Board Review 6/12

A 42-year-old female presents for follow-up after being treated for recurrent respiratory problems at an urgent care facility. She is feeling a little better after a short course of oral prednisone and use of an albuterol (Proventil, Ventolin) inhaler. She has had a gradual increase in shortness of breath, a chronic cough, and a decrease in her usual activity level over the past year. She has brought a copy of a recent chest radiograph report for your review that describes panlobular basal emphysema. She does not have a history of smoking, secondhand smoke exposure, or occupational exposures. Spirometry in the office reveals an FEV1/FVC ratio of 0.67 with no change after bronchodilator administration.

Which one of the following underlying conditions is the most likely cause for this clinical presentation?

• α1-Antitrypsin deficiency

• Bronchiectasis

• Diffuse panbronchiolotis

• Interstitial lung disease

While reviewing laboratory studies for a patient who was recently started on antihypertensive medication, you note new hyperkalemia. Which one of the following medications is most likely to cause this finding? 

• Amlodipine (Norvasc)

• Chlorthalidone

• Hydrochlorothiazide

• Metoprolol

• Olmesartan (Benicar)

An otherwise healthy 57-year-old male presents with mild fatigue, decreased libido, and erectile dysfunction. A subsequent evaluation of serum testosterone reveals hypogonadism.

Which one of the following would you recommend at this time?

• No further diagnostic testing

• A prolactin level

• A serum iron level and total iron binding capacity

• FSH and LH levels

• Karyotyping

A 4-year-old female is brought to your office because of a history of constipation over the past several months. Her mother reports that the child has 1–2 bowel movements per week composed of small lumps of hard stool. She strains to have the bowel movements, and they are painful. The child eats normally like her two siblings.

Which one of the following would be most effective at this time?

• Daily fiber supplements

• Lactuose

• Magnesium hydroxide (Milk of Magnesia)

• Polyethylene glycol (MiraLAX)

• Senna

Acne appearing at which one of the following ages should prompt detailed endocrine laboratory testing for possible underlying systemic disease?

• 3 weeks

• 7 months

• 5 years

• 9 years

• 13 years

A 36-year-old female presents for evaluation of elevated blood pressure. She is asymptomatic and does not take any medications. On examination her blood pressure is 160/96 mm Hg and her BMI is 26 kg/m2. Fasting laboratory studies include the following:

Sodium ............................  142 mEq/L (N 136–145)
Potassium.........................  3.0 mEq/L (N 3.5–5.1)
Creatinine ........................  0.76 mg/dL (N 0.6–1.1)
Glucose ...........................  97 mg/dL

Which one of the following additional laboratory evaluations should be performed to assess her blood pressure?

• A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)

• A serum aldosterone/renin ratio

• A serum cortisol level

• A serum cystatin C level

A 26-year-old male diagnosed with coccidioidomycosis (valley fever) develops a rash on the extensor surfaces of his lower legs consisting of painful, subcutaneous, nonulcerated, erythematous nodules. This rash is consistent with which one of the following?

• Erythema ab igne

• Erythema infectiosum

• Erythema migrans

• Erythema multiforme

• Erythema nodosum

A 30-year-old female presents with a 5-day history of subjective fever and malaise. She does not have a thermometer at home but has felt alternately warm and chilled. She has felt generally unwell and is sleeping more than usual. She has had a decreased appetite but has been drinking fluids without difficulty. She does not have a runny nose, cough, headache, abdominal pain, vomiting, diarrhea, joint pain, rash, or pain with urination. Her medical history includes substance use disorder and she takes buprenorphine/naloxone (Suboxone). She smokes one pack of cigarettes daily, has 0–2 alcoholic drinks daily, and began using intravenous heroin again 1 week ago.

An examination reveals a blood pressure of 112/68 mm Hg, a pulse rate of 88 beats/min, a respiratory rate of 16/min, a temperature of 38.9°C (102.0°F), and an oxygen saturation of 95% on room air. The patient appears fatigued and uncomfortable but nontoxic. Her heart has a regular rate and rhythm with no murmur. Her lungs are clear to auscultation bilaterally and her abdomen is soft and nontender. There is no swelling or redness in the extremities and a skin examination reveals no rashes or lesions.

Which one of the following would be most important at this point?

• A viral swab

• An antinuclear antibody level

• Blood cultures

• An erythrocyte sedimentation rate

• A chest radiograph

A 29-year-old male presents to your office because of pain and paresthesia in his right fourth and fifth fingers for the last several weeks. He has had some generalized weakness in his hands, noting that it is more difficult for him to grasp and pick up small objects with his thumb and forefinger. There is no history of trauma. He is very physically active and lifts weights 5–6 days per week. On physical examination you note weakness of the pincer mechanism and decreased sensation over the hypothenar eminence and fourth and fifth fingers.

These findings are associated with peripheral entrapment of which one of the following nerves?

• Axillary

• Median

• Radial

• Suprascapular

• Ulnar

A 35-year-old female comes to your office for evaluation of a tremor. During the interview you note jerking movements first in one hand and then the other, but when the patient is distracted the symptom resolves. Aside from the intermittent tremor the neurologic examination is unremarkable. She does not drink caffeinated beverages and takes no medications.

Which one of the following is the most likely diagnosis?

• Parkinson's disease

• Cerebellar tremor

• Essential tremor

• Physiologic tremor

• Psychogenic tremor