Board Review 10/9

A 70-year-old male without underlying lung disease presents with a 36-hour history of fever, body aches, cough, and dyspnea. He did not receive influenza vaccine this year, and was recently exposed to his grandson who had influenza.

On examination the patient has a temperature of 38.8°C (101.8°F), a blood pressure of 90/50 mm Hg, a heart rate of 110 beats/min, and an O2 saturation of 87% on room air. A nasal swab rapid antigen test is negative, and his WBC count is 15,000/mm3 (N 4300–10,800). A viral culture is sent to the laboratory. A chest radiograph shows a large lobar pneumonia.

You hospitalize the patient and initiate?

• ceftriaxone (Rocephin) and azithromycin (Zithromax)

• levofloxacin (Levaquin)

• oseltamivir (Tamiflu)

• oseltamivir, ceftriaxone, and azithromycin

• oseltamivir, ceftriaxone, azithromycin, and vancomycin (Vancocin)

A mother brings her 10-year-old son to your office because he has recently experienced a flare-up of atopic dermatitis, including increased pruritus. Physical findings include increased erythema of the involved skin on the flexural surfaces of his arms and legs, with weeping eruptions located within areas of lichenification.

Which one of the following topical treatments for managing this episode is supported by the best available evidence?

• Emollients

• Pimecrolimus (Elidel)

• Mupirocin (Bactroban)

• Corticosteroids

• Antihistamines

Which one of the following is a preferred first-line agent for managing hypertension in patients with stable coronary artery disease?

• A thiazide diuretic

• An angiotensin receptor blocker

• A β-blocker

• A long-acting calcium channel blocker

• A long-acting nitrate

A 54-year-old female presents with a complaint of dizziness. Two days ago, while riding in a friend’s car and trying to read a book, she experienced sudden extreme nausea and a “spinning” feeling that lasted for 20 minutes. She also had a headache that mainly felt like a fullness in the area around her left ear. Since then she has had only mild dizziness when she moves her head too quickly. She recalls experiencing these symptoms on two other occasions but cannot remember the circumstances, although she thinks one episode may have been related to having had too much caffeine.

A review of systems is positive for a humming in her ears over the last few years. On examination both ears appear normal. Mild horizontal nystagmus can be seen on movement of the head to the left. Audiograms are normal in the right ear, with a low-frequency hearing loss on the left.

Which one of the following is the most likely diagnosis?

• Motion sickness

• Meniere’s disease

• Vestibular migraine

• Benign positional vertigo

A 32-year-old female has a 3-week history of depressed mood. She reports markedly diminished interest or pleasure in most activities, fatigue, a diminished ability to concentrate, and insomnia. She has had recurrent suicidal thoughts, but has no specific plan. Further investigation reveals a past history of several hypomanic episodes lasting 4–5 days, characterized by a persistently elevated, expansive mood. During these episodes she needed little sleep, was talkative, met multiple goals, and had trouble keeping up with the thoughts that were running through her head. She was treated with lithium in her early twenties but she stopped taking it because it stifled her artistic creativity. She currently takes no medication.

Her physical examination is unremarkable. Results from comprehensive laboratory studies, including a urine toxicology screen, are also normal.

Which one of the following is most appropriate for her current depressive symptoms?

• Aripiprazole (Abilify)

• Venlafaxine

• Divalproex (Depakote)

• Divalproex and bupropion (Wellbutrin)

• Lithium and paroxetine (Paxil)

A 65-year-old male with type 2 diabetes mellitus is having increasing symptoms of angina pectoris. His cardiologist has recommended that he undergo heart catheterization and possible intervention if coronary artery disease is found. He comes to your office prior to the procedure and asks for your thoughts regarding treatment options presented by the cardiologist.

In addition to optimal medical treatment, if this patient is found to have multivessel coronary disease at the time of heart catheterization, you would recommend which one of the following?

• Angioplasty without stenting

• Angioplasty with bare-metal stents

• Angioplasty with drug-eluting stents

• Angioplasty of the most significantly blocked artery, followed by coronary artery bypass graft surgery

• Coronary artery bypass graft surgery

A 2½-year-old male is brought to the emergency department with the acute onset of diffuse abdominal pain that began approximately 6 hours ago. He has also had 3 episodes of bilious emesis in the last 2 hours. A review of systems is positive for anorexia today but negative for fever, weight loss, diarrhea, and bloody stools.

On examination the patient’s height and weight are in the 50th percentile for age, his blood pressure is normal, his heart rate is 110 beats/min, and his temperature is 36.9°C (98.4°F). Cardiovascular and pulmonary examinations are unremarkable. The abdominal examination is significant for slightly hypoactive bowel sounds and diffuse tenderness to palpation without rebound, guarding, or rigidity. A genitourinary examination is normal.

Which one of the following studies is the most appropriate next step to diagnose the cause of abdominal pain in this patient?

• Scrotal ultrasonography

• Abdominal ultrasonography

• Abdominal and pelvic CT

• An upper gastrointestinal series

Which one of the following juices can greatly increase the blood level of a statin?

• Apple

• Grapefruit

• Orange

• Pineapple

• Tomato

A 62-year-old female presents to your office with diarrhea and signs and symptoms of
dehydration. She has a temperature of 38.6°C (101.5°F) and a WBC count of 17,000/mm3 (N
5300–10,800). You admit her to the hospital, and a Clostridium difficile toxin assay is positive.
Because of the severity of her infection, you initiate oral vancomycin (Vancocin), 125 mg 4
times daily. She has a poor clinical response and you decide to alter the antibiotic regimen to
include intravenous coverage.

Which one of the following intravenous antibiotics would be most appropriate?

• Ciprofloxacin (Cipro)

• Imipenem/cilastatin (Primaxin)

• Meropenem (Merrem)

• Metronidazole

• Vancomycin

An 11-year-old female who plays in a local youth soccer league presents with right heel pain that has persisted for several months. She does not recall a specific injury that could have caused the pain. On examination the skin is intact and she is tender over the right posterior heel. Examination of the ankle and forefoot is unremarkable and a neurovascular examination is normal. You decide that rest and physical therapy would be the best initial management.

Which one of the following is CONTRAINDICATED for this patient?

• Ice packs

• Moist heat

• Whirlpool therapy

• An exercise prescription

• Therapeutic ultrasound