AAFP Random 2
Which one of the following is the greatest risk factor for abdominal aortic aneurysm (AAA)? (check one) A. Cigarette smoking B. Diabetes mellitus C. Hypertension D. African-American race E. Female gender
A. Cigarette smoking. Cigarette smokers are five times more likely than nonsmokers to develop an abdominal aortic aneurysm (AAA). The risk is associated with the number of years the patient has smoked, and declines with cessation. Diabetes mellitus is protective, decreasing the risk of AAA by half. Women tend to develop AAA in their sixties, 10 years later than men. Whites are at greater risk than African-Americans. Hypertension is less of a risk factor than cigarette smoking (SOR A).
A 40-year-old female with chronic plaque psoriasis requests topical treatment. Which one of the following topical therapies would be most effective and have the fewest adverse effects? (check one) A. High-potency corticosteroids B. Tazarotene (Tazorac) C. Coal tar polytherapy D. Anthralin
A. High-potency corticosteroids. Chronic plaque psoriasis is the most common type of psoriasis and is characterized by redness, thickness, and scaling. A variety of treatments were found to be more effective than placebo, but the best results were produced by topical vitamin D analogues and topical corticosteroids. Vitamin D and high-potency corticosteroids were equally effective when compared head to head, but the corticosteroids produced fewer local reactions (SOR A).
Which one of the following has been shown to be effective for improving symptoms of varicose veins? (check one) A. Horse chestnut seed extract B. Vitamin B12 C. Ephedra D. Milk thistle E. St. John's wort
A. Horse chestnut seed extract. Horse chestnut seed extract has been shown to have some effect when used orally for symptomatic treatment of chronic venous insufficiency, such as varicose veins. It may also be useful for relieving pain, tiredness, tension, and swelling in the legs. It contains a number of anti-inflammatory substances, including escin, which reduces edema and lowers fluid exudation by decreasing vascular permeability. Milk thistle may be effective for hepatic cirrhosis. Ephedra is considered unsafe, as it can cause severe life-threatening or disabling adverse effects in some people. St. John's wort may be effective for treating mild to moderate depression. Vitamin B12 is used to treat pernicious anemia.
A 25-year-old male presents to your office with a 1-week history of neck pain with radiation to the left hand, along with intermittent numbness and tingling in the left arm. His history is negative for injury, fever, or lower extremity symptoms. Extension and rotation of the neck to the left while pressing down on the head (Spurling's maneuver) exacerbates the symptoms. His examination is otherwise normal. Cervical radiographs are negative. Which one of the following would be most appropriate at this point? (check one) A. NSAIDs for pain relief B. A trial of tricyclic antidepressants C. Cervical corticosteroid injection D. Cervical MRI E. Referral to a spine subspecialist
A. NSAIDs for pain relief. Patients who present with acute cervical radiculopathy and normal radiographs can be treated conservatively. The vast majority of patients with cervical radiculopathy improve without surgery. Of the interventions listed, NSAIDs are the initial treatment of choice. Tricyclic antidepressants, as well as tramadol and venlafaxine, have been shown to help with chronic neuropathic pain. Cervical MRI is not indicated unless there are progressive neurologic defects or red flags such as fever or myelopathy. Likewise, referral to a subspecialist should be reserved for patients who have persistent pain after 6-8 weeks of conservative management and for those with signs of instability. Cervical corticosteroid injections have been found to be helpful in the management of cervical radiculopathy, but should not be administered before MRI is performed (SOR C).
A 38-year-old day-care worker consults you for "a cold that won't go away." It began with a runny nose, malaise, and a slight temperature elevation up to 100°F (37.8°C). She notes that after 2 weeks she is now experiencing "coughing fits," which are sometimes so severe that she vomits. She has had no immunizations since her freshman year in college and does not smoke. On examination you note excessive lacrimation and conjunctival injection. Her lungs are clear. Which one of the following is the most likely diagnosis? (check one) A. Pertussis B. Rhinovirus infection C. Nonasthmatic eosinophilic bronchitis D. Cough-variant asthma E. Gastroesophageal reflux
A. Pertussis. Pertussis, once a common disease in infants, declined to around 1000 cases in 1976 as a result of widespread vaccination. The incidence began to rise again in the 1980s, possibly because the immunity from vaccination rarely lasts more than 12 years. The disease is characterized by a prodromal phase that lasts 1-2 weeks and is indistinguishable from a viral upper respiratory infection. It progresses to a more severe cough after the second week. The cough is paroxysmal and may be severe enough to cause vomiting or fracture ribs. Patients are rarely febrile, but may have increased lacrimation and conjunctival injection. The incubation period is long compared to a viral infection, usually 7-10 days. Nonasthmatic eosinophilic bronchitis, cough-variant asthma, and gastroesophageal reflux disease cause a severe cough not associated with a catarrhal phase. A rhinovirus infection would probably be resolving within 2-3 weeks.
A 25-year-old male presents to your office for evaluation of pain in the right index finger that has been present for the past 4 days. The pain has been getting progressively worse. On examination the finger is swollen and held in a flexed position. The pain increases with passive extension of the finger, and there is tenderness to palpation from the tip of the finger into the palm. Which one of the following is the most appropriate management of this patient? (check one) A. Surgical drainage and antibiotics B. Antiviral medication C. Oral antibiotics and splinting D. Needle aspiration E. Corticosteroid injection
A. Surgical drainage and antibiotics. This patient has pyogenic tenosynovitis. When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient's infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics. A delay in treatment of these infections can lead to ischemia of the tendons and damage to the flexor tendon and sheath. This can lead to impaired function of the finger. Needle aspiration would not adequately drain the infection. Antiviral medication would not be appropriate, as this is a bacterial infection. Corticosteroid injections are contraindicated in the presence of infection.
