Rosh Review Exam 26 Questions &
Answers
A 52-year-old obese man presents to your office with complaints of burning chest pain, food
regurgitation and cough approximately once every week. He tells you that he likes to eat spicy
foods and often eats a large meal shortly before bedtime to help him sleep. Which of the
following is the most appropriate initial therapy?
Bismuth subsalicylate
Metoclopramide
Omeprazole
Ranitidine - ANSWERSCorrect Answer ( D )
Explanation:
Gastroesophageal reflux disease (GERD) occurs when excessive amounts of gastric juice reflux
into the esophagus causing uncomfortable symptoms or complications. Patients with GERD
present with esophageal symptoms including heartburn, dysphagia and regurgitation.
Extraesophageal symptoms such as cough, sore throat, hoarseness, noncardiac chest pain, and
erosion of the teeth enamel may also be seen. Patients who are morbidly obese or who have an
elevated body mass index have a greater risk of developing GERD. The diagnosis of GERD may
be made clinically and the role of endoscopy is controversial. Upper endoscopy is recommended
when the diagnosis is unclear and in patients with alarm features including recurrent vomiting,
gastrointestinal bleeding, anemia, weight loss and dysphagia. Other indications for endoscopy
include GERD that is refractory to initial treatment, men older than 50 years with risk factors for
Barrett's esophagus and esophageal carcinoma, and patients with severe erosive esophagitis.
Treatment strategies involve using either a step-up or step-down approach to therapy and all
include lifestyle modifications as an initial recommendation. Step-up therapy is recommended
for patients with mild GERD, which is defined as episodes occurring less than twice every week.
Initial treatment is with a histamine 2 receptor antagonists, such as ranitidine.
,Bismuth subsalicylate (A) is an antidiarrheal agent available over the counter that is used to
treat diarrhea and as part of the treatment for Helicobactor pylori infection. Metoclopramide
(B) is an antiemetic that is not recommended as monotherapy or adjunctive therapy in patients
with GERD. Omeprazole (C) is a proton-pump inhibitor that is used in the step-down approach
to treatment of GERD.
Question: What lifestyle modifications are recommended for patients with gastroesophageal
reflux disease? - ANSWERSAnswer: Weight loss, elevating the head of the bed, waiting three
hours before lying down after a meal, avoiding large meals and trigger foods.
Rapid Review
Gastroesophageal Reflux Disease (GERD)
Patient with a history of nocturnal cough or asthma
Complaining of retrosternal burning sensation radiating upward ("heartburn") usually after
eating
Diagnosis is made clinically
Most commonly caused by LES dysfunction
Treatment is weight loss, elevation head of bed during sleep, avoidance of certain foods
(caffeine, alcohol, acidic foods)
A 56-year-old overweight woman presents with a painful mouth for the past week. She says this
is her third flare of these "mouth sores" in 6 months. Her only daily medication is losartan for
hypertension. An exam reveals an erythematous oral cavity with clumpy, adherent, white
patches that bleed when removed with a tongue depressor. Which of the following laboratory
tests is appropriate at this time?
Anti-Epstein-Barr virus titer
Fasting blood glucose
,Thyroid stimulating hormone
Vitamin B12 assay - ANSWERSCorrect Answer ( B )
Explanation:
This patient has recurrent oral candidiasis, for which uncontrolled diabetes mellitus is a
common risk factor. A fasting blood glucose is the most appropriate test at this time to screen
for diabetes. Oral candidiasis, or thrush, usually presents as painful, curd-like, creamy-white
patches overlying an erythematous oral mucosa or pharynx. Though these patches can easily be
removed with a tongue depressor, removal may reveal bleeding mucosa. Oral candidiasis is
usually diagnosed clinically, though a wet preparation using potassium hydroxide might show
spores or non-septate mycelia. In addition to underlying diabetes mellitus, risk factors for oral
candidiasis include poor overall health or oral hygiene, use of dentures, prior head or neck
radiation, and current use of chemotherapy or systemic or inhaled corticosteroids. Further
work-up may be necessary to rule out an underlying anemia or HIV infection. Oral candidiasis
usually responds well to antifungal therapy in the form of Nystatin mouth rinse or oral
fluconazole. However, newer anti-fungal agents like voriconazole might be needed for patients
with underlying HIV or otherwise fluconazole-refractory candidiasis. Oral candidiasis should
resolve rapidly once an appropriate treatment is initiated.
