Random AAFP questions
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?
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 21-year-old sexually active female presents with acute pelvic pain of several days' duration. A pelvic examination reveals right-sided tenderness and a general fullness in that area. In addition to laboratory testing, you decide to order an imaging study. Which one of the following is the best choice at this time?
B. Transvaginal ultrasonography The best initial imaging study for acute pelvic pain in women is transvaginal ultrasonography (SOR C). This provides the greatest level of detail regarding the uterus and adnexae, superior to transcutaneous ultrasonography
A 17-year-old white female has a history of anorexia nervosa, and weight loss has recently been a problem. The patient is an academically successful high-school student who lives with her parents and a younger sibling. Her BMI is 17.4 kg/m2 . Her serum electrolyte levels and an EKG are normal. Which one of the following interventions is most likely to be successful?
A. Family-based treatment Family-based treatment for the adolescent with anorexia nervosa has been found to provide superior results when compared with individual adolescent-focused therapy (SOR B). Antidepressants have not been successful. They may be indicated for coexisting conditions, but this is more common with bulimia.
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?
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.
Which one of the following has been shown to be effective for improving symptoms of varicose veins?
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.
A 55-year-old female who has hypertension, hyperlipidemia, and osteoarthritis of the knees develops acute gout and is found to have hyperuricemia. Discontinuation of which one of the following medications may improve her hyperuricemia?
A. Hydrochlorothiazide Hydrocholorthiazide are known to increase serum uric acid levels and Losartan has been shown to decrease uric acid
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?
A. NSAIDs for pain relief
A 22-year-old female presents with lower right leg pain. She reports that it hurts when she presses her shin. She has been training for a marathon over the past 4 months and has increased her running frequency and distance. She now runs almost every day and is averaging approximately 40 miles per week. She has little pain while at rest, but the pain intensifies with weight bearing and ambulation. She initially thought the pain was from shin splints, but it has intensified this week and she has had to shorten her usual running distances due to worsening pain. On examination you note tenderness to palpation over the anterior aspect of her mid-tibia. She also has trace edema localized to the area of tenderness. Which one of the following imaging studies should be performed first?
A. Plain radiographs The findings in this patient are consistent with a stress fracture. Plain radiographs should be the initial imaging modality because of availability and low cost (SOR C). These are usually negative initially, but are more likely to be positive over time. If the initial films are negative and the diagnosis is not urgently needed, a second plain radiograph can be performed in 2-3 weeks. MRI is now recommended as the second-line imaging modality when plain radiographs are negative and clinical suspicion of stress fracture persists (SOR C).
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?
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.
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:
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.
A 42-year-old male with well-controlled type 2 diabetes mellitus presents with a 24-hour history of influenza-like symptoms, including the sudden onset of headache, fever, myalgias, sore throat, and cough. It is December, and there have been a few documented cases of influenza recently in the community. The CDC recommends initiating treatment in this situation:
A. on the basis of clinical symptoms alone Influenza is a highly contagious viral illness spread by airborne droplets. This patient's symptoms are highly suggestive of typical influenza: a sudden onset of malaise, myalgia, headache, fever, rhinitis, sore throat, and cough. While influenza is typically uncomplicated and self-limited, it can result in severe complications, including encephalitis, pneumonia, respiratory failure, and death.
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:
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.
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?
Answer: 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.
A 21-year-old female complains of bulging veins in her right shoulder region, along with swelling and a "tingling" sensation in her right arm that has developed over the past 2 days. There were no unusual events other than her regular workouts with her swim team. Ultrasonography confirms an upper extremity deep-vein thrombosis of her right axillary vein. Which one of the following would be the most appropriate treatment? (check one) A. Intravenous heparin for 72 hours, followed by oral warfarin (Coumadin) for 3 months B. Low molecular weight heparin (LMWH) subcutaneously for 5 days only C. LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months D. LMWH subcutaneously for at least 5 days, followed by oral warfarin indefinitely E. Oral warfarin for 3 months
Answer: LMWH subcutaneously for at least 5 days, followed by oral warfarin for 3 months Upper extremity deep-vein thrombosis (UE-DVT) accounts for 4% of all cases of DVT. Catheter-related thromboses make up the majority of these cases. Occult cancer, use of oral contraceptives, and inheritable thrombophilia are other common explanations. Another proposed risk factor is the repetitive compression of the axillary-subclavian vein in athletes or laborers, which is the most likely cause of this patient's UE-DVT. Taken as a whole, UE-DVT is generally associated with fewer venous complications, including less chance for thromboembolism, postphlebitic syndrome, and recurrence compared to lower-extremity deep-vein thrombosis (LE-DVT). However, the rates of these complications are still high enough that most experts recommend treatment identical to that of LE-DVT. Specifically, heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.