While evaluating a stroke patient, you ask him to stick out his tongue. At first he is unable to do this, but a few moments later he performs this movement spontaneously. This defect is known as: (check one) A. apraxia B. agnosia C. expressive (Broca's) aphasia D. astereognosis
A. apraxia. Apraxia is a transmission disturbance on the output side, which interferes with skilled movements. Even though the patient understands the request, he is unable to perform the task when asked, but may then perform it after a time delay. Agnosia is the inability to recognize previously familiar sensory input, and is a modality-bound deficit. For example, it results in a loss of ability to recognize objects. Aphasia is a language disorder, and expressive aphasia is a loss of the ability to express language. The ability to recognize objects by palpation in one hand but not the other is called astereognosis.
You have been treating a 43-year-old male for unipolar depression for 4 years. He has developed treatment-resistant depression, and despite having a good initial response to an SSRI, his symptoms are worsening. He has failed to improve despite escalated doses of multiple SSRIs and SNRIs. He is currently taking citalopram (Celexa), 60 mg daily. Of the following, the most effective adjunctive therapy would be augmentation with: (check one) A. lithium bicarbonate B. high-dose triiodothyronine C. an atypical antipsychotic, such as olanzapine (Zyprexa) D. an anticonvulsant, such as gabapentin (Neurontin)
A. lithium bicarbonate. Up to one-third of patients with unipolar depression will fail to respond to treatment with a single antidepressant, despite adequate dosing and an appropriate treatment interval. Lithium, triiodothyronine (T3 ), and atypical antipsychotics can all provide clinical improvement when used in conjunction with the ineffective antidepressant. The American Psychiatric Association and the Institute for Clinical Systems Improvement both recommend a trial of lithium or low-dose T 3 for patients who have an incomplete response to antidepressant therapy. A meta-analysis showed that a serum lithium level ≥0.5 mEq/L and a treatment duration of 2 weeks or greater resulted in a good response (SOR A). While thyroid supplementation as adjunctive therapy is effective, the recommended dosage is no higher than 50 μg/day (SOR B). Atypical antipsychotics can be used as add-on therapy, but are not as effective as lithium or T3 (SOR B). Anticonvulsant medications such as gabapentin have been shown to be effective in the management of bipolar affective disorder, but not as adjunctive therapy in the treatment of unipolar depression resistant to single-agent antidepressants.
You see a 90-year-old male with a 5-year history of progressive hearing loss. The most common type of hearing loss at this age affects: (check one) A. predominantly high frequencies B. predominantly mid frequencies C. predominantly low frequencies D. all frequencies roughly the same
A. predominantly high frequencies. In the geriatric population, presbycusis is the most common cause of hearing loss. Patients typically have the most difficulty hearing higher-frequency sounds such as consonants. Lower-frequency sounds such as vowels are preserved.
Which one of the following patients should be advised to take aspirin, 81 mg daily, for the primary prevention of stroke? (check one) A. A 42-year-old male with a history of hypertension B. A 72-year-old female with no chronic medical conditions C. An 80-year-old male with a history of depression D. An 87-year-old female with a history of peptic ulcer disease
B. A 72-year-old female with no chronic medical conditions. The U.S. Preventive Services Task Force (USPSTF) has summarized the evidence for the use of aspirin in the primary prevention of cardiovascular disease as follows: The USPSTF recommends the use of aspirin for men 45-79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation) The USPSTF recommends the use of aspirin for women 55-79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement) The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation) In summary, consistent evidence from randomized clinical trials indicates that aspirin use reduces the risk for cardiovascular disease events in adults without a history of cardiovascular disease. It reduces the risk for myocardial infarction in men, and ischemic stroke in women. Consistent evidence shows that aspirin use increases the risk for gastrointestinal bleeding, and limited evidence shows that aspirin use increases the risk for hemorrhagic strokes. The overall benefit in the reduction of cardiovascular disease events with aspirin use depends on baseline risk and the risk for gastrointestinal bleeding.
A 4-year-old is brought to the emergency department with abdominal pain and is noted to have 3+ proteinuria on a dipstick. Three days later the pain has resolved spontaneously, and a repeat urinalysis in your office shows 2+ proteinuria with normal findings on microscopic examination. A metabolic panel, including creatinine and total protein, is also normal. Which one of the following would be most appropriate at this point? (check one) A. Renal ultrasonography B. A spot first morning urine protein/creatinine ratio C. An antinuclear antibody and complement panel D. Referral to a nephrologist
B. A spot first morning urine protein/creatinine ratio. When proteinuria is noted on a dipstick and the history, examination, full urinalysis, and serum studies suggest no obvious underlying problem or renal insufficiency, a urine protein/creatinine ratio is recommended. This test correlates well with 24-hour urine protein, which is particularly difficult to collect in a younger patient. Renal ultrasonography is appropriate once renal insufficiency or nephritis is established. If pathogenic proteinuria is confirmed, an antinuclear antibody and/or complement panel may be indicated. A nephrology referral is not necessary until the presence of kidney disease or proteinuria from a cause other than benign postural proteinuria is confirmed.