An anti-Epstein-Barr virus titer (A) would be appropriate if Epstein-Barr virus (EBV) were
suspected as the cause of this patient's pain. However, oropharyngeal discomfort due to EBV
typically presents with a shaggy white-purple tonsillar exudate as opposed to the white, curd-
like patches of candidiasis. Other symptoms will usually include lymphadenopathy, fatigue, and
fever, which were not present in this patient. A thyroid stimulating hormone (C) will not be
beneficial in addressing an underlying cause of recurrent oral candidiasis
, Question: Prescription of which class of asthma inhalers requires patients to rinse the mouth
carefully after use to prevent oral candidiasis? - ANSWERSAnswer: Inhaled corticosteroids pose
an increased risk of oral candidiasis.
Rapid Review
Oral Candidiasis
Risk factors: HIV, oral steroid use
Lesions scrape off
A 24-year-old man presents to the ED with a rash on his left flank. He is an avid hiker in the
upper Midwest. He was bit by a tick two weeks ago. What would you expect to find on physical
examination?
Annular erythematous patch with central clearing
Diffuse erythroderma over the trunk and extremities
Maculopapular rash over the trunk following Langer's lines
Petechiae involving the palms and soles before spreading centrally - ANSWERSCorrect Answer
(A)
Explanation:
This patient is exhibiting risk factors for and signs of Lyme disease. Lyme disease is the most
common vector-borne disease in the United States. It is endemic to New England, the mid-
Atlantic states, and the upper Midwest. It is caused by the spirochete Borrelia burgdorferi and
transmitted by the Ixodes dammini tick, more commonly known as the deer tick. The tick must
Answers
A 52-year-old obese man presents to your office with complaints of burning chest pain, food
regurgitation and cough approximately once every week. He tells you that he likes to eat spicy
foods and often eats a large meal shortly before bedtime to help him sleep. Which of the
following is the most appropriate initial therapy?
Bismuth subsalicylate
Metoclopramide
Omeprazole
Ranitidine - ANSWERSCorrect Answer ( D )
Explanation:
Gastroesophageal reflux disease (GERD) occurs when excessive amounts of gastric juice reflux
into the esophagus causing uncomfortable symptoms or complications. Patients with GERD
present with esophageal symptoms including heartburn, dysphagia and regurgitation.
Extraesophageal symptoms such as cough, sore throat, hoarseness, noncardiac chest pain, and
erosion of the teeth enamel may also be seen. Patients who are morbidly obese or who have an
elevated body mass index have a greater risk of developing GERD. The diagnosis of GERD may
be made clinically and the role of endoscopy is controversial. Upper endoscopy is recommended
when the diagnosis is unclear and in patients with alarm features including recurrent vomiting,
gastrointestinal bleeding, anemia, weight loss and dysphagia. Other indications for endoscopy
include GERD that is refractory to initial treatment, men older than 50 years with risk factors for
Barrett's esophagus and esophageal carcinoma, and patients with severe erosive esophagitis.
Treatment strategies involve using either a step-up or step-down approach to therapy and all
include lifestyle modifications as an initial recommendation. Step-up therapy is recommended
for patients with mild GERD, which is defined as episodes occurring less than twice every week.
Initial treatment is with a histamine 2 receptor antagonists, such as ranitidine.
,Bismuth subsalicylate (A) is an antidiarrheal agent available over the counter that is used to
treat diarrhea and as part of the treatment for Helicobactor pylori infection. Metoclopramide
(B) is an antiemetic that is not recommended as monotherapy or adjunctive therapy in patients
with GERD. Omeprazole (C) is a proton-pump inhibitor that is used in the step-down approach
to treatment of GERD.
