1.

What condition presents with hypertension, hypernatremia, and hypokalemia?

Hyperaldosteronism from adrenal tumors (Cushing disease) will cause sodium retention and potassium excretion.

2.

According to the United States Preventive Services Task Force (USPSTF), what is the breast cancer screening recommendation for women?

Biennial (every other year) between age 50 and 74 years

3.

Foot pain with tenderness of the medial calcaneus that is worse when first getting out of bed or after sitting for a long rest without history of trauma is likely what condition?

Plantar fasciitis

4.

What conditions are commonly associated with a normal-MCV anemia?

Anemia of chronic disease, chronic renal disease, hypothyroidism

5.

What special steps must be completed for diabetics requiring insulin to obtain a commercial drivers license?

Diabetics requiring insulin must apply for and receive an exemption from the Federal Motor Carrier Safety Administration (FMCSA).

6.

What are the common presenting symptoms of dengue fever?

Dengue fever presents 3 to 7 days after exposure with high fever (>38.5°C—may be biphasic), headache, cough, sore throat/nasal congestion, relative bradycardia (typically seen in the febrile phase), abdominal pain, and vomiting, myalgia/arthralgia, lethargy, joint pain, and rash

7.

What visual fields are affected by macular degeneration?

Macular degeneration causes loss of central vision.

8.

A young woman returns from a recent trip to Brazil with diffuse arthralgias and conjunctivitis. What condition would cause worry if she were pregnant?

Zika virus infection; its symptoms include fever, myalgia, joint pain, conjunctivitis, retroocular pain, and maculopapular rash.

9.

Aspartate transaminase (AST) and alanine transaminase (ALT) findings consistent with chronic alcohol abuse show what ratio?

An AST-to-ALT ratio > 2.0

10.

What are the drugs of choice for an acute asthma exacerbation?

Inhaled β-agonists and systemic corticosteroids are indicated for mild, moderate, and severe asthma exacerbations.

11.

According to the USPSTF, what are the current testicular cancer screening recommendations?

Recommends against screening for testicular cancer in adolescent or adult men

12.

Which patients with joint replacements need antibiotic use before a dental procedure?

None. The American Dental Association recommend not routinely using antibiotics for SBE prophylaxis or prosthetic joint replacement unless the joint replacement was highly complicated and with the advice of the orthopedic surgeon.

13.

What is Addison disease due to?

Adrenal insufficiency (AI) is associated with fatigue, abdominal pain, depression, cold intolerance, hyponatremia, and hyperkalemia, which are a result of low serum cortisol and high adrenocorticotropic hormone (ACTH).

14.

Which cardiac conditions support the use of antibiotics before dental procedures?

Indications for antibiotics needed before a dental procedure include prosthetic cardiac valve or prosthetic material used for cardiac valve repair, a history of infective endocarditis, a cardiac transplant that develops cardiac valvulopathy, congenital heart disease, unrepaired cyanotic congenital heart disease, including palliative shunts and conduits, a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention during the first six months after the procedure, any repaired congenital heart defect with residual defect or a prosthetic device.

15.

How does Meckel diverticulum most commonly present?

Meckel diverticulum is the most common congenital gastrointestinal (GI) tract anomaly. It is typically a blind segment of bowel occurring in the distal ileum. It most commonly presents as painless rectal bleeding and can be associated with vomiting from intussusception or volvulus, and/or fever, similar to the presentation of an appendicitis.

16.

According to the USPSTF, what are the colorectal cancer screening recommendations?

Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years

17.

A patient presents with erythema migrans and a flulike illness. He is found to have retinal hemorrhages. What is the likely cause?

Babesiosis presents with a gradual onset of malaise and fatigue, fever up to 105°F (40.6°C) after recent tick bite transfusion. Common symptoms include chills, sweats, headache, anorexia, nonproductive cough, arthralgia, and nausea. Less common symptoms include vomiting, sore throat, abdominal pain, conjunctival injection, photophobia, weight loss, emotional lability, depression, and hyperesthesia. Jaundice and retinopathy with splinter hemorrhages and retinal infarcts can occur.

18.

Waldenström macroglobulinemia is similar to multiple myeloma with what difference?

Waldenström macroglobulinemia presents like multiple myeloma, but there are no bony lytic lesions as in multiple myeloma.

19.

What condition can present in a young woman who has just moved to the United States from Japan with a diffuse vasculitis and oral ulcers?

Behcet syndrome; presents with exacerbations and remissions of symptoms; often, the disease is silent between flares. It can affect all types of vessels, and various parts of the body. It can cause oral and genital mucocutaneous ulcerations, skin rashes, arthritis, thrombophlebitis, uveitis, colitis, and neurologic symptoms. It is rare in the United States, but common in Japan and the Middle East.

20.

What test of bone metabolism is commonly normal when concerned about multiple myeloma and bone lesions?

Alkaline phosphatase is often normal even with bone lesions. Symptoms and signs of multiple myeloma include bone pain, anemia, elevated creatinine, Bence Jones proteinuria, and an M-band spike on serum protein electrophoresis (SPEP).

21.

A patient with a diastolic murmur is found to have a bicuspid aortic valve (BAV). What are the risks of this genetic anomaly?

A BAV is an abnormal formation of the aortic valve that contains two valve leaflets instead of the usual three; it increases the risk of aortic aneurysms, aortic stenosis, and aortic insufficiency.

22.

In atrial fibrillation, what are the CHADS₂ criteria for prevention of stroke?

CHADS₂ criteria for stroke risk:

Congestive heart failure (1 point)

Hypertension (1 point)

Age ≥ 75 (1 point)

Diabetes (1 point)

Prior stroke/transient ischemic attack (TIA) (2 points)

23.

A 68-year-old smoker presents with painless hematuria. What diagnosis must be ruled out by cystoscopy?

Bladder cancer, most commonly transitional cell carcinoma, is the most worrisome cause of painless hematuria in a smoker.

24.

In CHADS₂, what score recommends initiation of anticoagulation to prevent stroke in atrial fibrillation?

CHADS₂ criteria for stroke risk:

Congestive heart failure (1 point)

Hypertension (1 point)

Age ≥ 75 (1 point)

Diabetes (1 point)

Prior stroke/TIA (2 points)

Score

Risk of stroke per year %

0

1.9

1

2.8

2

4.0

3

5.9

4

8.5

5

12.5

6

18.2

Recommended therapy includes:

Score

Anticoagulation therapy

0

Aspirin

1-2

Aspirin or anticoagulant

3 +

Anticoagulant

The main criticism of the CHADS₂ criteria is that an individual with atrial fibrillation and a previous history of stroke, but no other risk factors (i.e., CHADS₂ score 2), is only classified as moderate risk, whereas that person is in fact at high risk for another stroke.

25.

Heel pain over the lateral calcaneus that worsens with activity is consistent with what diagnosis?

Calcaneal stress fracture

26.

According to USPSTF, what are the current lung cancer screening recommendations?

Annual screening for lung cancer with lowdose computed tomography in adults aged 55-80 years who have a 30 pack-year smoking history and currently smoke or who have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

27.

What is the finding on a complete blood count that implies a vitamin B₁₂ or folate deficiency?

Macrocytosis (mean cell volume [MCV] > 100 fL)

28.

Ankle pain posterior to the medial malleolus that radiates to the arch and heel and is associated with tightness, burning, tingling, and numbness that worsens during standing or activity is likely what condition?

Tarsal tunnel syndrome; diagnosis can be confirmed with a compression test of applying pressure to the tarsal tunnel for 60 seconds to reproduce symptoms.

29.

Early vitamin B₁₂ deficiency may be associated with the elevation of what two compounds?

Elevation of methylmalonic acid and homocysteine may be a precursor to vitamin B₁₂ deficiency.

30.

What test should be done to discern if shoulder pain is due to a cervical radiculopathy?

Spurling test: laterally flex the patient’s neck 30 degrees to the affected side and then apply a downward axial compression taking care not to laterally flex the neck any further; reproduction of symptoms rules in cervical radiculopathy.

31.

What finding noted on lumbar puncture samples is indicative of subarachnoid hemorrhage?

Xanthochromia noted on lumbar puncture indicates subarachnoid hemorrhage (cerebral spinal fluid does not clear from tube 1 to tube 4—as is seen in traumatic taps).

32.

Hepatic vein obstruction causing right upper quadrant (RUQ) abdominal pain, portal hypertension, hepatomegaly, and ascites is called what?

Budd-Chiari syndrome; it is seen in patients with inherited thrombophilia or hypercoagulable states, malignancy, and pregnancy.

33.

At what time should antiviral medication be initiated in HIV patients?

AIDS antiviral therapy should be initiated on all patients at the time of diagnosis regardless of their CD4 counts.

34.

Episodes of overeating with loss of control, followed by compensatory behaviors such as self-induced vomiting and misuse of laxatives is called what?