A 48-year-old white female comes to see you because of abnormal vaginal bleeding. Her periods are lasting 3-5 days longer than usual, bleeding is heavier, and she has experienced some intermenstrual bleeding. Her physical examination is unremarkable, except for a parous cervix with dark blood at the os and in the vagina. She has no orthostatic hypotension, and her hemoglobin level is 11.5 g/dL. A pregnancy test is negative. Which one of the following is the most important next step in management? (check one) A. Laboratory tests to rule out thyroid dysfunction B. An endometrial biopsy C. Oral contraceptives, 4 times a day for 5-7 days D. Cyclic combination therapy with conjugated estrogens (Premarin) and medroxy-progesterone (Provera) each month E. Administration of a gonadotropin-releasing hormone analog such as leuprolide acetate (Eligard Lupron Depot)
B. An endometrial biopsy. A patient over the age of 35 who experiences abnormal vaginal bleeding must have an endometrial assessment to exclude endometrial hyperplasia or cancer. An endometrial biopsy is currently the preferred method for identifying endometrial disease. A laboratory evaluation for thyroid dysfunction or hemorrhagic diathesis is appropriate if no cancer is present on an endometrial biopsy and medical therapy fails to halt the bleeding. The other options listed can be used as medical therapy to control the bleeding once the histopathologic diagnosis has been made.
A 62-year-old male has been taking omeprazole (Prilosec) for over a year for gastroesophageal reflux disease. He is asymptomatic and has had no problems tolerating the drug, but asks you about potential side effects, as well as the benefits of continuing therapy. It would be most accurate to tell him that omeprazole therapy is associated with which one of the following? (check one) A. A decreased rate of hip fracture B. Decreased vitamin B12 absorption C. A reduced likelihood of pneumonia D. A reduced likelihood of Clostridium difficile colitis E. An increased likelihood of iron deficiency anemia
B. Decreased vitamin B12 absorption. Although proton pump inhibitors are the most effective treatment for patients with asymptomatic gastroesophageal reflux disease, there are several potential problems with prolonged therapy. Omeprazole is associated with an increased risk of community-acquired pneumonia and Clostridium difficile colitis. Omeprazole has also been shown to acutely decrease the absorption of vitamin B 12 , and it decreases calcium absorption, leading to an increased risk of hip fracture. The risk for Clostridium difficile colitis is also increased.
What is the most common cause of erythema multiforme, accounting for more than 50% of cases? (check one) A. Candida albicans B. Herpes simplex virus C. Mycoplasma pneumoniae D. Penicillin therapy E. Sulfonamide therapy
B. Herpes simplex virus. Erythema multiforme usually occurs in adults 20-40 years of age, although it can occur in patients of all ages. Herpes simplex virus (HSV) is the most commonly identified cause of this hypersensitivity reaction, accounting for more than 50% of cases.
A 21-year-old African-American female has been confused and delirious for 2 days. She has no significant past medical history, and she is taking no medications. She recently returned from a missionary trip to Southeast Asia. During your initial examination in the emergency department, she has several convulsions and rapidly becomes comatose. Her temperature is 37.9°C (100.3°F) and her blood pressure is 80/50 mm Hg. A neurologic examination shows no signs of meningeal irritation and a cranial nerve evaluation is normal. There is a mild, bilateral, symmetric increase in deep tendon reflexes. All other physical examination findings are normal. Laboratory Findings Hemoglobin........................... 7.0 g/dL (N 12.0-16.0) Hematocrit............................ 20% (N 36-46) WBCs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6500/mm3 (N 4300-10,800) Platelets. ............................. 450,000/mm3 (N 150,000-350,000) Serum bilirubin Total............................... 5.0 mg/dL (N 0.3-1.1) Direct.............................. 1.0 mg/dL (N 0.1-0.4) The urine is dark red and positive for hemoglobin. CT of the brain shows neither bleeding nor infarction. The most likely diagnosis is: (check one) A. vitamin B12 deficiency B. malaria C. ehrlichiosis D. sickle cell anemia
B. malaria. Clinical clues to the diagnosis of malaria in this case include an appropriately targeted recent travel history, a prodrome of delirium or erratic behavior, unarousable coma following a generalized convulsion, fever, and a lack of focal neurologic signs in the presence of a diffuse, symmetric encephalopathy. The peripheral blood smear shows normochromic, normocytic anemia with Plasmodium falciparum trophozoites and schizonts involving erythrocytes, diagnostic of cerebral malaria. Treatment of this true medical emergency is intravenous quinidine gluconate. Vitamin B 12 deficiency is a predominantly peripheral neuropathy seen in older adults. Ehrlichiosis causes thrombocytopenia but not hemolytic anemia. Sickle cell disease presents with painful vaso-occlusive crises in multiple organs. Coma is rare.