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
Answer: a topical corticosteroid cream 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.
Which one of the following would suggest that the sudden and unexpected death of a healthy infant resulted from deliberate suffocation rather than sudden infant death syndrome?
Answer: an age of 9 months Sudden infant death syndrome (SIDS) is the most common cause of death during the first 6 months of life in the United States, with a peak incidence at 2-4 months of age and a quick dropoff by the age of 6 months. The cause of death is a retrospective diagnosis of exclusion, and is supported by a history of quiet death during sleep in a previously healthy infant younger than 6 months of age. Evidence of terminal activity may be present, such as clenched fists or a serosanguineous, blood-tinged, or mucoid discharge from the mouth or nose. Lividity and mottling are frequently present in dependent areas.
Atrial flutter
Atrial flutter is an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations at a characteristic rate of approximately 300 beats/min and a regular ventricular rate of about 150 beats/min in patients not taking atrioventricular (AV) nodal blockers. It can lead to symptoms of palpitations, shortness of breath, fatigue, or lightheadedness, as well as an increased risk of atrial thrombus formation that may cause cerebral and/or systemic embolization. Atrial flutter occurs in many of the same situations as atrial fibrillation, which is much more common. Atrial flutter may be a stable rhythm or a bridge arrhythmia between sinus rhythm and atrial fibrillation. Typical P waves are absent, and the atrial activity is seen as a sawtooth pattern (also called F waves) in leads II, III, and aVF. There is typically 2:1 conduction across the atrioventricular (AV) node; as a result, the ventricular rate is usually one-half the flutter rate in the absence of AV node dysfunction.
An 81-year-old African-American female complains of increasing fatigue over the past several months. She has also noticed that her skin and hair feel dry and that she often feels cold. She also complains of intermittent swallowing difficulties. Her past medical history is significant for long-standing coronary artery disease, for which she takes metoprolol (Lopressor). Her physical examination is normal except for a resting pulse rate of 56 beats/min, dry skin, brittle hair, and a slow relaxation phase of the deep tendon reflexes. Her serum TSH level is 63.2 μU/mL (N 0.5-5.0). Which one of the following should you do now? (check one) A. Stop the metoprolol B. Start levothyroxine (Synthroid) C. Start liothyronine (Cytomel) D. Start propylthiouracil E. Refer for radioactive iodine ablation
Autoimmune hypothyroidism is common in elderly women. Symptoms often include fatigue, bradycardia, dry skin, brittle hair, and a prolonged relaxation phase of the deep tendon reflexes. While replacement therapy with levothyroxine is indicated, care must be taken in the elderly, particularly in those with coronary artery disease, to replace the deficit slowly. Levothyroxine replacement should begin at 25μg daily for 6 weeks, with the dosage increased in 25-μg increments as needed, based on TSH levels. Rapid replacement of thyroid hormone can increase the metabolic rate, and therefore myocardial oxygen demand, too quickly. This can precipitate complications of coronary artery disease such as atrial fibrillation, angina, and myocardial infarction. Stopping a β-blocker in this setting is likely to increase the risk.
A 20-year-old white female presents with painful and frequent urination that has had a gradual onset over the past week. She has never had a urinary tract infection. There is no associated hematuria, flank pain, suprapubic pain, or fever. She says she has not noted any itching or vaginal discharge. A midstream urine specimen taken earlier in the week showed significant pyuria but a culture was reported as no growth. She has taken an antibiotic for 2 days without relief. Her only other medication is an oral contraceptive agent. Which one of the following is the most likely infectious agent?
B. Chlamydia trachomatis Women who present with symptoms of acute dysuria, frequency, and pyuria do not always have bacterial cystitis. In fact, up to 30% will show either no growth or insignificant bacterial growth on a midstream urine culture. Most commonly these patients represent cases of sexually transmitted urethritis caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or herpes simplex virus.
What is the most common cause of erythema multiforme, accounting for more than 50% of cases?
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.