Bulimia nervosa; risk factors include female gender, body dissatisfaction, severe life stressors, low self-esteem, pressure to be thin, perfectionist or obsessive thinking, poor impulse control, substance abuse, family history of substance abuse, affective disorders; sexual abuse is not causally related to bulimia.

35.

What findings are associated with adrenal hyperplasia?

Adrenal hyperplasia causes inadequate aldosterone and cortisone production, leading to low sodium levels and elevated potassium levels.

36.

What is diffuse interstitial lung disease (DILD)?

DILD is a diverse group of chronic progressive lung diseases associated with alveolar inflammation and/or potentially irreversible pulmonary fibrosis. Causes include environmental, occupational, or drug-associated disease and some systemic disorders (e.g., sarcoidosis, Wegener granulomatosis, collagen vascular disease)

37.

What is the drug of choice for torsades de pointes?

Magnesium sulfate, to increase heart rate, which will shorten the QT interval. A lengthened QT interval is the common etiology of torsades de pointes.

38.

A 26-year-old male patient has postprandial abdominal pain that is not improved by proton pump inhibitors; there is no weight loss or other findings. What is the likely diagnosis?

Functional dyspepsia: bothersome postprandial fullness, early satiety, or epigastric pain/burning in the absence of causative structural disease (to include normal upper endoscopy) for the preceding 3 months with initial symptom onset at least 6 months prior to diagnosis

39.

What are the common side effects of metformin?

Common side effects include GI disturbances and B₁₂ deficiency. Rarely, lactic acidosis may occur.

40.

A patient has numerous clinically atypical nevi covering his chest, abdomen, and back and is diagnosed with atypical nevus syndrome. What disease risk is increased by having this syndrome?

Malignant melanoma

41.

What treatment should be given with a needlestick injury when the source is hepatitis B positive?

HBIG (hepatitis immune globulin), if the person stuck has negative hepatitis B titers. Give hepatitis B vaccine in three series if not previously immunized and HIV prophylaxis if patient status is unknown.

42.

According to the USPSTF, what are the current osteoporosis screening recommendations?

Screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors

43.

Following a head injury, a patient has polyuria and increased thirst. What condition can induce a decreased secretion of antidiuretic hormone (vasopressin) production?

Diabetes insipidus (DI) is a condition in which there is reduced ability to concentrate the urine due to impaired reabsorption of water in the renal collecting tubules. Symptoms include polyuria and increased thirst.

Two main forms of DI include central DI (CDI), which is due to vasopressin (antidiuretic hormone or ADH) deficiency seen following head trauma or related to tumor and nephrogenic DI (NDI), which represents renal tubule unresponsiveness to vasopressin/ADH. DI can be induced by pregnancy, known as gestational DI (GDI).

44.

When determining preoperative risk, what exercise tolerance is considered adequate?

Preoperative evaluation is usually sufficient if patient is capable of ≥ 4 METS (the ability to climb 4 flights of stairs or walk 4 miles/hr).

45.

What are the different types of hyperparathyroidism (HPT)?

Primary HPT: intrinsic parathyroid gland dysfunction resulting in excessive secretions of parathyroid hormone (PTH).

Secondary HPT is due to vitamin D deficiency or renal failure inducing hypocalcemia resulting in excessive secretion of PTH.

Tertiary HPT is due to longstanding secondary HPT resulting in hyperfunction of the parathyroid gland.

46.

What conditions and laboratory findings are associated with celiac disease?

Type 1 diabetics, thyroid disease, and rheumatoid arthritis

Dermatitis herpetiformis

Unexplained anemia

Detected with antiendomysial antibodies (IgA antiendomysial antibodies [IgA anti-EmA]) and IgA anti-tissue transglutaminase (IgA anti-TTG)

Diagnosis should be confirmed with biopsy of the distal duodenum, which will show villous flattening.

47.

What tests should be ordered when hypercalcemia is found incidentally?

PTH, creatinine, 25OH vitamin D level

48.

What blood indices are seen in iron deficiency anemia?

Microcytic, hypochromic indices

Decreased ferritin levels

Elevated total iron-binding capacity (TIBC)

Low iron levels

49.

A patient is found to have hypercalcemia and an elevated parathyroid hormone; what is the likely diagnosis?

Primary hyperparathyroidism (HPT); ultrasound of the thyroid and parathyroid glands should be obtained next.

50.

What class of medication is used in the treatment of Paget disease?

Antiresorptive agents such as bisphosphonates and calcitonin are used in Paget disease of the bone.

51.

A 58-year-old male has drug-resistant hypertension (BP 160/100 on triple antihypertensive therapy) and hypokalemia. What condition is a common cause of resistant hypertension with hypokalemia?

Conn syndrome (primary aldosteronism) is due to excess aldosterone production by the adrenal glands, resulting in hypokalemia and drug-resistant hypertension. Workup includes determination of the aldosterone to renin ratio (ARR), metabolic panel (for sodium, potassium, bicarbonate, and creatinine), plasma renin activity (PRA), plasma aldosterone concentration (PAC). ARR > 30 requires further workup, including CT of the adrenals.

52.

What serious neurologic side effect is associated with Tramadol?

Seizures

53.

What is the etiology of Addison disease?

Addison disease is a primary adrenal gland insufficiency due to destruction of the adrenal cells with inadequate secretion of glucocorticoids and mineralocorticoids, most often due to autoimmune-induced gland destruction.

54.

In adults over age 65 years, what is the most common cause of blindness?

Age-related macular degeneration

55.

What is the likely diagnosis in a patient with hyponatremia, hyperkalemia, and hyperpigmentation of the skin on areas with recurrent pressure and trauma?

Addison disease; patients develop hyperpigmentation in high-friction areas (extensor surfaces, plantar or palmar creases, dental-gingival margins, buccal and vaginal mucosae, lips, areolae, pressure points, scars; women may lose hair) along with adrenocortical insufficiency resulting in hyponatremia and hyperkalemia.

56.

What are common risk factors for osteoporosis?

Female sex

Advanced age

Late menarche

Early menopause

Cigarette smoking

Family history of premature fractures

Low body mass index (BMI)

Corticosteroid use

Caucasian and Asian ethnicity

Heavy ethanol use

57.

A few days after a recent upper respiratory infection (URI), a patient presents with a rash that begins on the back of hands and top of the feet and within 24 hours spreads centrally. The lesions, sharply demarcated and pink, turn from macules to papules, then plaques and increase in number rapidly. What is the likely diagnosis?

Erythema multiforme: this rash is seen following a viral infection (often herpes simplex), is sharply demarcated, round, red/pink, and flat (macules), and starts on the back of the hands and tops of the feet. The rash quickly spreads centrally, and becomes papules and ultimately forms plaques that increase in diameter. These lesions evolve within 72 hours. Mucous membranes may be involved.

58.

According to the USPSTF, what are the current prostate cancer recommendations?

The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer.

59.

What is the antibiotic of choice for treatment of outpatient dental infections?

Amoxicillin: 500 mg TID for 7-10 days; in children, 40-60 mg/kg/day divided TID

If penicillin-allergic, use clindamycin 300 mg PO TID for 7 days.

60.

A patient has a rash on the hip that is round plaque with central clearing; it started small and seems to be expanding. There is no pain or itch. What is the likely diagnosis?

Erythema annulare centrifugum (EAC) is an annular or figurate erythematous plaque with central clearing and a characteristic trailing scale along the inner border; it is often present on the trunk, upper arms, hips, or lower extremities and is thought to be a hypersensitivity reaction. Common associations include some medications (NSAIDs), tinea pedis, and onychomycosis. It is rarely associated with malignancy.

61.

What class of analgesic medication can induce acute renal insufficiency?

Nonsteroidal antiinflammatory agents can induce an elevation in creatinine and induce renal insufficiency, especially in the elderly.

62.

A 26-year-old female presents with bilateral, erythematous, tender nodules on her lower legs that evolve in color similar to bruises. What is the likely cause?

Erythema nodosum is a delayed-type hypersensitivity reaction or an autoimmune reaction that may evolve into a panniculitis that affects subcutaneous fat.

63.

What class of antihypertensive medications can induce renal failure in patients with renovascular hypertension?

Angiotensin converting enzyme (ACE) inhibitors (enalapril, lisinopril, moexipril, trandolapril)

64.

What common medications are associated with erythema nodosum?

Oral contraceptives and amoxicillin

65.

B-type natriuretic peptide is used to differentiate what conditions that present with shortness of breath?

Congestive heart failure (>400 pg/mL) versus chronic obstructive pulmonary disease (COPD) (<100 pg/mL)

66.

What causes unilateral ear fullness, giving a clogged or “underwater” sensation and muffled sounds from that ear and can last for weeks?

Eustachian tube dysfunction

67.

