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1. A pregnant patient is found to have an elevated serum alpha-fetoprotein level on routine screening.
It is confirmed on repeat testing. Which one of the following should be done next?
1.
2.
3.
4.
A lecithin/sphingomyelin ratio
Ultrasonography
Nonstress testing
Amniocentesis
Celecoxib (Celebrex)
Rofecoxib (Vioxx)
Diclofenac (Voltaren)
Ketoprofen (Orudis)
Ibuprofen
4. A 42-year-old African-American male with a duodenal ulcer is diagnosed with Helicobacter pylori
infection. Which one of the following treatment regimens do you recommend?
1.
2.
3.
4.
5.
Ranitidine (Zantac)
Clarithromycin (Biaxin) and omeprazole (Prilosec)
Penicillin, along with sucralfate (Carafate)
Mylanta, double-strength
Misoprostol (Cytotec)
5. Which one of the following statements regarding home visits by physicians is most accurate?
1. End-of-life decisions are more comfortably discussed with the patient in a controlled
environment within a health care facility, rather than at home during a physician visit
2. Important issues for physicians to assess during home visits include patient mobility, nutrition,
safety, and medication compliance
3. Home visits by physicians should be made independently of home health nursing personnel in
order to obtain nonbiased patient care data
4. A defibrillator, bag-valve mask, and tackle box containing ACLS medications are considered
essential equipment for physicians making home visits
6. Which one of the following is most appropriate for family members of patients with autosomal
dominant polycystic kidney disease?
1.
2.
3.
4.
5.
7. A 72-year-old white male in otherwise good health complains of generalized pruritus that worsens in
the winter. The itch is most intense after he bathes. Recently, he noticed a rash on his abdomen and
legs as well. On examination, you note poorly defined red, scaly plaques with fine fissures on the
abdomen. No eruption is present at other pruritic sites.
Which one of the following is the most likely cause of this problem?
1.
2.
3.
4.
5.
Candidiasis
Rosacea
Xerosis
Lichen simplex chronicus
Stasis dermatitis
NPH insulin
Glyburide (DiaBeta, Micronase)
Acarbose (Precose)
Metformin (Glucophage)
10. Which one of the following is true regarding commercial air travel?
1. Pregnant women should not travel by air near term, to prevent fetal compromise due to oxygen
desaturation
2. Patients who have an uncomplicated myocardial infarction should wait 3-6 months before
traveling by air
3. Patients on chronic O2 therapy need to make arrangements to carry their own O2 on board
when traveling by air
4. At cruising altitude, the normal person has a PaO2 of 60-70 mm Hg
ANSWERS:
1. Right answer: Ultrasonography
When interpreted in relation to maternal age, maternal serum alpha-fetoprotein, maternal serum
estriols, and hCG can be used in combination to identify approximately 65% of pregnancies with
3. if her colitis was in prolonged remission and required only medication monitoring, this would
be acceptable behavior
4. "once a patient, always a patient," and any romantic encounters would constitute unethical
conduct
2. Treating preterm labor with beta-adrenergic agonists has been shown to decrease the rate of which
one of the following?
1. Delivery within 48 hours of treatment
2. Low birth weight infants
3. Preterm delivery
4. Perinatal deaths
3. A high-school wrestler who is a type 1 (insulin-dependent) diabetic comes to see you before a match
because his glucose level is high. You confirm that it is 275 mg/dL. You should
1. check his urine for ketones and, if positive, do not let him participate
2. advise him that type 1 diabetes is a contraindication to wrestling
3. encourage him to take concentrated glucose, as his glucose level should be 300 mg/dL or more
before a strenuous match
4. tell him to go ahead and participate, as the exercise will lower his glucose level to a normal
range
4. An 18-year-old white male comes to your office complaining of rectal pain and drainage.
Examination reveals that the drainage is not from the rectum at all, but from the area above the gluteal
cleft in the lower back. Erythema, induration, and purulent drainage are noted. The diagnosis of a
pilonidal abscess is made. The patients past history is otherwise unremarkable, as is the remainder of
his examination. Which one of the following is the best treatment?
1. Incision and drainage with packing
2. Parenteral antibiotics
3. Oral antibiotics
4. Watchful waiting, as this condition often heals spontaneously
5. A 25-year-old male visits your office concerned about a painless ulcer on the glans of his penis.
After appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 million
units of benzathine penicillin intramuscularly in a single dose. Eight hours later, while you are
working the evening clinic, he returns because he has a fever of 100.6 F and a bad headache, which
he rarely gets. He says he "aches all over." Which one of the following is the most appropriate action
at this time?
1. Reassure and prescribe antipyretics
2. Add doxycycline (Vibramycin), 100 mg orally twice a day for 14 days
3. Perform a spinal tap
4. Order a CT scan of his head
5. Obtain three blood cultures from different sites at 30-minute intervals
6. An 81-year-old white female comes to your office complaining of being depressed. She also
complains of recurrent muscle cramping and tingling of her fingers. During your evaluation, you
discover that her serum calcium level is 6.8 mg/dL (N 8.5-10.8) and her serum phosphorous level is
5.6 mg/dL (N 2.5-4.5). Which one of the following additional findings would most suggest the
diagnosis of primary hypoparathyroidism?