The best drug treatment for symptomatic mitral valve prolapse is:
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 25-year-old female sees you in the office for follow-up after a visit to the emergency department for respiratory distress. She complains of several episodes of an acute onset of shortness of breath, wheezing, coughing, and a choking sensation, without any obvious precipitant. She has been on inhaled corticosteroids for 2 months without any improvement in her symptoms. Albuterol (Proventil, Ventolin) does not consistently relieve her symptoms. She is asymptomatic today. Spirometry shows a normal FEV1 , a normal FVC and FEV1 /FVC ratio, and a flattened inspiratory loop. The most likely diagnosis is:
B. vocal cord dysfunction Vocal cord dysfunction is an idiopathic disorder commonly seen in patients in their twenties and thirties in which the vocal cords partially collapse or close on inspiration. It mimics, and is commonly mistaken for, asthma. Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing. A careful history and examination reveal that the symptoms are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma.
Which one of the following is most characteristic of patellofemoral pain syndrome in adolescent females?
C. Inadequate hip abductor strength Patellofemoral pain syndrome is a common overuse injury observed in adolescent girls. The condition is characterized by anterior knee pain associated with activity. The pain is exacerbated by going up or down stairs or running in hilly terrain. It is associated with inadequate hip abductor and core strength
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?
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.
Which one of the following is most consistent with obsessive-compulsive disorder in adults?
C. Recognition by the patient that the obsessions or compulsions are excessive or unreasonable The DSM-IV criteria for obsessive-compulsive disorder (OCD) indicate that the patient at some point recognizes that the obsessions or compulsions are excessive or unreasonable.
A 62-year-old male with a history of prostate cancer and well-controlled hypertension presents with severe osteoporosis. At 55 years of age he received prostate brachytherapy and androgen deprivation for his prostate cancer and has been disease-free since. He presently takes lisinopril (Prinivil, Zestril), 5 mg daily; alendronate (Fosamax), 70 mg weekly; calcium, 1000 mg daily; and vitamin D, 1200 units daily. He has never smoked, exercises five times a week, and maintains a healthy lifestyle. In spite of his lifestyle and the medications he takes, he continues to have severe osteoporosis on his yearly bone density tests. In addition to recommending fall precautions, which one of the following would you consider next to treat his osteoporosis?
C. Teriparatide (Forteo) Teriparatide is indicated for the treatment of severe osteoporosis, for patients with multiple osteoporosis risk factors, or for patients with failure of bisphosphonate therapy (SOR B). Therapy with teriparatide is currently limited to 2 years and is contraindicated in patients with a history of bone malignancy, Paget disease, hypercalcemia, or previous treatment with skeletal radiation
A 73-year-old white female with a long history of rheumatoid arthritis has a normocytic normochromic anemia. Her hemoglobin level is 9.8 g/dL (N 12.0-16.0) with decreased serum iron, decreased total iron-binding capacity, and increased serum ferritin.
C. Treatment of the rheumatoid arthritis This patient has anemia of chronic disease secondary to her rheumatoid arthritis. This anemia is usually mild, with hemoglobin levels of 9.0-11.0 g/dL, and is usually normocytic-normochromic, although it can be microcytic. Characteristically, serum iron and total iron-binding capacity are decreased and ferritin is increased. The best treatment of this anemia is to treat the underlying systemic disease
Question 1 of 10 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
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.
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?
D. A dipyridamole-thallium scan 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.
Which one of the following has the best evidence that it is safe for use in pregnancy?
D. Fluoxetine (Prozac) Benzodiazepines such as alprazolam are controversial due to a possible link to cleft lip/palate. Studies have shown no significant risk of congenital anomalies from SSRI use in pregnancy, except for paroxetine. Paroxetine is a category D medication and should be avoided in pregnant women (SOR
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?
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.
An 8-year-old male is brought to the emergency department with an acute asthma attack that began 48 hours earlier. His mother initiated his asthma action plan when the attack began, starting oral prednisolone plus albuterol (Proventil, Ventolin) by metered-dose inhaler with a spacer every 3-4 hours. In the emergency department the child is alert, with a respiratory rate of 30 beats/min and an oxygen saturation of 94% on room air. He is audibly wheezing. Peak flow is 40% of the predicted value. (check one) A. Continue the current albuterol treatment but switch to a nebulizer B. Administer high-dose albuterol via nebulizer every 20 minutes for 1 hour C. Administer intravenous corticosteroids within the first hour D. Administer magnesium sulfate intravenously E. Prescribe high-dose mucolytics and chest physiotherapy
D. Administer magnesium sulfate intravenously-High-dose nebulized albuterol every 20 minutes for 1 hour has not been shown to be beneficial. In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization Repeated doses of a short-acting β2-agonist and correction of hypoxia are the main elements of initial emergency department treatment for acute asthma exacerbations in children. Nebulizer treatments are no better than a metered-dose inhaler with a spacer (SOR A). High-dose nebulized albuterol every 20 minutes for 1 hour has not been shown to be beneficial. In children already receiving standard treatment with albuterol and corticosteroids the addition of intravenous magnesium sulfate has been shown to improve lung function and reduce the need for hospitalization (SOR A).