What condition in women is associated with urinary frequency, urgency, dysuria, dyspareunia, and a negative urine culture?

Interstitial cystitis

68.

What are the common physical and clinical signs of Cushing syndrome?

Physical signs include moon face, weight gain, “buffalo” hump, menstrual irregularities, hirsutism, striae, and acne; laboratory findings include hypernatremia and hypokalemia.

69.

What are the clinical and laboratory criteria for diagnosis of interstitial cystitis?

The absence of genital infections or neoplastic disease

No history of radiation, tuberculosis, or chemical cystitis

Testing includes anesthetic bladder challenge and cystoscopy.

Antibiotics should not be used.

70.

What is the most common cause of Cushing syndrome?

Exogenous corticosteroid use in the form of steroids

71.

When should asymptomatic bacteriuria (significant bacteriuria not accompanied by signs and symptoms referable to urinary tract infection) be treated with antibiotics?

Treat asymptomatic bacteriuria with antibiotics only in pregnancy, in renal transplant patients, and before urologic procedures.

72.

When prescribing iron supplementation, what states can alter absorption?

Acidic environment

Absorption is increased in an acid environment (often given with ascorbic acid [vitamin C]) and decreased by antacids, soy protein, calcium, tannin (tea), and phytates (in bran).

73.

What is fibromyalgia?

Chronic, widespread noninflammatory musculoskeletal pain syndrome believed to be a disorder of altered central pain regulation

74.

What are the drugs of choice to treat Mycoplasma pneumonia?

Mycoplasma is susceptible to macrolide antibiotics (i.e., azithromycin) and some tetracyclines (i.e., doxycycline).

75.

What is the drug of choice for polycystic ovary syndrome (PCOS)?

Metformin; it helps preserve fertility and reduces insulin levels.

76.

What are the evidence-based treatments for fibromyalgia?

Cognitive behavioral therapy, aerobic exercise, and sleep hygiene

77.

Rhinitis medicamentosa (rebound congestion) is secondary with the use of

Chronic (>3 days) intranasal decongestants such as phenylephrine

78.

In the empiric treatment of gastroesophageal reflux disease (GERD), how long should a proton pump inhibitor (PPI) be used before weaning off?

8 weeks

79.

How many days after exposure to genital herpes is its incubation period?

4 days

80.

What are the uncommon adverse effects of longterm PPI use?

Hypomagnesemia, B12 deficiency, increased rates of pneumonia, Clostridium difficile infection, osteoporosis

81.

To help decrease the risk of postherpetic neuralgia, within what time frame should antiviral therapy be started?

3 days (72 hours)

82.

What are the most important lifestyle changes for the treatment of GERD?

Weight loss, elimination of trigger foods, smoking cessation, elevation of the head of the bed, not reclining within 2 hours of eating, stress reduction.

83.

Indications for bariatric surgery include

BMI > 35 and medical comorbidities (diabetes, hypertension, obstructive sleep apnea, etc.)

BMI > 40 or 100% over ideal weight without associated medical problems

Alcohol abuse is a contraindication to surgery.

84.

What are the risk factors for Barrett esophagitis?

Age > 50, male, symptoms over 5 years, and obesity

85.

What is the vector for human ehrlichiosis?

Lone star ticks

86.

Is diagnosing and treating Helicobacter pylori infection beneficial in GERD treatment?

Treating H. pylori may make GERD symptoms worse; testing and treatment is not recommended (the majority of US citizens are colonized with H. pylori, which may be protective against GERD)

87.

What is the vector for schistosomiasis?

Freshwater snails

It is an infection of flatworm (trematodes) and occurs in Africa, Asia, and South America.

88.

What are the three causes of peptic ulcer disease?

H. pylori infection, chronic NSAID use (including low-dose aspirin), and hypersecretion syndromes; alcohol, tobacco, and stress are risk factors, but are not by themselves considered causative.

89.

What is the vector for transmission of the Yersinia pestis (plague)?

Fleas

Transmission occurs mostly in the Southwestern United States and Peru.

90.

What is the risk lowdose, enteric-coated aspirin will induce a peptic ulcer?

It is estimated that chronic low-dose aspirin will induce a peptic ulcer in 3 out of 1,000 patients.

91.

What is the common cause of a gnawing abdominal pain after eating?

Peptic ulcer disease; symptoms that should require further investigation before treatment include episodic gnawing or burning epigastric pain, pain occurring after meals or on empty stomach, and nocturnal pain.

92.

What is the drug of choice for patients with end-stage (FEV₁ < 1.0 L or less and a Pao₂ of 60 mm Hg or less) that improves mortality?

Oxygen

β-agonists can lower rate of exacerbations but not directly improve mortality.

93.

Shingles (Herpes zoster) is caused by a reactivation of what infection?

Varicella (chicken pox)

94.

What agents are the most common cause of food poisoning?

Noroviruses are believed to cause greater than 50% of cases; bacterial causes include Salmonella (nontyphoidal), Campylobacter, Clostridium perfringens, and Staphylococcus aureus

95.

Sudden death is associated with what cardiac rhythm in patients with prolonged QT syndrome?

Torsades de pointes or ventricular fibrillation

96.

For food poisoning, what signs and symptoms should prompt more aggressive care?

In the setting of diarrhea, concerning signs and symptoms include high fever (≥101.3°F), ≥ 6 stools/day, blood in the stools, elevated white blood cell count, signs of dehydration, and diarrheal illness that lasts >2 to 3 days

97.

What four muscles make up the rotator cuff?

Supraspinatus

Infraspinatus

Subscapularis

Teres minor (not major)

98.

A group of college students develops nausea, vomiting, and diarrhea while traveling to Mexico on spring break. What is the likely diagnosis?

Food poisoning; symptoms can begin within one hour of eating the contaminated food or over 16 hours after exposure.

99.

What is the most common genetic disorder in white Americans?

Hereditary hemochromatosis (1 in 250-300 Caucasians are homozygous and 1 in 10 are carriers.)

100.

What is the risk of a patient with Barrett esophagitis developing esophageal cancer?

Depending on the degree of dysplasia, somewhere between 0.5 and 6%. Enrollment in a surveillance program dramatically lowers that risk.

101.

What is the classic triad of hemochromatosis?

Cutaneous hyperpigmentation

Diabetes mellitus

Cirrhosis (late manifestation)

102.

A 19-year-old male presents with diffuse nontender lymphadenopathy in his neck, axilla, and groin and night sweats. His history is significant for mononucleosis at age 14. What condition needs to be ruled out?

Hodgkin lymphoma; having an Epstein-Barr virus infection increases the risk.

103.

What are the best initial screening tests for family members of someone with hemochromatosis?

Ferritin and serum transferrin saturation (serum iron concentration divided by TIBC multiplied by 100—normal is 14%-50%)

104.

At what ages do patients develop Hodgkin lymphoma?

Hodgkin lymphoma has a bimodal distribution and is most common in early adulthood (15 to 40 years of age) and then again after age 55 years.

105.

In patients with cirrhosis, what biochemical marker is used to identify hepatocellular carcinoma?

Alfa fetoprotein

106.

Two weeks after returning from a camping trip in rural Maine, a patient develops loose, greasy, foul-smelling stools that tend to float, bloating, and lactose intolerance. What is the likely cause?

Giardia infection can occur following drinking nontreated water. Other risk factors include daycare centers, anal intercourse, wilderness camping, travel to developing countries, children adopted from developing countries, public swimming pools, and pets with Giardia infection/diarrhea.

107.

Elevations of B-human chorionic gonadotropin (hCG) is associated with which malignancies?

Liver and germ cell tumors

108.

What is the cause of open-angle glaucoma?

Primary open-angle glaucoma (POAG) is an optic neuropathy resulting in visual field loss frequently associated with increased intraocular pressure (IOP) due to impaired aqueous outflow through the trabecular meshwork.

109.

What condition is associated with an elevated vanillylmandelic acid (VMA) urine levels?

Pheochromocytoma

110.

What is the cause of acute closed-angle glaucoma?

Primary angle-closure suspect (PACS) occurs when the eye has a narrow or occluded anterior chamber angle, but no other abnormalities; it is a medical emergency.

111.

At what oxygen level is supplemental oxygen required for flight travel?

Sea-level Pao₂ < 68-70 mm Hg

112.

What are the risk factors for gout?

Age > 40 years, male gender, high-purine diet (meats and seafood), alcohol intake (especially beer), high fructose intake, obesity, hyperuricemia, congestive heart failure, renal disease, organ transplant, metabolic syndrome, diabetes mellitus, and some medications such as thiazide diuretics, loop diuretics, and niacin

113.

West Nile virus is transmitted by the bite of

Mosquitoes

114.

How do you discern gout from pseudogout?

Gout has urate crystals that cause negatively birefringent needle-shaped crystals under polarizing microscopy. Pseudogout is due to calcium pyrophosphate dihydrate (CPPD) crystal deposition in the joints that are positively birefringent and are rhomboid shaped.

