REVIEW QUESTIONS

Charles A. Morris

QUESTION 1. A 46-year-old salesman presents for follow-up to his primary care doctor after a recent upper respiratory infection (URI). He was treated with moxifloxacin. He also now notes easy bruisability and a nosebleed last week. He has a history of atrial fibrillation and takes warfarin. His examination reveals a few ecchymoses but otherwise is normal. He is guaiac negative and has no petechiae. His laboratory evaluation reveals hematocrit (Hct) of 42%, platelets 339,000/µL. His International Normalized Ratio (INR) is 6.2, and partial thromboplastin time (PTT) is 42 seconds. What is the most appropriate therapy?

    A. Fresh frozen plasma until INR <2.0

    B. Recombinant factor VIIa

    C. Protamine sulfate

    D. Oral vitamin K

    E. Platelet transfusion

QUESTION 2. A 32-year-old electrician presents with weight loss and cough with bloody sputum. He has a history of a positive purified protein derivative (PPD) for which he never received treatment. On examination, he appears comfortable. He is afebrile, blood pressure (BP) 122/68 mm Hg, heart rate 89 beats per minute, room air oxygen saturation of 97%. His chest x-ray demonstrates a left upper lobe consolidation. The next step in his management should be:

    A. Initiate therapy for community-acquired pneumonia (CAP) with levofloxacin 750 mg orally once daily

    B. Admit to the hospital to negative airflow room out of concern of active pulmonary Mycobacterium tuberculosis

    C. Initiate outpatient therapy with isoniazid for treatment of latent TB infection (LTBI)

    D. Initiate outpatient therapy with INH/RIF/ETH/PZA while awaiting acid-fast bacillus (AFB) results

    E. Have patient fitted for N95 mask to wear at all times

QUESTION 3. A 57-year-old attorney has a screening exercise stress test prior to participating in a gym program. He has a history of high blood pressure, tobacco use, and dyslipidemia. The stress test suggests some degree of ischemia, and you consider performing coronary angiography.

    Which of the following is true regarding the potential findings?

    A. Percutaneous cardiac intervention (PCI) without stenting is indicated if study shows single-vessel disease.

    B. PCI with stenting is indicated if study shows single vessel disease.

    C. PCI would be indicated if study shows multivessel disease.

    D. There is a survival benefit to the addition of clopidogrel.

    E. Blood pressure and lipid control would be preferred first-line therapy.

QUESTION 4. A 72-year-old farmer presents to his primary care physician (PCP) for a routine physical examination. He has a history of hypertension and diet-controlled diabetes mellitus (DM). His heart rate is 122 beats per minute, and a 12-lead electrocardiogram (EKG) demonstrates new atrial fibrillation. He is started on Coumadin and metoprolol ER, 50 mg daily, with reduction in his resting heart rate to 85 beats per minute. Which of the following is the most appropriate next step in his management?

    A. Initiate amiodarone therapy

    B. Admit to the hospital for DC cardioversion

    C. Make no changes

    D. Add aspirin, 81 mg daily

    E. Consult cardiology for radiofrequency ablation (RFA)

QUESTION 5. A 21-year-old teacher presents with pharyngitis, myalgias, and fatigue. She has a temperature of 38.9°C, 1cm anterior cervical lymphadenopathy, a lightly erythematous eruption on her chest, and an erythematous posterior oropharynx with scattered small ulcers but no exudates.

    A monospot test is performed, and is negative. Which of the following tests is LEAST likely to be helpful in making a diagnosis?

    A. A repeat monospot in 1 week

    B. An Epstein-Barr virus (EBV) VCA IgM

    C. A EBV nuclear antigen

    D. HIV enzyme-linked immunosorbent assay (ELISA)

    E. Cytomegalovirus (CMV) IgM and IgG

QUESTION 6. An 82-year-old retired librarian with a history of coronary artery disease (CAD), prior ischemic stroke, and hypertension presents to urgent care with 2 to 3 months of nausea, 16-lb weight loss, and abdominal pain. The pain is most concentrated around her umbilicus, and it is worse with eating; it has gotten especially intense in the last day. She denies fevers, chills, bright red blood per rectum (BRBPR), recent NSAID use, or prior episodes of pain. Her abdominal examination was notable for minimal tenderness. Her laboratory values are notable for an amylase of 233 U/L, blood urea nitrogen (BUN) of 61 mg/dL, creatinine of 2.3 mg/dL, and a lactic acid of 4.5 mg/dL. An abdominal CT was obtained (see Figure 104.1).

    Which of the following is the most relevant risk factor for her current presentation?

    A. Atherosclerosis

    B. Recent hypotension with poor perfusion of watershed territory

    C. Adhesions from prior abdominal surgery

    D. Bowel colonization with Clostridium difficile

    E. A colonic polyp acting as a “lead point”

QUESTION 7. A 74-year-old woman presents to her PCP with 11 months of dry cough and fatigue. She denies fevers, chills, reflux symptoms, or chest pain. She has never smoked, drinks 1 glass of wine daily, and has no known risk factors for M. tuberculosis. A course of azithromycin did not decrease her symptoms. Her chest x-ray is shown in figures 104.2 and 104.3.

    Which of the following is most true about her disease process?