ACE inhibitors and angiotensin II receptor blockers are renoprotective and their use is recommended in all diabetics. The use of low-dose aspirin and folic acid is recommended in all patients with diabetes, due to the vasculoprotective properties of these drugs. High-dose aspirin should be avoided because it acts as an NSAID. The best drug treatment for symptomatic mitral valve prolapse is: (check one) A. quinidine B. propranolol (Inderal) C. digoxin D. procainamide E. phenytoin (Dilantin)
B. propranolol (Inderal). The primary treatment for symptomatic mitral valve prolapse is β-blockers. Quinidine and digoxin were used to treat this problem in the past, especially if sinus bradycardia or cardiac arrest occurred with administration of propranolol. Procainamide and phenytoin have not been used to treat this syndrome. Asymptomatic patients require only routine monitoring, while those with significant mitral regurgitation may require surgery. Some patients with palpitations can be managed with lifestyle changes such as elimination of caffeine and alcohol. Orthostatic hypotension can often be managed with volume expansion, such as by increasing salt intake.
A primigravida at 38 weeks gestation is concerned that her fetus is getting too large and wants to know what interventions could prevent complications from a large baby. On examination her uterine fundus measures 41 cm from the pubic symphysis. Ultrasonography is performed and an estimated fetal weight of 4000 g (8 lb 13 oz) is reported. Which one of the following management options is supported by the best evidence? (check one) A. Induction of labor B. Cesarean section C. Awaiting spontaneous labor D. Weekly ultrasonography to follow fetal growth
C. Awaiting spontaneous labor. This estimated fetal weight is at the 90th percentile for a term fetus. Unfortunately, the accuracy of fetal weight estimates declines as pregnancy proceeds, and the actual size may be as much as 15% different from the estimate. Delivery of a large infant results in shoulder dystocia more often than delivery of a smaller infant, but most large infants are delivered without complications. Intuitively, it would seem logical to induce labor when the fetus seems to be getting large, but this intervention has been studied in controlled trials and the only difference in outcome was an increase in the cesarean rate for women who underwent elective induction for this indication. Recently, there has been an increase in requests from patients to have an elective cesarean section near term to avoid the risks of labor, including pain, shoulder dystocia, and pelvic relaxation. The American Congress of Obstetricians and Gynecologists (ACOG) recommends consideration of cesarean delivery without a trial of labor if the estimated fetal weight is 4500 g in a mother with diabetes mellitus, or 5000 g in the absence of diabetes. Even at that size, there is not adequate data to show that cesarean section is preferable to a trial of labor. Frequent ultrasonography is often performed to reduce anxiety for both patient and physician, but the problem of accuracy of weight estimates remains an issue even with repeated scans at term.
A 3-day-old female developed a rash 1 day ago that has continued to progress and spread. The infant was born at term after an uncomplicated pregnancy and delivery to a healthy mother following excellent prenatal care. The infant was discharged 2 days ago in good health. She does not appear to be irritable or in distress, and she is afebrile and feeding well. On examination, abnormal findings are confined to the skin, including her face, trunk, and proximal extremities, which have macules, papules, and pustules that are all 2-3 mm in diameter. Her palms and soles are spared. A stain of a pustular smear shows numerous eosinophils. Which one of the following is the most likely diagnosis? (check one) A. Staphylococcal pyoderma B. Herpes simplex C. Acne neonatorum D. Erythema toxicum neonatorum E. Rocky Mountain spotted fever
D. Erythema toxicum neonatorum. This infant has a typical presentation of erythema toxicum neonatorum. Staphylococcal pyoderma is vesicular and the stain of the vesicle content shows polymorphonuclear leukocytes and clusters of gram-positive bacteria. Because the mother is healthy and the infant shows no evidence of being otherwise ill, systemic infections such as herpes are unlikely. Acne neonatorum consists of closed comedones on the forehead, nose, and cheeks. Rocky Mountain spotted fever is a tickborne disease that does not need to be considered in a child who is not at risk.
A 22-year-old white female comes to your office complaining of dizziness. She was in her usual good health until about 2 weeks before this visit, when she developed a case of gastroenteritis that other members of her family have also had. Since that time she has been lightheaded when standing, feels her heart race, and gets headaches or blurred vision if she does not sit or lie down. She has not passed out but has been unable to work due to these symptoms. She is otherwise healthy and takes no regular medications. A physical examination is normal except for her heart rate, which rises from 72 beats/min when she is lying or sitting to 112 beats/min when she stands. Her blood pressure remains unchanged with changes of position. Routine laboratory tests and an EKG are normal. What is the most likely cause of this patient's condition? (check one) A. Myocarditis B. A seizure disorder C. Postural orthostatic tachycardia syndrome (POTS) D. Systemic lupus erythematosus E. Somatization disorder
C. Postural orthostatic tachycardia syndrome (POTS). Postural orthostatic tachycardia syndrome (POTS) is manifested by a rise in heart rate >30 beats/min or by a heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enough. This condition is most prevalent in white females between the ages of 15 and 50 years old. Often these patients are hardworking, athletic, and otherwise in good health. There is a high clinical correlation between POTS and chronic fatigue syndrome. Although no single etiology for POTS has been found, the condition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers.
Which one of the following tinea infections in children always requires systemic antifungal therapy? (check one) A. Tinea cruris B. Tinea corporis C. Tinea capitis D. Tinea pedis E. Tinea versicolor
C. Tinea capitis. Dermatophyte infections caused by aerobic fungi produce infections in many areas. Tinea capitis requires systemic therapy to penetrate the affected hair shafts. Tinea cruris and tinea pedis rarely require systemic therapy. Extensive outbreaks of tinea corporis and tinea versicolor benefit from both oral and topical treatment (SOR A), but more localized infections require only topical treatment.