115.

Which blood test has the highest specificity for the detection of acute pancreatitis?

Serum lipase

Better than serum amylase, which can be elevated with salivary gland abnormalities

116.

What are the symptoms of pseudogout?

Acute CPPD disease (pseudogout) presents with pain and swelling of ≥1 or more joints; knee involved in 50% of cases; involvement of ankle, wrist, toe, and shoulder is also common. It often involves proximal joints (mimicking polymyalgia rheumatica), and can be accompanied by tibiofemoral and ankle arthritis and tendinous calcifications.

117.

In polycythemia vera (primary polycythemia), the erythropoietin (EPO) level is

Low

In secondary causes of polycythemia (COPD, renal artery stenosis, renal cell carcinoma, and obstructive sleep apnea), the EPO levels are elevated.

118.

What is the most common cause of hyperthyroidism?

Graves disease is an autoimmune disease in which thyroid-stimulating antibodies cause increased thyroid function; classic findings include goiter, ophthalmopathy (orbitopathy), and occasionally dermopathy (pretibial or localized myxedema).

119.

According the American Heart Association and the American College of Cardiology, at what level of risk over 10 years should a statin be strongly encouraged?

≥7.5%

120.

What are the risk factors for developing Graves disease?

Risk factors for Graves include female gender; childbirth (postpartum period); stressful life events; medications such as iodine, amiodarone, and lithium; highly active antiretroviral treatment (HAART); and smoking.

121.

At what low-density lipoprotein (LDL) level, regardless of 10-year risk, should a patient be encouraged to initiate statin therapy?

≥190 mg/dL

122.

In patients with known coronary artery disease, current recommendations suggest the LDL goal be less than what level?

70 mg/dL

123.

What is Hashimoto thyroiditis?

Hashimoto thyroiditis is an autoimmune destruction of the thyroid gland that can result in progression to overt hypothyroidism and/or goiter formation.

124.

What is the most common cause of bacterial diarrhea in the United States?

Campylobacter

125.

What condition can cause unilateral sensorineural hearing loss with tinnitus and loss of balance?

Acoustic neuroma

126.

What tests should be obtained when Hashimoto thyroiditis is suspected?

A TSH should be obtained; if elevated, consider a T4 and a thyroid peroxidase antibody (TPO, an antibody to the thyroid) and a thyroglobulin antibody (TG or TGAb, antibody targets thyroglobulin, the storage form of thyroid hormones).

127.

What are the indications for antiviral use in the treatment of influenza?

Antivirals should be started within 48 hours of symptom onset and if patient has a condition (i.e., diabetes, coronary heart disease [CHD], COPD, asthma) where risk of complication is great. Antivirals are not indicated in patients at low risk of complication.

128.

What are the early symptoms of Huntington disease?

Huntington disease is an autosomal dominant inherited condition that presents in ages 30-50 (after they may have passed it on). Symptoms include:

chorea (nonrepeating, complex, involuntary rhythmic movements);

ballism (sometimes violent, involuntary movements, typically of the upper extremity and unilateral);

tics (repeated spasmodic, typically of the face and upper extremity);

dystonia (movement with persisting spasm);

motor impersistence (inability to sustain a desired movement), myoclonus (sudden, involuntary jerk);

cognitive changes (patients often lack insight into their cognitive deficits);

executive dysfunction; emotional lability; and depression.

129.

In a monogamous relationship, what is the lifetime risk of sexual transmission of hepatitis C to an unaffected partner?

<1%

HCV is transmitted through parenteral exposures to contaminated blood, usually through sharing of needles.

130.

A 30-year-old female returns with 3 weeks of cough that has been unresponsive to azithromycin and albuterol inhaler; she lets you know that her basement flooded last month and she has been tearing out the carpet. What is her likely diagnosis?

Hypersensitivity pneumonitis; it is a diffuse inflammatory disease of the lung parenchyma caused by an immunologic reaction to aerosolized antigenic particles found in a variety of environments. Initially, it may present with fever, but recurrent exposure can result in prolonged and progressive cough, dyspnea, fatigue, weight loss, could ultimately lead to fibrosis and respiratory failure.

131.

How is Hypersensitivity pneumonitis treated?

Decreased exposure to offending agents, oral corticosteroids tapered over 2 weeks, and bronchodilators

132.

What category of asthma is classified by daytime symptoms occurring no more than 2 days per week, nighttime symptoms no more than 2 nights per month, and the peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV₁) is 80% or more of predicted?

Mild intermittent asthma

133.

An 82-year-old patient presents after passing out; she states she was fine until 3 seconds beforehand she felt “funny.” Her husband helped her up quickly, and since she feels fine. What condition is most concerning with a brief prodrome preceding syncope?

A prodrome lasting less than 5 seconds before syncope implies a cardiac arrhythmia and deserves rapid cardiac evaluation. Prodromes lasting more than a few seconds, and associated with nausea or vomiting are likely to have vasovagal syncope.

134.

Daytime symptoms occurring more than 2 days per week, but less than once daily, and nighttime symptoms more than two times per month is classified as what category of asthma?

Mild persistent asthma

135.

An obese male presents with a persistent numbness over the anterolateral aspect of his thigh with no other associated symptoms. What is the likely diagnosis?

Meralgia paraesthetica is an entrapment of the lateral femoral cutaneous nerve (LFCN). Symptoms include pain, paresthesias, and sensory loss over the anterolateral aspect of the thigh. It is typically caused by a belt or tight-fitting clothes across the lower abdomen. The diagnosis is made clinically by decreased sensation over the anterolateral thigh, and treated by wearing loose clothes, using suspenders, etc.

136.

What category of asthma is classified by daytime symptoms occurring daily and nighttime symptoms occurring more than 1 night per week with a PEF or FEV₁ 60%-80% of predicted?

Moderate persistent asthma

137.

What are the symptoms of narcolepsy?

Narcolepsy is defined as excessive daytime sleepiness often associated with cataplexy (sudden bilateral weakness of skeletal muscles) and other rapid eye movement (REM) sleep phenomena, such as sleep paralysis and hypnagogic hallucinations (e.g., vivid auditory or visual perceptions without an external stimulus that occur as one is falling asleep).

138.

Continuous daytime symptoms and frequent nighttime symptoms with a PEF or FEV₁ less than 60% of predicted is classified as what category of asthma?

Severe persistent asthma

139.

A 58-year-old male with chronic back pain who uses high doses of NSAIDs presents with peripheral edema; workup finds large proteinuria and new onset hyperlipidemia. What is the likely cause?

Nephrotic syndrome is a clinical syndrome of heavy proteinuria, hypoalbuminemia, hyperlipidemia, and edema.

140.

Who should be treated for tuberculosis in recent purified protein derivative converters?

All patients should be treated regardless of age.

141.

How is Nephrotic Syndrome treated?

Nephrotic syndrome is treated by salt restriction and salt-wasting diuretics (loop and thiazide diuretics), statins, ACEi or ARBs, and addressing the underlying cause.

142.

Why are women usually diagnosed with hemochromatosis at menopause?

Menstrual blood loss (auto-phlebotomy) stops and allows iron overload to occur.

143.

An obese patient has an incidentally identified enlarged liver. What condition does obesity induce causing hepatomegaly?

Nonalcoholic fatty liver disease (NAFLD) is due to obesity; the etiology is due to large vacuoles of triglyceride fat accumulate in hepatocytes.

144.

For people who received the pneumococcal vaccine (PPSV23) at or after age 65, when should they receive the PCV13 vaccination?

One dose of PCV13 is recommended for all adults 65 years of age or older who have not previously received the vaccine.

For adults 65 years and older who have already received one or more doses of PPSV23, the dose of PCV13 should be given at least 1 year after receiving the most recent dose of PPSV23.

145.

How does NAFLD differ from nonalcoholic steatohepatitis (NASH)?

NASH is a progression of NAFLD, but in NASH, liver function tests (LFTs) are elevated and liver biopsy finds fatty deposits in >50% of cells with ballooning, acute/chronic inflammation. In some cases, NASH progresses to cirrhosis and liver failure.

146.

Fever and white blood cell (WBC) casts on urinalysis are associated with what condition?

Acute pyelonephritis

147.

What causes a painless whitish thickening of the great toe in a 71-year-old man with diabetes?

Onychomycosis, which is a fungal infection of the nails; it predominantly happens on the toes, but can also happen on the hands.

148.

Red blood cell casts on urinalysis are associated with what renal abnormality?

Glomerulonephritis

149.

What two oral agents increase the risk of avascular necrosis?

Avascular necrosis is associated with chronic corticosteroid use (the dose is cumulative) and alcohol abuse.

150.

What is the most common cause of adverse events in hospitalized patients?