Which one of the following is associated with vacuum-assisted delivery?
D. An increased incidence of shoulder dystocia
Which one of the following treatments for diabetes mellitus reduces insulin resistance? (check one) A. Acarbose (Precose)-a competitive inhibitor of α-glucosidases, enzymes that break down complex carbohydrates into monosaccharides. This B. Sitagliptin (Januvia)-DPP-IV inhibitor, and this class of drugs inhibits the enzyme responsible for the breakdown of the incretins GLP-1 and GIP. C. Repaglinide (Prandin) D. Exenatide (Byetta)-incretin mimetic that stimulates insulin secretion in a glucose-dependent fashion, slows gastric emptying, and may promote satiety. E. Pioglitazone (Actos)
E. Pioglitazone (Actos) Repaglinide and nateglinide are nonsulfonylureas that act on portion of the sulfonylurea receptor to stimulate insulin secretion. Actos: thiazolidinedione that reduces insulin resistance. The mechanism is through the activation of PPAR-Y, receptor that affects several insulin-responsive genes.
A 23-year-old white male is brought to the emergency department with slurred speech, confusion, and ataxia. He works as an auto mechanic and has been known to consume alcohol heavily in the past, but denies recent alcohol intake. He appears intoxicated, but no odor of alcohol is noted on his breath. Abnormalities on the metabolic profile include a carbon dioxide content of 10 mmol/L (N 20-30). His blood alcohol level is <10 mg/dL (0.01%). A urinalysis shows calcium oxalate crystals and an RBC count of 10-20/hpf. Woods lamp examination of the urine shows fluorescence. His arterial pH is 7.25. Which one of the following would be most appropriate at this point?
D. Fomepizole (Antizol) Until recently, ethylene glycol poisoning was treated with sodium bicarbonate, ethanol, and hemodialysis. Treatment with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected. If ethylene glycol poisoning is treated early, hemodialysis may be avoided, but once severe acidosis and renal failure have occurred hemodialysis is necessary. Ethylene glycol is rapidly absorbed, and use of ipecac or gastric lavage is therefore not effective. Large amounts of activated charcoal will only bind to relatively small amounts of ethylene glycol, and the therapeutic window for accomplishing this is less than 1 hour.
Breastfeeding a full-term, healthy infant is contraindicated when which one of the following maternal conditions is present?
D. Herpes simplex viral lesions on the breasts 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?
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?
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
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?
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.
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?
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.
A 52-year-old patient is concerned about a biopsy result from a recent screening colonoscopy. Which one of the following types of colon polyp is most likely to become malignant?
D. Villous adenoma Hamartomatous (or juvenile) polyps and hyperplastic polyps are benign lesions and are not considered to be premalignant. Adenomas, on the other hand, have the potential to become malignant. Sessile adenomas and lesions >1.0 cm have a higher risk for becoming malignant. Of the three types of adenomas (tubular, tubulovillous, and villous), villous adenomas are the most likely to develop into an adenocarcinoma.
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:
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 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.
A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence is ideally treated by: (check one) A. appropriate antibiotics B. office banding C. office cryotherapy D. thrombectomy under local anesthesia E. total hemorrhoidectomy
D. thrombectomy under local anesthesia A thrombosed external hemorrhoid is manifested by the sudden development of a painful, tender, perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the acutely thrombosed tissue under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.
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?
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.
Which one of the following tinea infections in children always requires systemic antifungal therapy
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.
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?
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.
Which one of the following is most commonly implicated in interstitial nephritis?
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.
An 82-year-old resident of a local nursing home is brought to your clinic with fever, difficulty breathing, and a cough productive of purulent sputum. The patient is found to have an oxygen saturation of 86% on room air and a chest radiograph shows a new infiltrate. A decision is made to hospitalize the patient. Which one of the following intravenous antibiotic regimens would be most appropriate for this patient?