1. Normal renal function
2. Intracranial calcifications
3. Papilledema
4. Prolongation of the QT interval on EKG
7. Which one of the following preventive measures is recommended for nearly all international
travelers to developing countries?
1.
2.
3.
4.
5.
8. A high-school football player is brought to you the day after a game in which he suffered a sudden
valgus impact to his knee. He reported feeling a "pop" with the injury, was unable to continue activity
immediately after the injury, and has the feeling that the knee "gives way" or is unstable. He also
reports that the knee began swelling almost immediately.
When you examine his knee you find it tensely swollen. Aspiration of the joint returns a bloody
effusion. Based on this information, the most likely diagnosis is which one of the following?
1. Posterior cruciate ligament tear
2. Anterior cruciate ligament tear
3. Lateral collateral ligament tear
4. Patellar subluxation
9. Which one of the following statements concerning treatment of acute myocardial infarction is
correct?
1. Beta blockers reduce infarct size and chest pain when given for acute myocardial infarction
2. Calcium channel blockers reduce mortality from acute myocardial infarction
3. Angiotensin converting enzyme (ACE) inhibitors cause congestive heart failure if given during
an acute myocardial infarction
4. Lidocaine must be given routinely for myocardial infarction
5. Magnesium reduces the risk of sudden death from myocardial infarction
10. Which one of the following conditions is associated with high serum cholesterol?
1. Diabetes insipidus
2. Amyloidosis
3. Multiple sclerosis
4. Nephrotic syndrome
5. Hyperthyroidism
ANSWERS:
1. Right answer: he should inform her that he can no longer see her as a patient if they begin a dating
relationship
Contrary to a frequently held belief, it is not always unethical for a physician to enter into a dating,
romantic, or sexual relationship with a patient. The current principles of medical ethics clearly state
that "sexual contact that occurs concurrent with the physician-patient relationship constitutes sexual
misconduct. Sexual or romantic interactions between physicians and patients detract from the goals of
the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the
physicians objective judgment concerning the patients health care, and ultimately may be detrimental
to the patients well-being.
"If a physician has reason to believe that nonsexual contact with a patient may be perceived as or may
lead to sexual contact, then he or she should avoid the nonsexual contact. At a minimum, a physicians
ethical duties include terminating the physician-patient relationship before initiating a dating,
romantic, or sexual relationship with a patient.
"Sexual or romantic relationships between a physician and a former patient may be unduly influenced
by the previous physician-patient relationship. Sexual or romantic relationships with former patients
are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from
the previous professional relationship." If the physician is not using his position to exploit trust,
knowledge or influence derived from the previous professional relationship he may enter a dating or
more intimate relationship with the patient provided the physician-patient relationship is terminated
before the relationship begins. This should be a formal termination detailing why the physician will
not be able to provide further care for the patient. If further doctor-patient contact can be limited to
emergency situations, it would not be necessary for the patient to change medical groups, but rather to
select another physician who can provide continuing care.
2. Right answer: Delivery within 48 hours of treatment
In women with premature labor, beta-adrenergic agonists have been clearly shown to reduce the
incidence of delivery within 24 and 48 hours of administration. These tocolytic agents have not been
shown to consistently reduce the rates of preterm delivery, low birth weight, severe respiratory
distress, or perinatal death. A statistically non-significant trend toward reduced perinatal mortality has
been suggested in women given beta-adrenergic agonists earlier in pregnancy, for preterm labor before
28 weeks gestation. It appears that more effective use of the 24-48 hours gained by tocolysis with betaadrenergic agonists holds promise for reducing perinatal morbidity and mortality, perhaps through
more liberal use of predelivery glucocorticoid therapy.
3. Right answer: check his urine for ketones and, if positive, do not let him participate
Athletes with glucose levels greater than 300 mg/dL should postpone exercise even if no ketones are
in the urine. Athletes with glucose levels of 250-300 mg/dL should check their urine for ketones.
Exercise can raise, rather than lower, glucose levels when there is an increase in glucagon,
epinephrine, growth hormone, and cortisol in an already hypoinsulinemic patient. Urinary ketones may
indicate that severe hypoinsulinemia has caused release of fatty acids from adipose tissues and
subsequent conversion to ketones in the liver.
4. Right answer: Incision and drainage with packing
Pilonidal abscesses occur in young people, primarily men, and often have hair within the abscess
(as the pilo word root implies). These are best treated with incision and drainage, as antibiotics alone
are not sufficient. A simple stab incision will not suffice, as they will often close prematurely.
Therefore, an ellipse of tissue should be removed, allowing for adequate drainage and proper healing.
5. Right answer: Reassure and prescribe antipyretics
This man is experiencing the Jarisch-Herxheimer reaction-an acute, transient febrile reaction that
occurs within the first few hours after treatment for syphilis. The illness peaks at 6-8 hours, and
disappears within 12-24 hours after therapy. Temperature elevation is usually low grade, and there is
often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be
treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to
liberation of antigens from the spirochetes.
6. Right answer: Normal renal function