Medication-related problems

151.

What are the classic findings of cardiac tamponade?

Pericardial effusion/cardiac tamponade presents with Beck triad: hypotension, muffled heart sounds, jugular venous distention.

152.

In patients undergoing radiographic procedures that require iodinated contrast, what medication theoretically may increase the risk of lactic acidosis?

Metformin

153.

What are the treatment methods for peripheral artery disease (PAD)?

Treating PAD requires an exercise rehabilitation program (walk until symptoms develop, then rest and start again for 30 minutes, then increased by 5 minutes until 50 minutes of intermittent walking is achieved); smoking cessation, weight loss, antiplatelet therapy (aspirin), and statin use.

154.

The presence of delta waves with a widened QRS complex and a short PR interval of 0.10 seconds on electrocardiography (ECG) tracings suggest the diagnosis of

Wolff-Parkinson-White (WPW) syndrome

155.

What condition would present as a 27-year-old male with weeks of atypical back pain without trauma, burning pain with urination, and conjunctivitis?

Reiter syndrome is a seronegative, multisystem, inflammatory disorder classically involving the joints, the eye, and the lower genitourinary (GU) tract. Axial joints (e.g., spine, sacroiliac joints) are the common presenting complaint. The classic triad includes arthritis, conjunctivitis/iritis, and either urethritis or cervicitis (“can’t see; can’t pee; can’t bend my knee”).

156.

What is the intravenous (IV) drug of choice for supraventricular tachyarrhythmia (SVT)?

Adenosine

157.

A 28-year-old, otherwise healthy male has a persistent nonproductive cough unresponsive to empiric treatment; chest x-ray shows bilateral hilar adenopathy and parenchymal infiltrates. What is the likely cause?

Sarcoidosis; a noninfectious, multisystem granulomatous disease of unknown cause, commonly affecting young and middle-aged adults.

It frequently presents with hilar adenopathy, pulmonary infiltrates, ocular and skin lesions, and in ˜50% of cases is diagnosed in asymptomatic patients with abnormal chest x-rays.

158.

To screen for peripheral neuropathy, what test is recommended annually to document sensory function in diabetic patients?

Monofilament line test

159.

What are the clinical manifestations of Sjogren syndrome?

Sjogren syndrome is a chronic inflammatory disorder resulting in lymphocytic infiltrates in exocrine organs (diminished salivary and lacrimal gland function, resulting in sicca symptoms such as dry eyes (xerophthalmia), dry mouth (xerostomia), and parotid enlargement). Extraglandular manifestations: arthralgia, myalgia, Raynaud phenomenon, pulmonary disease, GI disease, leukopenia, anemia, lymphadenopathy, vasculitis

160.

Which class of drugs slows the progression from microalbuminuria to macroalbuminuria (renal protective) in diabetic patients?

ACE inhibitors

161.

What are the complications of obstructive sleep apnea?

Obstructive sleep apnea increases the risk of hypertension, stroke, myocardial infarction, diabetes, cardiovascular disease, and work-related and driving accidents.

162.

To screen for diabetes-induced nephropathy, what urine test should be checked yearly?

Microalbuminuria

163.

What are the symptoms of spinal stenosis?

Spinal stenosis symptoms worsen with extension (prolonged standing, walking downhill, or down stairs) and improve with flexion (sitting, leaning forward while walking, walking uphill or upstairs, lying in a flexed position).

164.

What is the cutoff level of albumin in the urine to be called microalbuminuria?

Urinary albumin of 30-300 mg/day is consistent with microalbuminuria.

If one screening urine is positive, diabetic nephropathy should be confirmed in a total of two out of three samples collected over a 3- to 6-month period because of day-to-day variability.

165.

What is SIADH (syndrome of inappropriate antidiuretic hormone secretion)?

A syndrome of abnormal production of antidiuretic hormone (ADH), despite low serum osmolality, leading to hyponatremia and inappropriately elevated urine osmolality. It results in abnormal water retention that leads to dilutional hyponatremia (total body sodium levels may be normal or near normal, but the patient’s total body water is increased).

166.

In a patient with persistent diarrhea, the presence of a large number of fecal leukocytes is consistent with what?

A bacterial infection

167.

What tests should be ordered to rule out von Willebrand disease?

vWF antigen (vWF:Ag), vWF activity/ristocetin cofactor activity (vWF:RCo), and FVIII activity

168.

Headaches that are present upon waking but do not interrupt sleep are associated with what condition?

Headaches that are present upon waking may imply increased intracranial pressure. If general, consider tumor; if just occipital and patient has hypertension, consider improving hypertension control.

169.

What are the common causes of SIADH?

SIADH can be caused by medications (NSAIDs, others), neurologic disease or trauma, carcinomas, pulmonary conditions, some infections (including HIV), and hypothyroidism.

170.

Headaches that appear mid to late afternoon associated with rhinorrhea are commonly caused by what?

Sinus-related inflammation, either from allergic rhinitis or infection

171.

What is the treatment of choice for patients diagnosed with Salmonella enterocolitis?

Observation

Antibiotics are contraindicated because they tend to prolong the carrier state.

172.

What is the pathophysiology of a TIA?

A TIA is a transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction.

173.

How does having a TIA influence stroke risk?

Having a TIA is the most important predictor of stroke: 7%-40% of patients with stroke report previous TIA.

174.

How long does a neurologic deficit have to be present to be considered a TIA?

Any loss of function is considered a TIA; there is no longer a time requirement.

175.

What is the treatment of choice for patients with symptomatic iron overload due to hemochromatosis?

Phlebotomy; 500 mL/wk (about 250 mg of iron) until serum iron levels are normal and transferrin saturation is below 50%; 2-6 phlebotomies per year

176.

Thiazide diuretics can cause loss of what electrolytes?

Sodium and potassium

177.

In patients who are symptomatic from severe hypercalcemia, what is the treatment of choice?

Aggressive fluid administration, followed by loop diuretics, and then calcitonin or bisphosphonates

178.

What condition is associated with elevated WBC count and the Philadelphia chromosome?

Chronic myelogenous leukemia is a leukemia with a natural history of three clinical phases: a chronic phase, an accelerated phase, and blast phase or crisis (transformation to acute leukemia).

179.

In patients with osteoporosis and hypertension, what class of antihypertensive is beneficial for both conditions?

Thiazide diuretics decrease urine calcium excretion.

180.

What are the lifestyle treatments for osteoporosis?

Weightbearing exercise

Smoking cessation

Physical therapy for muscle strengthening

Vitamin D 2,000 IU/day

181.

How is osteopenia defined?

The World Health Organization defines osteopenia as a T-score between -1 and -2.5; it should be treated with lifestyle modification (weightbearing exercise, smoking cessation, vitamin D supplementation). Treatments with agents for osteoporosis (bisphosphonates, etc.) are not indicated.

182.

How is osteoporosis defined?

On bone mineral density testing, osteoporosis is diagnosed when T-score is ≤2.5.

183.

What are the recommended management options for women with atypical squamous cells of undetermined significance (ASC-US)?

Repeat cytology at 12 months (if <25 years) or reflex DNA testing for oncogenic human papillomavirus (HPV) infection types or colposcopy.

184.

What is the most commonly involved tendon in shoulder impingement syndrome?

Supraspinatus tendon

185.

What is the most common cause of atraumatic shoulder pain in adults?

Impingement syndrome (formerly rotator cuff tendonitis)

186.

What is the most common chronic myeloproliferative disorder?

Polycythemia vera

187.

What is the international normalized ratio (INR) goal for patients with nonvalvular atrial fibrillation?

2.0-3.0

188.

What is the INR goal for patients with artificial cardiac valves?

2.5-3.5

189.

What is the INR goal for patients with a deep vein thrombosis (DVT) or pulmonary embolism (PE)?

2.0-3.0

190.

What oral dose of vitamin B₁₂ is required to effectively treat vitamin B₁₂ deficiency?

1-2,000 mg given daily, even with the absence of intrinsic factor (pernicious anemia)

191.

What is the most common finding associated with celiac sprue in adults?

Iron deficiency anemia

192.

What is the mechanism of action for thiazolidinediones in type 2 diabetes?

Decreasing insulin resistance and decreasing gluconeogenesis

They have no effect on insulin release or production by the pancreas or carbohydrate absorption.

May cause hypoglycemia

193.

What is the mechanism of action of polyethylene glycol for constipation?

Osmotic changes in the intestines

194.

What is the treatment of choice for cluster headaches?

100% oxygen

195.

Noncardiac conditions related to the development of atrial fibrillation include

Hypertension

Diabetes mellitus

COPD

Hyperthyroidism

Primary pulmonary hypertension

Acute PE

Acute ethanol ingestion

196.