You see a 6-year-old male for the third time in 3 months with a persistently painful hand condition. He has been treated with oral amoxicillin, followed by oral trimethoprim/ sulfamethoxazole (Bactrim, Septra), with no improvement. A physical examination reveals retraction of the proximal nail fold, absence of the cuticle, and erythema and tenderness around the nail fold area. The thumb and second and third fingers are affected on both hands. The patient is otherwise healthy. First-line treatment for this condition includes: (check one) A. warm soaks three times a day B. avoidance of emollient lotions C. a topical corticosteroid cream D. an oral antifungal agent
C. a topical corticosteroid cream. This patient has symptoms and signs consistent with chronic paronychia. This condition is often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking. Findings on examination are similar to those of acute paronychia, with tenderness, erythema, swelling, and retraction of the proximal nail fold. Often the adjacent cuticle is absent. Chronic paronychia has usually been persistent for at least 6 weeks by the time of diagnosis. In addition to medication, basic treatment principles for the condition include avoidance of contact irritants, avoiding immersion of the hands in water, and use of an emollient. Topical corticosteroids have higher efficacy for treating chronic paronychia compared to oral antifungals (SOR B), particularly given the young age of the patient. A topical antifungal can also be tried in conjunction with the corticosteroid.
A 26-year-old female calls your office to inquire about the results of her recent Papanicolaou (Pap) test. The report indicates the presence of atypical squamous cells of undetermined significance (ASC-US), and her reflex HPV test is negative for high-risk HPV types. The patient has never had an abnormal Pap test and has had three normal tests over the past 6 years. She is a nonsmoker. You advise the patient that the most appropriate next step would be to: (check one) A. repeat the Pap test every 3 months for 1 year B. repeat the Pap test in 6 months and 12 months C. repeat the Pap test in 12 months D. continue routine Pap tests, with the next test in 3 years E. schedule colposcopy as soon as possible
C. repeat the Pap test in 12 months. The ASC-US/LSIL Triage Study (ALTS) demonstrated that there are three appropriate follow-up options for managing women with an ASC-US Papanicolaou (Pap) test result: (1) two repeat cytologic examinations performed at 6-month intervals; (2) reflex testing for HPV; or (3) a single colposcopic examination. This expert consensus recommendation has been confirmed in more recent clinical studies, additional analyses of the ALTS data, and meta-analyses of published studies (SOR A). Reflex HPV testing refers to testing either the original liquid-based cytology residual specimen or a separate sample collected for HPV testing at the time of the initial screening visit. This approach eliminates the need for women to return to the office or clinic for repeat testing, rapidly reassures women who do not have a significant lesion, spares 40%-60% of women from undergoing colposcopy, and has been shown to have a favorable cost-effectiveness ratio. In this patient's case, the HPV testing was negative, and there is no need to repeat the Pap test at 6-month intervals or to perform colposcopy. Although women in certain low-risk groups need routine cervical cancer screening only every 3 years, this patient should have a repeat Pap test in 12 months. Immediately repeating the test or testing at 3-month intervals is not recommended in any of the algorithms to manage ASC-US results for otherwise healthy women.
The CAGE-AID questionnaire is a tool for screening for: (check one) A. depression B. bipolar illness C. substance abuse risk D. psychosis E. compatibility
C. substance abuse risk. The CAGE-AID (CAGE Adapted to Include Drugs) questionnaire is a tool for assessing potential substance abuse risk. In one study it had a sensitivity of 70% and a specificity of 85% for drug abuse when two or more affirmative responses were defined as a positive result. It consists of the following four questions: Have you ever felt you ought to Cut down on your drinking or drug use? Have people Annoyed you by criticizing your drinking or drug use? Have you ever felt bad or Guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning as an Eye opener to steady your nerves or to get rid of a hangover?
A 65-year-old female who is morbidly obese presents to your office with intertrigo in the axilla. On examination you detect small, reddish-brown macules that are coalescing into larger patches with sharp borders. You suspect cutaneous erythrasma complicating the intertrigo. What would be the most appropriate topical treatment for this condition? (check one) A. Cornstarch B. A mild corticosteroid lotion C. A high-potency corticosteroid lotion D. Erythromycin
D. Erythromycin. Intertrigo is inflammation of skinfolds caused by skin-on-skin friction and is common on opposing cutaneous or mucocutaneous surfaces. Secondary cutaneous bacterial and fungal infections are common complications. Cutaneous erythrasma may complicate intertrigo of interweb areas, intergluteal and crural folds, axillae, or inframammary regions. Erythrasma is caused by Corynebacterium minutissimum and presents as small reddish-brown macules that may coalesce into larger patches with sharp borders. Intertrigo complicated by erythrasma is treated with topical or oral erythromycin.
