Board Review 8/14

A 70-year-old male presents to the emergency department with a sudden onset of severe abdominal pain that radiates to his back. The patient has a history of stroke, hypertension, and type 2 diabetes. He has a 40-pack-year smoking history. A physical examination reveals a pulsatile mass just above the umbilicus. CT of the abdomen confirms the diagnosis.

Which one of the following is the greatest risk factor for developing this condition?

• Cigarette smoking

• Hypertension

• Male sex

• Stroke

• Type 2 diabetes

Of the following, which one is the most effective abortive treatment for cluster headache?

• Hydromorphone (Dilaudid)

• Ketorolac

• Ondansetron

• Propranolol

• Sumatriptan (Imitrex)

A 4-month-old female is brought to your office for a well child check. She is here with her mother and 2 older brothers, who are also your patients. The family looks forward to swimming at the local outdoor community pool, going to the beach, and gardening this summer.

Which one of the following should you recommend to reduce this family's risk for skin cancer related to sun exposure?

• Applying sunscreen with an SPF ≥15 to the infant before taking her outside

• Avoiding going to the pool during the middle of the day, and encouraging them to take breaks in the shade

• Going to the beach only on cloudy days when ultraviolet rays are absent

• Wearing a baseball cap for sun protection when gardening

A 36-year-old female presents with a medical history of hypertension, hyperlipidemia, obesity, and 3 miscarriages. She is not currently pregnant. She was recently discharged from the hospital with her second deep vein thrombosis (DVT) in the past several years. A workup for the underlying cause of her thrombophilia is positive for antiphospholipid antibodies.

Which one of the following medications would be most appropriate for the long-term treatment of this patient’s DVT?

• Apixaban (Eliquis)

• Aspirin

• Clopidogrel (Plavix)

• Enoxaparin (Lovenox)

• Warfarin

You see a 45-year-old male with a history of opioid use disorder for a health maintenance examination. The patient has successfully remained in a treatment program using methadone, and an examination is normal. He has not had a recent EKG.

You order an EKG because which one of the following is a very rare but serious complication of methadone treatment?

• Paroxysmal atrial fibrillation

• QTc prolongation

• First-degree heart block

• Second-degree Mobitz type II heart block

• Complete heart block

A 24-year-old female sees you for treatment of significant depression and associated hypomanic symptoms. She has been experiencing racing thoughts, agitation, and a decreased need for sleep

Which one of the following is CONTRAINDICATED in this patient?

• Cariprazine (Vraylar) monotherapy

• Quetiapine (Seroquel) monotherapy

• Sertraline (Zoloft) monotherapy

• Lurasidone (Latuda) plus valproic acid

• Quetiapine plus lithium

A 59-year-old male presents to your office accompanied by his wife for evaluation of a 6-month history of worsening weakness. He reports having difficulty lifting light items to the top shelf at work. His wife adds that he has recently been clumsier around the house.The patient’s vital signs are normal today. On physical examination you note mild dysarthria during conversation, proximal weakness of the upper extremities that is more pronounced on the left, hyperreflexia of the biceps tendon reflex bilaterally, atrophy of the quadriceps that is more pronounced on the right, and absent reflexes of the patellar tendon.

Which one of the following is the most likely diagnosis? 

• Amyotrophic lateral sclerosis

• Guillain-Barré syndrome

• Hypothyroidism

• HIV

• Myasthenia gravis

A 49-year-old female presents to your office with severe left ear pain. The patient describes the pain as sharp and deep inside her ear and reports that it has been occurring occasionally for several years. The pain has become more constant over the last 2 months, and she currently rates it as 8 out of 10 on a pain scale. She has not previously sought an evaluation.On physical examination you find a normal ear canal and tympanic membrane. The patient is only able to open her mouth 2 finger widths, has clicking over the left temporomandibular joint with opening, and has pain with palpation of the submandibular musculature.

Which one of the following is the most appropriate next step in the management of this disorder?

• Reassurance that her ear is normal, and follow-up in 4 weeks if symptoms have not improved

• A trial of naproxen and cyclobenzaprine

• Noncontrast CT of the facial bones

• Referral to an otolaryngologist for further evaluation

• Referral to a maxillofacial surgeon for consideration of jaw realignment surgery

A 6-month-old male is brought to your office by his parents for a well baby examination. This is the patient's first visit to your office as his family recently immigrated to the United States. The infant appears to be developing normally, but the parents are concerned because they have not observed a right testicle.On examination you are able to palpate the left testicle in the normal location. The right testicle is not located in the scrotum but is palpable along the inguinal canal. It can be moved into the upper scrotum but requires constant tension to remain in this position and immediately retracts after release.

Which one of the following would be the most appropriate next step in management?

• Reassurance that the condition will resolve spontaneously

• Follow-up in 2 months

• An ultrasound of the scrotum and pelvis

• Referral to an endocrinologist

• Referral to a urologist

A 23-year-old kindergarten teacher presents with a 2-day history of fever up to 102 °F, a sore throat, headache, and swollen glands. She has not had a runny nose or cough. Her throat is hyperemic and has tonsillar exudates. The anterior cervical nodes are enlarged and tender, but there is no other lymphadenopathy. She requests an antibiotic to prevent complications and to reduce the likelihood of spreading the infection to her students. A throat swab for group A Streptococcus is positive.

Which one of the following is true regarding the use of antibiotics in this patient?

• Her current symptoms will not be reduced

• Her risk for developing poststreptococcal glomerulonephritis will not change

• Her risk for developing rheumatic fever will not change

• She will remain contagious for 7–10 days even with treatment