A headache that consists of at least five severe, recurrent attacks that are unilateral, orbital, supraorbital, or temporal, causing pain lasting 15-180 minutes if untreated and is associated with conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating, miosis and/or ptosis, and sense of restlessness or agitation:

Cluster headache

197.

Celiac sprue is associated with what food?

Gluten

Found in wheat and rye and cereal protein in barley and oats, but not corn

198.

What additional vaccine should those with sickle cell anemia receive?

Pneumococcal vaccine because of decreased ability to fight encapsulated organisms

199.

What drug is first-line treatment to prevent a painful sickle cell crisis in those with sickle cell anemia?

Hydroxyurea

Also reduces the incidence of acute chest syndrome and transfusion requirements

200.

What is the drug of choice for treating trigeminal neuralgia?

Carbamazepine

201.

A headache that is moderate to severe in intensity, located unilaterally, and is associated with an aura, photophobia, nausea, and vomiting is classified as a

Classical migraine headache

202.

What is the most serious potential adverse effect of amiodarone therapy?

Pulmonary toxicity

203.

Where does the maculopapular erythematous rash associated with Rocky Mountain spotted fever begin?

Petechial rash begins on the extremities (palms and soles) and spreads centrally.

204.

In malnourished patients with alcohol abuse, Wernicke encephalopathy is related to a deficiency of

Thiamine coupled with the ingestion of carbohydrates

205.

What bone abnormality does celiac sprue predispose patients to?

Osteopenia due to vitamin D deficiency

Laboratory values include hypocalcemia and elevated alkaline phosphatase levels.

206.

What class of antihypertensive agents is associated with rebound hypertension?

Alpha antagonist (i.e., clonidine)

207.

Patients who complain of “clunking” with shoulder range of motion and apprehension when reaching behind their backs are likely to have

Torn labrum of the scapula predisposing patient to dislocation

208.

ACE inhibitors are associated with what electrolyte abnormality?

Hyperkalemia—especially in elderly patients with renal disease or those taking β-blockers, nonsteroidal antiinflammatory drugs (NSAIDs), and potassium-sparing diuretics

209.

Furosemide use can induce what electrolyte abnormality?

Hypokalemia by enhanced potassium excretion by increasing delivery of sodium to the collecting tubules

210.

What condition causes difficulty swallowing associated with chest pain and is due to increased pressure of the lower esophageal sphincter?

Achalasia

211.

A patient presents with chest pain with eating and occasionally vomits. You suspect achalasia. What is the most sensitive test for achalasia?

Esophageal manometry

212.

A patient presents with an insidious onset of general weakness and fatigue. Examination finds hypotension and hyperpigmentation of the skin and mucous membranes; workup identifies hyponatremia and hyperkalemia. What is the most likely diagnosis?

Primary AI (Addison disease)

213.

The cosyntropin stimulation test is used to detect adrenal insufficiency (AI), How is the test conducted?

250 mg of cosyntropin (synthetic analogue of ACTH) is given intravenously or intramuscularly. The serum cortisol is measured 30-60 minutes later. A normal result is a serum cortisol 500 nmol/L. Lower levels suggest the diagnosis of AI.

214.

Dexamethasone suppression test is used to diagnose what disease?

Cushing disease (cortisol excess)

215.

With iron supplementation, how long does it take for hemoglobin levels to return to a normal level?

Two months

Once ferritin levels have returned to normal, iron replacement can be discontinued.

216.

When Neisseria meningitides is diagnosed, what antibiotic prophylaxis is necessary for close contacts?

Antibiotic prophylaxis within 24 hours of the diagnosis; treatment options include the following:

Rifampin 600 mg PO BID × 2 days

Ciprofloxacin 500 mg PO × 1 dose

Ceftriaxone 250 mg IM × 1 dose

217.

How does the development of congestive heart failure (CHF) in patients with aortic stenosis impact treatment and mortality?

In aortic stenosis and CHF, without valve replacement, 50% will die in 2 years.

218.

What is the most common cause of hypercoagulable state?

Factor V Leiden mutation

Other conditions include the following:

Antithrombin III deficiency

Protein C deficiency

Protein S deficiency

Lupus anticoagulant

Antiphospholipid syndrome

219.

The presence of spongiform changes (vacuoles in the neurons and glia of the brain) in an individual that develops a rapidly progressive dementia accompanied by myoclonic seizures suggests what diagnosis?

Creutzfeldt-Jakob disease

220.

What tests should be followed for patients taking amiodarone?

Liver and thyroid function tests should be monitored at least every 6 months.

221.

An S4 gallop is heard just before normal heart sounds and is associated with what conditions?

S4 gallop is associated with poor ventricular compliance (increased stiffness of the ventricle) due to left ventricular hypertrophy (hypertensive heart disease), aortic stenosis, heart failure, or acute myocardial infarction (MI)

222.

What is the infectious cause of posttransfusion hepatitis infections?

Hepatitis C

223.

What medication is indicated for the treatment of acute pericarditis?

NSAIDs

224.

What diagnostic test can be used to detect hepatitis B in the “window period” (the period between the presence of hepatitis B surface antigen and the development of hepatitis B surface antibody)?

IgM hepatitis B core antibody (IgM anti-HBc)

225.

According to the USPSTF, who should be screened for hepatitis C?

Offer one-time screening for hepatitis C virus (HCV) infection to adults born between 1945 and 1965 and those at high risk for infection (hemodialysis, tattoo in unregulated setting, blood/blood product transfusion or organ transplantation before 1992, hemophilia treatment before 1987, exposure to infected body fluids, history of incarceration, children born to HCV-positive mothers, current sexual partners of HCV-positive persons, any history of injection drug use, intranasal illicit drug use, and HIV or hepatitis B infection).

226.

What is Hepatitis D?

Hepatitis D virus or delta agent

It is a serologic marker associated with an unusually severe acute infection with hepatitis B. It is a defective RNA virus that replicates only in the presence of hepatitis B virus and represents a coinfection and is especially seen in illicit drug users.

227.

What infection is associated with ingesting contaminated raw milk products?

Brucellosis is transmitted via contact with secretions or excretions of infected animals or ingesting raw milk or products of raw milk.

228.

Clear, watery stools with a fishy odor and flecks of mucus (rice water diarrhea) are in what conditions?

Cholera and shigella

229.

What infectious disease affects hunters, butchers, fur handlers, and farmers who harvest wild rabbit fur?

Tularemia

The organism may be found in skin lesions.

230.

What conditions can induce erectile dysfunction?

Diabetes, vascular problems, prolactinoma, hypothyroidism, testosterone deficiency

The most common cause is psychological, which is likely if the patient has morning erections.

231.

Visual flashes of light (photopsia), associated with the sudden appearance of floaters, and/or peripheral visual field loss suggest what diagnosis?

Retinal detachment

232.

Vitreous detachment (separation of the vitreous from the retina) may lead to what dangerous eye condition?

Retinal detachment

233.

What vitamin is used to correct elevations in INR values secondary to warfarin use?

Parenteral vitamin K

234.

What classes of medications should all CHF patients be on, if not contraindicated?

Aspirin

ACE inhibitor

β-Blocker

For those with Class II-IV, loop diuretics and potassium-sparing diuretics

235.

What potentially life-threatening condition affecting the mucous membranes and airways is associated with the use of ACE inhibitors?

Angioneurotic edema

236.

Bulimia induces what electrolyte abnormalities?

Hypokalemia and metabolic alkalosis

237.

What are common secondary causes of resistant hypertension?

Most common secondary causes of resistant hypertension are obstructive sleep apnea, renal artery stenosis, renal parenchymal disease, and primary aldosteronism.

238.

What is the most common type of lung cancer?

Non-small cell lung cancer is the most common, making up 85% of primary lung malignancies. These lesions typically begin at the periphery. Subtypes include adenocarcinoma, squamous cell lung cancer, and large cell carcinoma.

239.

What are the clinical symptoms of periodic limb movement disorder?

Periodic limb movement disorders is characterized by periodic repetitive limb movements during sleep, typically of the lower extremities, and associated with sleep disturbance and arousal, which can lead to sleep disruption and ultimately daytime sleepiness.

240.

What are the four cardinal features of restless legs syndrome (RLS)?

The four cardinal features of RLS are

1. 
   

   an urge to move the limbs often associated with paresthesias or dysesthesias

   
   
2. 
   

   symptom onset or becoming worse with inactivity

   
   
3. 
   

   some relief of symptoms with movement

   
   
4. 
   

   worsening of symptoms in the evening or at night

241.

What is a normal postvoid residual of the bladder?

A normal postvoid residual volume is less than 50 mL.

242.

What oral and dental clues are consistent with bulimia?

Eroded dental enamel, dental caries, angular cheilitis, gingivitis, and swollen salivary glands

243.

What electrolyte abnormality can be caused by both selective serotonin reuptake inhibitors (SS-RIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)?

Hyponatremia

244.