You are asked to perform a preoperative evaluation on a 55-year-old white female with type 2 diabetes mellitus prior to elective femoral-anterior tibial artery bypass surgery. She is unable to climb a flight of stairs or do heavy work around the house. She denies exertional chest pain, and is otherwise healthy. Based on current guidelines, which one of the following diagnostic studies would be appropriate prior to surgery because the results could alter the management of this patient? (check one) A. Pulmonary function studies B. Coronary angiography C. Carotid angiography D. A dipyridamole-thallium scan E. A hemoglobin A1c level
D. A dipyridamole-thallium scan. Family physicians are often asked to perform a preoperative evaluation prior to noncardiac surgery. This requires an assessment of the perioperative cardiovascular risk of the procedure involved, the functional status of the patient, and clinical factors that can increase the risk, such as diabetes mellitus, stroke, renal insufficiency, compensated or prior heart failure, mild angina, or previous myocardial infarction. This patient is not undergoing emergency surgery, nor does she have an active cardiac condition; however, she is undergoing a high-risk procedure (>5% risk of perioperative myocardial infarction) with vascular surgery. As she cannot climb a flight of stairs or do heavy housework, her functional status is <4 METs, and she should be considered for further evaluation. The patient's diabetes is an additional clinical risk factor. With vascular surgery being planned, appropriate recommendations include proceeding with the surgery with heart rate control, or performing noninvasive testing if it will change the management of the patient. Coronary angiography is indicated if the noninvasive testing is abnormal. Pulmonary function studies are most useful in patients with underlying lung disease or those undergoing pulmonary resection. Hemoglobin A1c is a measure of long-term diabetic control and is not particularly useful perioperatively. Carotid angiography is not indicated in asymptomatic patients being considered for lower-extremity vascular procedures.
A 60-year-old male is referred to you by his employer for management of his hypertension. He has been without primary care for several years due to a lapse in insurance coverage. During a recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm Hg. He has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago. He has no other health problems and does not smoke or drink alcohol. A review of systems is negative except for minor residual weakness in his right upper extremity resulting from his remote stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse, and you obtain a similar reading during your examination. In addition to counseling him regarding lifestyle modifications, which one of the following is the most appropriate treatment for his hypertension? (check one) A. An angiotensin receptor blocker B. A β-blocker C. A calcium channel blocker D. A thiazide diuretic/ACE inhibitor combination E. No medication
D. A thiazide diuretic/ACE inhibitor combination. This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. For patients with a history of previous stroke, JNC-7 recommends using combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke. Other classes of drugs have not been shown to be of benefit for secondary stroke prevention. Although blood pressure should not be lowered quickly in the setting of acute ischemic stroke, this patient is not having an acute stroke, so treatment of his hypertension is warranted.
Breastfeeding a full-term, healthy infant is contraindicated when which one of the following maternal conditions is present? (check one) A. Chronic hepatitis B infection B. Seropositive cytomegalovirus carrier state C. Current tobacco smoking D. Herpes simplex viral lesions on the breasts E. Undifferentiated fever
D. Herpes simplex viral lesions on the breasts. Breastfeeding provides such optimal nutrition for an infant that the benefits still far outweigh the risks even when the mother smokes tobacco, tests positive for hepatitis B or C virus, or develops a simple undifferentiated fever. Maternal seropositivity to cytomegalovirus (CMV) is not considered a contraindication except when it has a recent onset or in mothers of low birthweight infants. When present, the CMV load can be substantially reduced by freezing and pasteurization of the milk. All patients who smoke should be strongly encouraged to discontinue use of tobacco, particularly in the presence of infants, but smoking is not a contraindication to breastfeeding. Mothers with active herpes simplex lesions on a breast should not feed their infant from the infected breast, but may do so from the other breast if it is not infected. Breastfeeding is also contraindicated in the presence of active maternal tuberculosis, and following administration or use of radioactive isotopes, chemotherapeutic agents, "recreational" drugs, or certain prescription drugs.
An 81-year-old male with type 2 diabetes mellitus has a hemoglobin A 1c of 10.9%. He is already on the maximum dosage of glipizide (Glucotrol). His other medical problems include mild renal insufficiency and moderate ischemic cardiomyopathy. Which one of the following would be the most appropriate change in this patient's diabetes regimen? (check one) A. Add metformin (Glucophage) B. Add sitagliptin (Januvia) C. Add pioglitazone (Actos) D. Initiate insulin therapy
D. Initiate insulin therapy. This geriatric diabetic patient should be treated with insulin. Metformin is contraindicated in patients with renal insufficiency. Sitagliptin should not be added to a sulfonylurea drug initially, the dosage should be lowered in patients with renal insufficiency, and given alone it would probably not result in reasonable diabetic control. Pioglitazone can cause fluid retention and therefore would not be a good choice for a patient with cardiomyopathy.
Because of safety concerns, which one of the following asthma medications should be used only as additive therapy and not as monotherapy? (check one) A. Inhaled corticosteroids B. Leukotriene-receptor antagonists C. Short-acting β2-agonists D. Long-acting β2-agonists E. Mast cell stabilizers
D. Long-acting β2-agonists. Because of the risk of asthma exacerbation or asthma-related death, the FDA has added a warning against the use of long-acting β2-agonists as monotherapy. Inhaled corticosteroids, leukotriene-receptor antagonists, short-acting β2-agonists, and mast-cell stabilizers are approved and accepted for both monotherapy and combination therapy in the management of asthma (SOR A).
A 52-year-old Hispanic female with diabetes mellitus and stage 3 chronic kidney disease sees you for follow-up after tests show an estimated glomerular filtration rate of 56 mL/min. Which one of the following medications should she avoid to prevent further deterioration in renal function? (check one) A. Lisinopril (Prinivil, Zestril) B. Folic acid C. Low-dose aspirin D. Candesartan (Atacand) E. Ibuprofen
E. Ibuprofen. Patients with chronic kidney disease (CKD) and those at risk for CKD because of conditions such as hypertension and diabetes have an increased risk of deterioration in renal function from NSAID use. NSAIDs induce renal injury by acutely reducing renal blood flow and, in some patients, by causing interstitial nephritis. Because many of these drugs are available over the counter, patients often assume they are safe for anyone. Physicians should counsel all patients with CKD, as well as those at increased risk for CKD, to avoid NSAIDs.
