QUESTIONS

1. A 20-year-old woman presents with a cough of 3 weeks’ duration. She describes it as paroxysmal, dry, and hacking, with strong paroxysms of cough early in the morning. There is no sputum production or fever. She has occasional posttussive emesis. The cough occurs during the day and at night and frequently awakens her. She has no exertional dyspnea, symptoms of heartburn, or allergies. She does not smoke. She has had all appropriate vaccinations since infancy. She is a college student who baby-sits a 3-year-old boy on weekends. Results of an earlier pulmonary function test with bronchoprovocation challenge were normal. After this test, a trial of a proton-pump inhibitor and an antihistamine did not improve the symptoms. One week ago, when she visited the emergency department with the same complaints, a chest x-ray showed no infiltrates. A course of amoxicillin/clavulanate potassium (Augmentin) was prescribed, but her symptoms did not improve. What is the next step in management?

A. Obtain a nasopharyngeal culture, and prescribe erythromycin (Ery-Tab, PCE Dispertab) regardless of result

B. Obtain a sputum culture, and prescribe antibiotics according to sensitivities of the isolated organism

C. Refer to otolaryngology services for evaluation of her vocal cords and larynx

D. Order a computed tomography (CT) scan of the chest

2. A 72-year-old woman with a history of hypertension, diabetes, and chronic kidney disease comes to the emergency department because of 2 days of shortness of breath. She has no chest pain. Physical examination reveals: heart rate, 120 beats/min; blood pressure, 115/76 mm Hg; jugular venous pressure, elevated; there are rales in the lower lung fields; and pitting edema of the legs is noted. Her electrocardiogram (ECG) is shown (Figure). Which of the following treatments should be instituted emergently?

A. Electrical cardioversion

B. IV loading dose of amiodarone (Cordarone), 150 mg over 10 minutes, followed by amiodarone infusion

C. IV bolus of 10% calcium chloride solution, 5 mL

D. IV bolus of procainamide HCl, 100 mg

E. IV bolus of adenosine (Adenocard), 6 mg

3. You are seeing a 58-year-old Korean woman for a follow-up visit. Four years earlier she was diagnosed with osteoporosis based on a bone mineral density (BMD) T score of –2.6 at the lumbar spine and –1.8 at the hip. She was prescribed calcium (1200 mg/d) and vitamin D (800 IU/d) supplementation, along with alendronate sodium (Fosamax), 70 mg weekly. She started menopause at the age of 48. She has never had a fragility fracture but has a family history of osteoporosis. Her body mass index is 20 kg/m². She is tolerating treatment well, and her latest bone densitometry scan showed a T score of –1.0 at the vertebrae and –0.8 at the hip. She tells you that her health insurance has stopped paying for the bisphosphonate therapy, because she no longer has osteoporosis. She wants your advice. What would you tell her?

A. Continue the calcium/vitamin D supplements, and stop the alendronate

B. Continue the alendronate at 70 mg/week

C. Measure markers of bone turnover to stratify her risk of fragility fracture

D. Replace alendronate with raloxifene (Evista), a selective estrogen receptor modulator

E. Prescribe a generic low-dose conjugated estrogen

4. A healthy 53-year-old black man undergoes routine screening colonoscopy. He has no family history of colon cancer and no symptoms of any gastrointestinal illness. A single 0.7-cm polyp found at the rectosigmoid junction is successfully removed. Pathologic examination shows a tubular adenoma with low-grade dysplasia. What is the most appropriate follow-up?

A. None; schedule repeat colonoscopy in 10 years

B. Flexible sigmoidoscopy in 1 year

C. Colonoscopy in 1 year

D. Colonoscopy in 3 years

E. Colonoscopy in 5 years

5. In a study on the use of antibiotic therapy to prevent the occurrence of febrile neutropenia during chemotherapy, 760 patients were randomly assigned to either oral levofloxacin (Levaquin) or placebo beginning at the time that chemotherapy was initiated and continuing until the neutropenia resolved.

Febrile neutropenia developed in 65% of patients who received levofloxacin and 85% of those who received placebo. Mortality rates and side effect profiles were similar in both groups. What is the number needed to treat to prevent 1 episode of febrile neutropenia?

A. 50 patients

B. 20 patients

C. 10 patients

D. 5 patients

E. 2 patients

6. A 48-year-old HIV-infected man presents to the clinic with a 6-month history of a dry, hacking cough; weight loss; and night sweats. Chest radiography shows cavitary lesions in both upper lung fields. Sputum was positive for acid-fast bacilli, and the patient was started on antituberculosis (anti-TB) therapy with rifampin (Rifadin), isoniazid (Nydrazid), pyrazinamide, and ethambutol HCl (Myambutol). He returns to the clinic 3 months later, complaining of progressive blurry vision. He is also having difficulty distinguishing the color of traffic lights and is afraid to continue driving. Which drug is probably the culprit?

A. Rifampin

B. Isoniazid

C. Pyrazinamide

D. Ethambutol

7. A 32-year-old man comes to your office for a routine checkup. He is healthy; has no known medical conditions; and does not smoke, drink, or use illicit drugs. He exercises at a health club 3 to 4 times weekly. He has no family history of diabetes mellitus or colon cancer. He says he is homosexual and has been living with the same man for 3 years. They use condoms during sexual activity. Results of an HIV test he had 6 months age were negative. Aside from routine screening appropriate for his age, what other measure is indicated?

A. Influenza vaccination

B. Pneumococcal vaccination

C. Hepatitis A vaccination

D. Prostate cancer screening

E. Colon cancer screening

8. A 32-year-old man is being evaluated for bilateral leg edema that has been worsening over the past month. Laboratory tests show: BUN, 18 mg/dL; serum creatinine, 1.1 mg/dL; urine protein-to-creatinine ratio, 8; serum albumin, 2.8 mg/dL; total cholesterol, 300 mg/dL. HIV, hepatitis B, and hepatitis C tests were negative. A biopsy of the left kidney showed subepithelial immune complexes along the glomerular basement membrane. Two days later, he complains of severe right-sided flank pain with gross hematuria. Urinalysis shows numerous red blood cells (RBCs) but no casts. Creatinine level had increased to 3.0 mg/dL, and serum lactic dehydrogenase (LDH) was 1000 U/L. Ultrasonography shows an enlarged right kidney, but no renal calculi. What is the most likely explanation?

A. Development of rapidly progressive glomerulonephritis

B. Acute renal vein thrombosis

C. Capsular hematoma secondary to renal biopsy

D. Renal calculi not seen on ultrasonography

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