What condition occurs when patients on chronic opioid treatment develop painful sensitivity to skin pressure?

Opioid-induced hyperalgesia

It is treated by lowering the opioid dose.

245.

When treating stroke, thrombolytics must be administered within what time frame from the onset of stroke-related symptoms?

180 minutes (3 hours)

246.

A patient without a spleen should have what intervention whenever he or she develops a fever?

All patients who are asplenic should have antibiotics prescribed whenever they have a fever.

247.

What immunizations should patients receive if they are asplenic?

Both pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) should be given at least 8 weeks apart as well as the influenza vaccine each year.

248.

Define chronic bronchitis.

Chronic bronchitis is associated with excessive cough and sputum production on most days for at least 3 months during 2 consecutive years.

249.

Based on 2014 JNC VIII guidelines, what drugs should be used first line in the general nonblack population for essential hypertension?

For nonblack adults, including those with diabetes, initial treatment should include a thiazide-type diuretic, calcium-channel blocker (CCB), ACE inhibitor, or angiotensin receptor blocker (ARB).

250.

What are contraindications to the use of ACE inhibitors?

History of angioneurotic edema, pregnancy, and renal artery stenosis

251.

According to the 2014 JNC VIII guidelines, what drugs are first choice for the black population?

In the general black population, including those with diabetes, initial treatment should include a thiazide-type diuretic or a CCB.

252.

What type of ultraviolet exposure is associated with skin cancer?

Ultraviolet B (UVB)

253.

What BMI is consistent with obesity?

≥30 kg/m²

254.

What weight loss medication is associated with flatus, oily stools, and diarrhea?

Orlistat (Xenical)

255.

What is the cause of a tremor that affects the hands and forearms when the limb is voluntarily moved and/or when held against gravity?

Essential tremor is a postural (occurring with voluntary maintenance of a position against gravity) or kinetic (occurring during voluntary movement) flexion-extension tremor that is slow and rhythmic and primarily affects the hands and forearms, head, and voice.

256.

What medications are used for control of essential tremors?

Propranolol or primidone

257.

What percentage of diarrheal cases in the United States are not associated with an identifiable pathogen?

More than 50%

258.

What condition is associated with lytic lesions of the bone, hypercalcemia, and increased infection risk?

Multiple myeloma. It is a clonal proliferation of malignant plasma cells in the bone marrow that can cause osteolytic lesions and pathologic fractures. The malignant plasma cells produce monoclonal Bence Jones protein in the blood and urine.

259.

What condition can cause a lytic lesion on a plain x-ray but have a normal bone scan?

Multiple myeloma will not be seen on a conventional bone scan.

260.

The presence of proteinuria and lytic bone lesions should suggest what diagnosis?

Multiple myeloma

261.

A progressive destructive arthritis secondary to peripheral neuropathy and the associated loss of pain in a diabetic is called

Charcot foot

262.

A rapidly growing domeshaped lesion with a central umbilication is likely a

Keratoacanthoma

263.

What selective estrogen receptor modulator (SERM) is used to treat osteoporosis and can lower the risk of breast cancer?

Raloxifene (Evista)

Its common side effects include hot flushes and leg cramps.

264.

How does a vegan diet differ from a vegetarian diet?

Vegans will not use any animal products (eggs, milk, and milk products). Some vegans also will not use leather and wool.

265.

Herpes simplex virus type 1 (HSV-1) traditionally affects what region of the body?

HSV-1 traditionally presents with blisters on lips and in mouth, face, and eyes.

266.

A patient who develops a low-grade fever, myalgias, headache, tachycardia, and rash shortly after the first dose of doxycycline for Lyme disease has what condition?

Jarisch-Herxheimer reaction

267.

Digoxin needs to be dosed carefully in patients with what organ deficiency?

Kidney disease

Digoxin is primarily excreted through the kidneys; only about 10% is metabolized by the liver.

268.

What drug is used for digoxin toxicity?

Digoxin-specific antibody fragments (Digibind)

269.

Runners who develop lateral knee pain related to running on uneven surfaces are likely to have

Iliotibial band (ITB) syndrome

270.

What condition is associated with tinnitus, hearing loss, and vertigo?

Meniere disease

271.

What medications are used for the treatment of Meniere disease?

Thiazide diuretics such as hydrochlorothiazide, and antiemetics

272.

Which test is commonly used to confirm systemic lupus erythematosus (SLE)?

Anti-double-stranded DNA test

273.

What condition is associated with idiopathic intermittent episodes of vasoconstriction of digital arteries, in response to cold, emotional stress, or blunt trauma?

Raynaud phenomenon

274.

What class of medication is used to control the symptoms of Raynaud phenomenon?

Calcium-channel blockers (nifedipine and diltiazem)

275.

What condition is the most common risk factor for the development of acute respiratory distress syndrome (ARDS)?

Sepsis (especially from an abdominal source)

276.

Polydipsia, polyphagia, polyuria, weight loss, and fatigue are among the presenting symptoms of what diagnosis?

Type 1 diabetes mellitus

277.

Chronic acid exposure to the lower esophagus that causes a transformation of squamous to columnar epithelium is called

Barrett’s esophagus

278.

Presence of elevated serum carboxyhemoglobin levels is associated with what condition?

Carbon monoxide poisoning

279.

What is the treatment for acute carbon monoxide poisoning?

100% oxygen administration

280.

What functional intestinal disorder is associated with abdominal pain, a change in bowel habits, and no organic process?

Irritable bowel syndrome

It can present as diarrhea predominant or constipation predominant; initial treatments include fiber supplements and antispasmodics.

281.

What area of induration is considered positive on a Mantoux tuberculin skin test?

An area of induration of >15 mm (without risk factors)

An area of induration of >10 mm (with risk factors)

An area of induration of > 5 mm (in HIV patients)

282.

What activity results in the single largest health risk in the United States?

Smoking

283.

What class of antihypertensive medications slows progression of renal disease in diabetes mellitus?

ACE inhibitors

If patient cannot tolerate an ACE inihibitor, an ARB may be used.

284.

A painless ulcer that develops on the genitals is consistent with what sexually transmitted infection (STI)?

Syphilis

A skin lesion that begins as a papule that ruptures and develops into a painless ulcer is called a chancre.

285.

What tests are used to screen for syphilis?

Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) tests

286.

When a patient has a positive VDRL or RPR test, what test should be ordered to confirm the diagnosis of syphilis?

Fluorescent treponemal antibody absorption test

287.

What is the most common etiology of adults with chronic cough?

Postnasal drip

288.

Which class of antihypertensives is associated with cough?

ACE inhibitors

289.

What is the most common cell type of testicular tumor?

Seminoma

290.

Cryptorchidism is associated with what condition?

Testicular tumors

291.

Carpal-pedal spasms, anxiety, and circumoral paresthesias are associated with what condition?

Hyperventilation

292.

How is orthostatic hypotension diagnosed?

Blood pressure determination when supine and standing, with a decrease in systolic blood pressure of at least 20 mm Hg and in diastolic blood pressure of at least 10 mm Hg

293.

What is the condition that occurs within days to weeks following an MI that causes chest pain, fever, pleurisy, pleural effusions, and joint pain called?

Postmyocardial infarction syndrome (or Dressler syndrome)

294.

A chronic inflammatory syndrome associated with dry mouth, dry eyes (keratoconjunctivitis sicca), dryness of other mucous membranes, and arthritis is

Sjogren syndrome

295.

What are the clinical states requiring placement of a permanent pacemaker?

Symptomatic bradycardia, asymptomatic Mobitz II atrioventricular (AV) block, and complete heart block

296.

What clinical syndrome characterized by pain and morning stiffness of the shoulder, hip girdles, and neck in patients over age 50 is associated with a vasculitis?

Polymyalgia rheumatica.

It is associated with giant cell (temporal) arteritis.

297.

What is the treatment of choice for polymyalgia rheumatica?

Corticosteroids (high dose)

298.

Aspirin is used for primary prevention of what two conditions?

Colon cancer and atherosclerotic cardiovascular disease

299.

A herpes zoster infection that affects the facial nerve is called

Ramsay Hunt syndrome

It is a herpes zoster infection of the facial nerve’s geniculate ganglion.

300.

What is the first-line therapy for the treatment of mild Clostridium difficile?

Metronidazole

For infections unresponsive to metronidazole or severe infections, oral vancomycin is used.

301.

What test should be performed after finding a positive Mantoux test?

Chest x-ray should be done before initiating treatment to exclude active tuberculosis.

302.

What intervention is as effective as medication for mild to moderate depression?

Cognitive behavioral therapy

303.

To prevent decompression illness, how long should a diver wait to fly after scuba diving?

12 hours

304.

What is erysipelas?

Erysipelas is a cellulitis notable for acute, well-demarcated, superficial bacterial skin infection with lymphatic involvement almost always caused by Streptococcus pyogenes in infants, children, and adults >40 years; the incidence is greatest in the elderly (>75 years).