A 52-year-old male with stable coronary artery disease and controlled hypertension sees you for a routine visit and asks for advice regarding prevention of altitude illness for his upcoming trip to Bhutan to celebrate his anniversary. His medical chart indicates that he had a reaction to a sulfa drug in the past. Which one of the following would be most appropriate? (check one) A. Advise the patient to not make the trip B. Recommend ginkgo biloba C. Prescribe acetazolamide D. Prescribe dexamethasone
D. Prescribe dexamethasone. Altitude illness is common, affecting 25%-85% of travelers to high altitudes. The most common manifestation is acute mountain sickness, heralded by malaise and headache. Risk factors include young age, residence at a low altitude, rapid ascent, strenuous physical exertion, and a previous history of altitude illness. However, activity restriction is not necessary for patients with coronary artery disease who are traveling to high altitudes (SOR C). Ginkgo biloba has been evaluated for both prevention and treatment of acute mountain sickness and high-altitude cerebral edema, and it is not recommended. Acetazolamide is an effective prophylactic agent (SOR B), but is contraindicated in patients with a sulfa allergy. If used, it should be started a minimum of one day before ascent and continued until the patient acclimatizes at the highest planned elevation. Dexamethasone is an effective prophylactic and treatment agent (SOR B), and it is not contraindicated for those with a sulfa allergy. It would be the best option for this patient.
Which one of the following seafood poisonings requires more than just supportive treatment? (check one) A. Ciguatera B. Neurotoxic shellfish C. Paralytic shellfish D. Scombroid fish
D. Scombroid fish. Only symptomatic treatment is indicated for ciguatera poisoning, as there is no specific treatment. The same is true for shellfish poisoning, although potential respiratory distress or failure must be kept in mind. Scombroid poisoning is a pseudoallergic condition resulting from consumption of improperly stored scombroid fish such as tuna, mackerel, wahoo, and bonito. Nonscombroid varieties such as mahi-mahi, amberjack, sardines, and herring can also cause this problem. The poisoning is due to high levels of histamine and saurine resulting from bacterial catabolism of histidine. Symptoms occur within minutes to hours, and include flushing of the skin, oral paresthesias, pruritus, urticaria, nausea, vomiting, diarrhea, vertigo, headache, bronchospasm, dysphagia, tachycardia, and hypotension. Therapy should be the same as for allergic reactions and anaphylaxis, and will usually lead to resolution of symptoms within several hours.
An asymptomatic 35-year-old female asks about having a thyroid test performed because hypothyroidism runs in her family. You order the tests, which show a TSH level of 7.6μU/mL (N 0.4-5.1) and a free T4 level within the normal range. Which one of the following is most likely in this patient? (check one) A. A euthyroid state B. Primary hyperthyroidism C. Secondary hyperthyroidism D. Subclinical hypothyroidism E. Overt hypothyroidism
D. Subclinical hypothyroidism. Subclinical hypothyroidism is defined as slightly elevated TSH (approximately 5-10 mIU/L) and normal levels of thyroid hormone (free T4 or free T3 ) in an asymptomatic patient. There is a low rate of progression to overt hypothyroidism manifested by symptoms, TSH levels >10 mIU/L, or reduced levels of thyroid hormone. Recent studies have shown that there is an increased risk for cardiovascular morbidity and mortality in those with subclinical hypothyroidism. However, treatment with thyroid replacement hormone did not seem to affect this risk. The decision about whether to recommend thyroid replacement therapy to patients like the one described here should be individualized. An alternative to treating the patient with medication at this time would be to retest her TSH annually, or sooner if she becomes symptomatic.
With regard to the cardiovascular system, activation of the sympathetic branch of the autonomic nervous system will cause a decrease in which one of the following? (check one) A. Heart rate B. Coronary flow rate C. Metabolic demand D. Contractility of cardiac myocytes E. The P-R interval
E. The P-R interval. The sympathetic nervous system acts as a positive chronotropic (increases heart rate) and inotropic (increases contractility) agent. This additional work by the heart will increase metabolic demand and coronary flow rate. The increased heart rate will decrease the time intervals between electrical events shown on an EKG.
A 75-year-old African-American male with no previous history of cardiac problems complains of shortness of breath and a feeling of general weakness. His symptoms have developed over the past 24 hours. On physical examination you find a regular pulse with a rate of 160 beats/min. You note rales to the base of the scapula bilaterally, moderate jugular venous distention, and hepatojugular reflux. His blood pressure is 90/55 mm Hg; when he sits up he becomes weak and diaphoretic and complains of precordial pressure. An EKG reveals atrial flutter with 2:1 block. Management at this time should include: (check one) A. intravenous digoxin B. intravenous verapamil (Calan, Isoptin) C. amiodarone (Cordarone) D. electrical cardioversion E. insertion of a pacemaker
D. electrical cardioversion. Atrial flutter is not ordinarily a serious arrhythmia, but this patient has heart failure manifested by rales, jugular venous distention, hepatojugular reflux, hypotension, and angina. Electrical cardioversion should be performed immediately. This is generally a very easy rhythm to convert. Digoxin and verapamil are appropriate in hemodynamically stable patients. A pacemaker for rapid atrial pacing may be beneficial if digitalis intoxication is the cause of atrial flutter, but this is unlikely in a patient with no previous history of cardiac problems. Amiodarone is not indicated in this clinical situation.
