C (99.9°F), and an oxygen saturation of 89% on room air. Which one of the following test results is most likely to confirm the diagnosis? A) Elevated troponin levels B) Acid-fast bacilli on a Gram stain C) A filling defect on CT angi - ANS C You have assumed the care of a well established patient in your practice whose medications include chronic alprazolam (Xanax) treatment for anxiety and codeine for chronic back pain following a work accident years earlier. His Prescription Drug Monitoring Program report shows a consistent pattern of filling the medications as prescribed. You order a urine immunoassay for opioids and benzodiazepines. The results are positive for opioids but negative for benzodiazepines. Which one of the following would be the most appropriate next step? A) Perform confirmatory testing for alprazolam B) Repeat the urine immunoassay for benzodiazepines C) Investigate for possible diversion of alprazolam D) Stop prescribing alprazolam E) Stop prescribing controlled substances - ANS A For patients with atrial fibrillation, which one of the following comorbid conditions represents the strongest indication for thromboprophylaxis with warfarin (Coumadin), rather than a direct oral anticoagulant? A) A CHA2DS2-VASc score 3
B) End-stage chronic kidney disease C) A mechanical heart valve D) Mild mitral stenosis E) Severe mitral regurgitation - ANS C According to the Institute of Medicine, which one of the following domains of health care quality is most impacted by social determinants of health? A) Effectiveness B) Efficiency C) Equity D) Safety E) Timeliness - ANS C The most common symptom of alcohol withdrawal in the elderly is A) confusion B) seizures C) tachycardia D) tremor E) vomiting - ANS A According to the Ottawa ankle and foot rules, which one of the following patients with ankle or foot pain after a twisting injury requires radiographs to rule out a fracture? A) An 18-year-old male basketball player who landed on an opposing player's foot while rebounding the ball and has tenderness anterior to the lateral malleolus B) A 23-year-old female who twisted her ankle while playing soccer and has tenderness at the base of the fifth metatarsal
C) A 30-year-old male who twisted his ankle a week ago after stepping on his child's toy and has persistent swelling with tenderness anterior to the medial malleolus D) A 48-year-old female who slipped while going down stairs and has tenderness and bruising inferior to the lateral malleolus - ANS B A 65-year-old female presents to the emergency department with a 24-hour history of abdominal pain, nausea, and vomiting. She reports that her last bowel movement was 2 days ago and she has not passed any flatus. The pain is diffuse and she rates it as 4 on a scale of 10 but says that it reaches a level of 8 at times. She has hypertension, which has been controlled with amlodipine (Norvasc), 5 mg daily. She had an appendectomy at age 25 and had two normal vaginal deliveries. She has been postmenopausal since age 52. An examination reveals a blood pressure of 120/80 mm Hg, a pulse rate of 110 beats/min, a respiratory rate of 16/min and nonlabored, and an oxygen saturation of 95% on room air. Examination of the heart and lungs is normal. On examination of the abdomen you note high-pitched bowel sounds, and the abdomen is distended and tympanic, and diffusely tender with no appreciable masses. A radiograph of the abdome - ANS B A 68-year-old female comes to your office to discuss results from recent laboratory testing. During routine monitoring of electrolytes while taking lisinopril (Prinivil, Zestril) for hypertension, she was found to have a serum calcium level of 10.6 mg/dL (N 8.6-10.0). Follow-up laboratory studies revealed a parathyroid hormone level of 106 pg/mL (N 10-65) and normal levels of vitamin D, phosphorus, albumin, and
creatinine. The patient feels well today and has no symptoms of concern. The patient's past medical history includes hypertension, hypothyroidism, and osteoporosis. Her current medications include lisinopril, levothyroxine (Synthroid), alendronate (Fosamax), and vitamin D. An examination today is normal, including a blood pressure of 122/74 mm Hg. Which one of the following characteristics would be an indication for surgical management of this patient's condition? A) Age >50 B) Hypertension C) Hypothyroidism D - ANS D You are examining a 65-year-old male from Central America with a history of rheumatic valvular disease. Which one of the following is the principal auscultatory finding of aortic regurgitation? A) An S3 gallop heard best at the cardiac apex with the patient supine B) A triphasic pericardial friction rub with the patient seated and leaning forward C) A low-pitched decrescendo diastolic murmur that is loudest at the lower left sternal border with the patient seated and leaning forward D) A high-pitched crescendo/decrescendo midsystolic murmur that is loudest at the right upper sternal border and radiates to the carotid arteries with the patient sitting upright E) A harsh holosystolic murmur that is loudest at the lower left sternal border and radiates
to the left lateral chest wall with the patient in the left lateral decubitus position - ANS C A 50-year-old male with no significant past medical history presents with a 5-day history of fever to 101°F, chills, and mild diffuse joint and muscle pains. He also reports a mild headache but has not had any sore throat, rhinorrhea, cough, shortness of breath, nausea, vomiting, or change in bowel habits. He noticed a round red rash (shown below) a few days ago on his leg that has grown in size since then. It is minimally pruritic but not painful. He has no other rashes. He recently traveled to Vermont for his family's annual fall hiking trip but does not recall any insect bites. He does not take any medications and has no drug allergies. He has a blood pressure of 120/74 mm Hg, a pulse rate of 84 beats/min, and a temperature of 37.8°C (100.0°F). Cardiac, pulmonary, musculoskeletal, and abdominal examinations are normal. Which one of the following is the most likely diagnosis? A) Adenovirus B) Ehrlichiosis C) Inf - ANS D A 16-year-old male who was recently diagnosed with moderate persistent asthma sees you for follow-up in early September. He uses fluticasone propionate/salmeterol (Advair), 250/50 g twice daily. He has an Asthma Control Test score of 22, which indicates well controlled asthma, and his peak flow is 90% of the predicted value. Spirometry performed 6 months ago showed an FEV1 of 90% of the predicted value. He can demonstrate good technique for using his inhalers.