    A. A chest CT would likely show an endobronchial lesion

    B. A purified protein derivative (PPD) test will be useful as a diagnostic test

    C. Induced sputum for AFB and mycobacterial culture is indicated

    D. Prednisone 60 mg daily is indicated

    E. She is highly infectious

QUESTION 8. A 42-year-old chef presents to her PCP with leg pain for the last 6 months. It is localized to the thighs, worse with weight bearing, and does not wake her from sleep. She denies fevers, weight loss, rash, joint discomfort, new medications, or HMG-CoA reductase inhibitor therapy. A physical examination is unremarkable. Laboratory testing is notable for calcium of 8.1 mg/dL, phosphorus 0.8 mg/dL, Vitamin D of 4 mg/mL, and an alkaline phosphatase of 177 IU/L. X-rays of the extremities show osteopenia and a bone density is notable for a T-score of –2.8.

    What is the most appropriate next step?

    A. Initiate calcium, vitamin D, and bisphosphonate therapy

    B. Initiate vitamin D therapy at 50,000 IU per week for 12 weeks

    C. Arrange for a bone biopsy

    D. Perform skeletal survey to rule out multiple myeloma

    E. Initiate therapy with a PTH analogue.

QUESTION 9. A 26-year-old graduate student sees her primary care doctor for advice on contraception. She does not smoke, has no history of clotting disorder, and no family history of breast cancer. When counseling the patient about the risks and benefits of oral contraceptives, all of the following should be included EXCEPT:

    A. Increased risk of new-onset hypertension

    B. Increased risk of cervical cancer with increased duration of use

    C. Increased risk of venous thromboembolic disease

    D. Decreased risk of endometrial cancer

    E. Decreased risk of breast cancer

QUESTION 10. A 22-year-old law student presents with back pain for the last 2 years. It sometimes wakes him from sleep and has prevented him from playing sports (see Figure 104.4). He has also had recurrent “conjunctivitis” over the last year. More recently, he has developed some chest wall pain. On examination, he has a positive Schober test and decreased chest wall expansion with inspiration. Which of the following tests, if positive, will be the most useful to confirm the diagnosis?

    A. HLA-B27

    B. Colonoscopy

    C. Lumbosacral (L/S) spine and sacral plain films

    D. C-reactive protein (CRP)

    E. Skin biopsy

QUESTION 11. A 68-year-old retired secretary presents to her PCP with dyspnea on exertion. She is a former smoker of 50+ pack years and stopped smoking 10 years ago. She has a daily cough productive of a couple teaspoons of whitish phlegm. Her PCP is concerned she may have chronic obstructive pulmonary disease (COPD). The most appropriate way to diagnose her with COPD is:

    A. Lung volumes that demonstrate total lung capacity (TLC) and reserve volume (RV) that are >20% of predicted

    B. Spirometry that reveals bronchodilator responsiveness (200 cc and 12% change)

    C. Spirometry that reveals an FEV₁/FVC <70% of predicted

    D. Chest radiograph with hyperinflated lungs and flattened diaphragms

    E. No further studies are required—the history alone is sufficient.

QUESTION 12. A 33-year-old pharmacist comes to her primary care doctor to discuss her risks for developing breast cancer. She has no symptoms and no family history of breast or ovarian cancer. She does not smoke, had her first menstrual period at age 10 years and her first child 2 years ago. She used oral contraceptives from age 18 to 28 years. Which statement about her risk for breast cancer is NOT true?

    A. The lifetime chance of developing breast cancer for each woman in the United States is 1:8.

    B. Early onset of menarche lowers her risk for breast cancer.

    C. First delivery at older age increases the risk for breast cancer.

    D. Her oral contraceptive pill (OCP) use increases her risk for breast cancer only modestly.

    E. The risk for breast cancer can be calculated in an individualized manner based on the patient’s history.

QUESTION 13. A 55-year-old postal worker has a routine physical examination. He has mild hypertension and no symptoms. His physical examination is unremarkable. He asks about prostate-specific antigen (PSA) testing. For this patient, all of the following are true except:

    A. He has a significant risk of a false-positive PSA result even at this age.

    B. PSA is more sensitive than digital rectal examination.

    C. Alternative causes of an elevated PSA include prostatitis and benign prostatic hypertrophy (BPH).

    D. Use of total PSA with percentage free (unbound) PSA may improve sensitivity.

    E. A single PSA level below 4.0 ng/mL essentially rules out the possibility of prostate cancer.

QUESTION 14. A 56-year-old physicist returns for follow-up with his primary care physician after a recent admission for decompensated heart failure. He has a history of coronary artery disease, s/p coronary artery bypass graft (CABG) 10 years prior, with ischemic cardiomyopathy. A recent echocardiogram showed his ejection fraction to be 30%. He describes mild dyspnea with climbing the stairs to his bedroom. He sleeps on two pillows at baseline and notes mildly increased leg swelling. Which of his medications has NOT been shown to have a mortality benefit in patients with class III heart failure?

    A. Enalapril

    B. Candesartan

    C. Metoprolol

    D. Digoxin

    E. Spironolactone

QUESTION 15. A 34-year-old brick layer presents to urgent care with recurrent substernal chest pain and shortness of breath. He also noted increased fatigue and a 10 lb unintentional weight loss. He has no past medical history, has been smoking 2 packs of cigarettes daily, and uses cocaine occasionally, most recently 2 weeks ago. His physical examination is unremarkable. A chest x-ray is obtained (see figures 104.5 and 104.6).

    Which is the LEAST likely diagnosis?

    A. Thymoma

    B. Extragonadal germ cell tumor

    C. Hodgkin lymphoma

    D. Fibrosing mediastinitis

    E. Thyroid neoplasm

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