A 12-month-old white female whom you have seen regularly for all of her scheduled well child care is found to have a hemoglobin level of 9.0 g/dL (N for age 10.5-13.5). She started whole milk at 9 months of age. She appears healthy otherwise and has no family history of anemia. A CBC reveals a mild microcytic, hypochromic anemia with RBC poikilocytosis, but is otherwise normal. The RBC distribution width is also elevated. Of the following, the most appropriate next step would be to: (check one) A. order tests for serum iron and total iron-binding capacity B. order a serum ferritin level C. order hemoglobin electrophoresis D. prescribe oral iron E. perform stool guaiac testing
D. prescribe oral iron. Iron deficiency is almost certainly the diagnosis in this child. The patient's response to a therapeutic trial of iron would be most helpful in establishing the diagnosis. Additional tests might be necessary if there is no response.
The mother of a 16-year-old male brings him to your office stating that she wants to find out if he has Crohn's disease. She says that both she and the child's aunt were diagnosed with this condition by another physician with "blood tests." The son tells you that for the past several years his stool is intermittently loose and he has up to three bowel movements in a day. He says he does not have fever, pain, hematochezia, weight loss, or any extraintestinal symptoms. A physical examination is normal. Which one of the following would be the most appropriate preliminary testing? (check one) A. A plain radiograph of the abdomen B. CT of the abdomen and pelvis C. An inflammatory bowel disease serologic panel D. Colonoscopy with a biopsy E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate
E. A CBC, serum chemistry panel, and erythrocyte sedimentation rate. The diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available). Endoscopy is usually reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation. It is recommended that this preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate. Patients who have minimal symptoms and normal preliminary testing likely do not have a significant case of IBD. Plain radiographs and CT of the abdomen may help rule out other etiologies but are not considered adequate to diagnose or exclude IBD. Panels of serologic blood tests have recently been developed and are being assessed as to their place in evaluating patients who may have IBD. However, this testing is expensive, lacks sufficient predictive value, and has yet to prove its utility compared to standard testing.
Which one of the following is most commonly implicated in interstitial nephritis? (check one) A. NSAIDs B. ACE inhibitors C. Diuretics D. Corticosteroids E. Antibiotics
E. Antibiotics. Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other drugs listed may cause renal injury, but not acute interstitial nephritis.
A 44-year-old female who suffers from obstructive sleep apnea complains of gradual swelling in her legs over the last several weeks. Her vital signs include a BMI of 44.1 kg/m2 , a respiratory rate of 12/min, a blood pressure of 120/78 mm Hg, and an O 2 saturation of 86% on room air. An EKG and a chest radiograph are normal. Pulmonary function testing shows a restrictive pattern with no signs of abnormal diffusion. Abnormal blood tests include only a significantly elevated bicarbonate level. Which one of the following treatments is most likely to reduce this patient's mortality rate? (check one) A. ACE inhibitors B. Routine use of nebulized albuterol (AccuNeb) C. High-dose diuretic therapy D. Continuous oxygen therapy E. Continuous or bilevel positive airway pressure (CPAP or Bi-PAP)
E. Continuous or bilevel positive airway pressure (CPAP or Bi-PAP). This patient has obesity-hypoventilation syndrome, often referred to as Pickwickian syndrome. These patients are obese (BMI >30 kg/m 2 ), have sleep apnea, and suffer from chronic daytime hypoxia andcarbon dioxide retention. They are at increased risk for significant respiratory failure and death compared to patients with otherwise similar demographics. Treatment consists of nighttime positive airway pressure in the form of continuous (CPAP) or bi-level (BiPAP) devices, as indicated by sleep testing. The more hours per day that patients can use this therapy, the less carbon dioxide retention and less daytime hypoxia will ensue. Several small studies suggest that the increased mortality risk from obesity-hypoventilation syndrome can be decreased by adhering to this therapy. The use of daytime oxygen can improve oxygenation, but is not considered adequate to restore the chronic low respiratory drive that is characteristic of this condition.
When an interpreter is needed for a patient with limited English proficiency, which one of the following should be AVOIDED when possible? (check one) A. Using mostly short sentences, with frequent pauses B. Using diagrams and pictures C. Addressing the patient in the second person (i.e., "you") D. Maintaining eye contact with the patient when speaking E. Using an educated adult family member who is bilingual
E. Using an educated adult family member who is bilingual. Using trained, qualified interpreters for patients with limited English proficiency leads to fewer hospitalizations, less reliance on testing, a higher likelihood of making the correct diagnosis and providing appropriate treatment, and better patient understanding of conditions and therapies. Although the patient may request that a family member interpret, there are many pitfalls in using untrained interpreters: a lack of understanding of medical terminology, concerns about confidentiality, and unconscious editing by the interpreter of what the patient has said. Additionally, the patient may be reluctant to divulge sensitive or potentially embarrassing information to a friend or family member. The other principles listed are important practices when working with interpreters. Pictures and diagrams can help strengthen the patient's understanding of his or her health care.