Question: What lifestyle modifications are recommended for patients with gastroesophageal
reflux disease? - ANSWERSAnswer: Weight loss, elevating the head of the bed, waiting three
hours before lying down after a meal, avoiding large meals and trigger foods.
Rapid Review
Gastroesophageal Reflux Disease (GERD)
Patient with a history of nocturnal cough or asthma
Complaining of retrosternal burning sensation radiating upward ("heartburn") usually after
eating
Diagnosis is made clinically
Most commonly caused by LES dysfunction
Treatment is weight loss, elevation head of bed during sleep, avoidance of certain foods
(caffeine, alcohol, acidic foods)
A 56-year-old overweight woman presents with a painful mouth for the past week. She says this
is her third flare of these "mouth sores" in 6 months. Her only daily medication is losartan for
hypertension. An exam reveals an erythematous oral cavity with clumpy, adherent, white
patches that bleed when removed with a tongue depressor. Which of the following laboratory
tests is appropriate at this time?
Anti-Epstein-Barr virus titer
Fasting blood glucose
,Thyroid stimulating hormone
Vitamin B12 assay - ANSWERSCorrect Answer ( B )
Explanation:
This patient has recurrent oral candidiasis, for which uncontrolled diabetes mellitus is a
common risk factor. A fasting blood glucose is the most appropriate test at this time to screen
for diabetes. Oral candidiasis, or thrush, usually presents as painful, curd-like, creamy-white
patches overlying an erythematous oral mucosa or pharynx. Though these patches can easily be
removed with a tongue depressor, removal may reveal bleeding mucosa. Oral candidiasis is
usually diagnosed clinically, though a wet preparation using potassium hydroxide might show
spores or non-septate mycelia. In addition to underlying diabetes mellitus, risk factors for oral
candidiasis include poor overall health or oral hygiene, use of dentures, prior head or neck
radiation, and current use of chemotherapy or systemic or inhaled corticosteroids. Further
work-up may be necessary to rule out an underlying anemia or HIV infection. Oral candidiasis
usually responds well to antifungal therapy in the form of Nystatin mouth rinse or oral
fluconazole. However, newer anti-fungal agents like voriconazole might be needed for patients
with underlying HIV or otherwise fluconazole-refractory candidiasis. Oral candidiasis should
resolve rapidly once an appropriate treatment is initiated.
An anti-Epstein-Barr virus titer (A) would be appropriate if Epstein-Barr virus (EBV) were
suspected as the cause of this patient's pain. However, oropharyngeal discomfort due to EBV
typically presents with a shaggy white-purple tonsillar exudate as opposed to the white, curd-
like patches of candidiasis. Other symptoms will usually include lymphadenopathy, fatigue, and
fever, which were not present in this patient. A thyroid stimulating hormone (C) will not be
beneficial in addressing an underlying cause of recurrent oral candidiasis
, Question: Prescription of which class of asthma inhalers requires patients to rinse the mouth
carefully after use to prevent oral candidiasis? - ANSWERSAnswer: Inhaled corticosteroids pose
an increased risk of oral candidiasis.
Rapid Review
Oral Candidiasis
Risk factors: HIV, oral steroid use
Lesions scrape off
A 24-year-old man presents to the ED with a rash on his left flank. He is an avid hiker in the
upper Midwest. He was bit by a tick two weeks ago. What would you expect to find on physical
examination?
Annular erythematous patch with central clearing
Diffuse erythroderma over the trunk and extremities
Maculopapular rash over the trunk following Langer's lines
Petechiae involving the palms and soles before spreading centrally - ANSWERSCorrect Answer
(A)
Explanation:
This patient is exhibiting risk factors for and signs of Lyme disease. Lyme disease is the most
common vector-borne disease in the United States. It is endemic to New England, the mid-
Atlantic states, and the upper Midwest. It is caused by the spirochete Borrelia burgdorferi and
transmitted by the Ixodes dammini tick, more commonly known as the deer tick. The tick must