305.

In patients with chronic abdominal pain and a negative laboratory and clinical exam, what condition should be screened for?

Domestic violence, past or present; history of sexual abuse

306.

With right upper quadrant abdominal pain that worsens after meals and normal liver function tests (LFTs) and ultrasound, what test should be considered to rule out biliary dysfunction?

HIDA Scan (hepatobiliary scintigraphy or hepatobiliary iminodiacetic acid scan)

307.

What is the drug of choice to treat acetaminophen overdose?

N-acetylcysteine (NAC)

308.

What conditions are commonly associated with a low-MCV anemia?

Iron-deficiency anemia, thalassemia, lead poisoning, hemoglobinopathies, sideroblastic anemia

309.

What conditions are included in a Wells Score to determine risk of DVT?

One point each for cancer, calf swelling >3 cm, collateral vein engorgement, pitting edema, previous DVT, venous pain, recent immobilization (cast, paralysis), recent bedriddenness

Subtract 2 points if any other diagnosis is likely.

310.

What is vertigo that comes on with head movement, lasting just seconds to minutes, associated with rotary nystagmus during Dix-Hallpike maneuver?

Benign paroxysmal positional vertigo (BPPV)

311.

How is BPPV treated?

Epley’s maneuver

312.

What is the first step in evaluating hyponatremia?

Obtain serum osmolality: if >280 mEq/L, it is likely pseudohyponatremia due to hyperlipidemia, hyperglycemia, or hyperproteinemia. If <280 mEq/L, obtain a urinary sodium test.

313.

What are the likely causes of hyponatremia with serum osmolality <280 mEq/L and an elevated urine sodium?

Hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, thiazide diuretics, central nervous system disease, Addison disease

314.

Knee pain and swelling that begin without trauma and within a few days of new activity, and pain with going down stairs is likely

Meniscus injury

315.

Preoperative evaluation for noncardiac surgery in an adult without cardiovascular disease and ability to walk up a flight of stairs without symptoms (equivalent to 4 METS) include which tests?

None

Labs and ECGs are no longer indicated.

316.

Impingement syndrome of the shoulder affects which tendon most frequently?

Supraspinatus tendon

The other tendons of the rotator cuff are infraspinatus, teres minor, and subscapularis.

317.

According to the USPSTF, who should be screened for abdominal aortic aneurysm?

Men aged 65-75 who have ever smoked should receive a one-time abdominal ultrasound.

318.

What is a idiopathic inflammatory condition affecting just the colonic mucosa, associated with large joint arthritic conditions, sacroiliitis, and ankylosing spondylitis?

Ulcerative colitis

319.

What is a chronic relapsing inflammatory disorder that can affect the entire GI tract, causes transmural lesions that skip areas, and can increase the risk of GI cancer?

Crohn disease

320.

What can cause shoulder pain that has an insidious onset, has been present for months, and initially had pain only with active range of motion (ROM) but now has pain with both active and passive ROM?

Adhesive capsulitis (“frozen shoulder”)

321.

A patient’s bilirubin is mildly elevated; on repeat, it remains so and is unconjugated. The hemoglobin and hematocrit (H&H) is normal, as are the rest of the LFTs. What is the likely diagnosis?

Gilbert syndrome is mild, chronic, or intermittent unconjugated hyperbilirubinemia (not due to hemolysis) with otherwise normal liver function.

322.

What is the likely cause of jaundice in a patient with a direct bilirubin <0.3 mg/dL and whose alkaline phosphatase is normal?

Prehepatic jaundice from hemolytic anemia or resorption of a large hematoma

323.

An obese patient presents with rash about the neck that is composed of symmetric, hyperpigmented, hyperkeratotic, velvety to verrucous brown plaques. What is the diagnosis?

Acanthosis nigricans due to hyperinsulinemia, often due to uncontrolled diabetes

Rash can also occur at flexural and intertriginous surfaces (axilla, elbow, inframammary areas, groin, and anogenital regions).

324.

What is the likely diagnosis of a sudden, diffuse hair loss that occurs 2-6 months after a major stressor?

Telogen effluvium

325.

Treatment of telogen effluvium includes what patient education?

Reassurance that the hair will regrow within a few months. No other intervention is recommended.

326.

What treatments are available for male-pattern hair loss (androgenic alopecia)?

Minoxidil (Rogaine), finasteride (Propecia), and spironolactone

327.

What tests should be obtained if anabolic steroid use is suspected?

Urine testosterone: epitestosterone (T:E) ratio (T:E ratio >3:1 suggests anabolic-androgenic steroid abuse)

Serum: Lipids (LDL increase, high-density lipoprotein [HDL] decrease) and LFT elevations (AST, ALT, and GGTP)

328.

What visual fields are affected by glaucoma?

Glaucoma affects peripheral vision, causing tunnel vision.

329.

A 25-year-old male has 5 months of back pain that gets worse when supine and has morning back stiffness that takes an hour to improve. What is the likely diagnosis?

Ankylosing spondylitis

330.

A patient who has recently returned from the topics has a high fever (104°F), anemia, diffuse myalgias and is anemic. What is the likely diagnosis?

Dengue hemorrhagic fever presents as a flulike illness, with high fever (104°F) and at least two additional symptoms: severe anemia or hemorrhage, retroorbital pain, myalgias/arthralgias, nausea/vomiting, adenopathy, and rash. It is thought to be an antibody reaction to a different serotype of dengue than prior exposure.

331.

Painful ovoid or round ulcerations on the mucous membranes of the mouth and tongue are called

Aphthous ulcers or canker sores

Treatment is symptomatic.

332.

What clinical finding differentiates Zika virus from Dengue fever?

Conjunctivitis; Zika and dengue share the other common symptoms of fever, myalgia, joint pain, retroocular pain, and maculopapular rash.

333.

What is the difference between Cushing syndrome and Cushing disease?

Cushing syndrome is the result of excess glucocorticoids; Cushing disease is due to excess ACTH production, most commonly from a pituitary adenoma.

334.

What are the universal findings in a patient with fibromyalgia?

Chronic bilateral, widespread pain ≥ 3 months involving limbs and axial skeleton, and fatigue with sleep disturbance

335.

What tests should be performed on a patient with alarm symptoms for peptic ulcer disease (episodic gnawing or burning epigastric pain, pain occurring after meals or on empty stomach, and nocturnal pain)?

If peptic ulcer is suspected by history, rectal exam for heme testing should be done, followed by H. pylori testing (breath urea or stool antigen; serum antibody testing is inconsistent), and esophagogastroduodenoscopy (EGD) if risk factors exist.

336.

What are the laboratory findings of acute Graves disease?

Suppressed (low) TSH with an elevated T4; the next step in the evaluation is to obtain a radioactive iodine uptake (RAIU) scan. Patients with Graves disease will have diffuse, elevated RAIU (vs. localized/nodular elevated uptake in adenoma and multinodular goiter and a decreased uptake in thyroiditis or exogenous thyroid hormone)

337.

What are the symptoms of Hashimoto thyroiditis?

Early in the disease, patients may present with symptoms of hyperthyroidism including palpitation, weight loss, and tremors. However, most patients present with symptoms of hypothyroidism including fatigue, cold intolerance, mild weight gain, hoarse voice, dry skin, hair loss, brittle nails, constipation, menstrual irregularity, galactorrhea, and decreased libido.

338.

A headache that consists of at least five severe, recurrent attacks that are unilateral, orbital, supraorbital, or temporal, causing pain lasting 15-180 minutes if untreated and is associated with conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating, miosis and/or ptosis, and sense of restlessness or agitation:

Cluster headache

339.

What hepatitis vaccine is recommended for travelers to endemic areas where the infectious agent is associated with fecal to oral transmission?

Hepatitis A

340.

What cardiac conditions are indications for ACE inhibitors?

MI and CHF

341.

What type of lung cancer begins centrally and is very aggressive?

Small cell carcinoma (previously called oat cell carcinoma)

342.

Use of anorectic medication for obesity is acceptable when the BMI is

Greater than 30 kg/m² or 27 kg/m² with comorbidities such as hypertension or diabetes mellitus

343.

What conditions are commonly associated with an elevated-MCV anemia?

B₁₂ deficiency, folate deficiency, alcohol abuse, liver disease, chronic blood loss (menorrhagia, etc.).

344.

What test should be ordered with a low-probability Wells Score (-2 to 0) to rule out DVT?

When risk is low, order a d-dimer test. When risk is intermediate (Wells score 1-2), order a high-sensitivity d-dimer; when high (Wells score >2), obtain d-dimer and venous duplex ultrasound.

345.

According to the USPSTF, at what ages should women be screened for cervical cancer?

Women age 21-65 years with cytology (Pap smear) every 3 years or, for women age 30-65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years