E. Ceftazidime, levofloxacin, and vancomycin Nursing home-acquired pneumonia should be suspected in patients with a new infiltrate on a chest radiograph if it is associated with a fever, leukocytosis, purulent sputum, or hypoxia
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.
E. Continuous or bilevel positive airway pressure (CPAP or Bi-PAP)
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?
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. 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.
A 72-year-old white male develops a rapidly growing epithelial tumor just in front of his right ear. He states that it began as a firm red papule about 6 weeks ago. It is now 1.5 cm in diameter and has a horny plug in the center. The most likely diagnosis is: (check one) A. Bowen's disease B. Basal cell carcinoma C. Keratoacanthoma D. Kaposi's sarcoma E. Seborrheic keratosis
Keratoacanthoma is a relatively common lesion in the elderly, but is difficult to distinguish from squamous cell carcinoma.
A 75-year-old male consults you after his family expresses concern about his loss of interest in his usual activities. They believe he has become increasingly withdrawn since the death of his wife 8 months earlier. You note he has lost 8 kg (18 lb) since his last office visit 6 months earlier. He does not drink alcohol. His physical examination is unremarkable for his age except for a blood pressure of 105/70 mm Hg. Detailed laboratory studies, including thyroid function tests, are all within normal limits. He tells you he would be fine if he could just get some sleep. His Mini-Mental State Examination is normal, but he is obviously clinically depressed. The most appropriate medication for his depression would be: (check one) A. trazodone (Oleptro) B. mirtazapine (Remeron) C. bupropion (Wellbutrin) D. amitriptyline E. nortriptyline (Pamelor)
Mirtazapine has serotonergic and noradrenergic properties and is associated with increased appettie and weight gain. This is good for people with insomnia and weight loss
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?
Pertusis
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?
What would be the most appropriate topical treatment for this condition? 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.
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? 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 60-year-old male has a drug-eluting stent placed in his right coronary artery. He will require treatment to prevent stent thrombosis, and once his initial treatment period is completed he will be placed on aspirin, 75-165 mg/day indefinitely. Which one of the following is the preferred initial regimen for preventing stent thrombosis in this situation?
answer: D. Aspirin, 162-325 mg/day, plus clopidogrel, both for 12 months In patients with a drug-eluting stent, combined therapy with clopidrogel and aspirin is recommended for 12 months because of the increased risk of late stent thrombosis. After this time, aspirin at a dosage of 75-165 mg/day is recommended. The minimum duration of combined therapy is 1 month for a bare metal stent, 3 months for a sirolimus-eluting stent, and 6 months for other drug-eluting stents.
Which one of the following patients should be advised to take aspirin, 81 mg daily, for the primary prevention of stroke?
answer: . A 72-year-old female with no chronic medical conditions Men: 45-79 Women:55-79 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)
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?
answer: 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.
A previously healthy 82-year-old male is brought to your office by his daughter after a recent fall while getting up to go to the bathroom in the middle of the night. The patient denies any history of dizziness, chest pain, palpitations, or current injury. He has a history of bilateral dense cataracts. On examination, he is found to have an increased stance width and walks carefully and cautiously with his arms and legs abducted. A timed up-and-go test is performed, wherein the patient is asked to rise from a chair without using his arms, walk 3 meters, turn, return to his chair, and sit down. It takes the patient 25 seconds and he is noted to have an "en bloc" turn. Which one of the following is the most likely cause of this patient's gait and balance disorder?
answer: A. Visual impairment Gait and balance disorders are one of the most common causes of falls in older adults. Correctly identifying gait and balance disorders helps guide management and may prevent consequences such as injury, disability, loss of independence, or decreased quality of life. The "Timed Up and Go" test is a reliable diagnostic tool for gait and balance disorders and is quick to administer. A time of <10 seconds is considered normal, a time of >14 seconds is associated with an increased risk of falls, and a time of >20 seconds usually suggests severe gait impairment. This patient has the cautious gait associated with visual impairment. It is characterized by abducted arms and legs; slow, careful, "walking on ice" movements; a wide-based stance; and "en bloc" turns. Patients with cerebellar degeneration have an ataxic gait that is wide-based and staggering. Frontal lobe degeneration is associated with gait apraxia that is described as "magnetic," with start and turn hesitation and freezing. Parkinson's disease patients have a typical gait that is short-stepped and shuffling, with hips, knees, and spine flexed, and may also exhibit festination and "en bloc" turns. Motor neuropathy causes a "steppage" gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.
A 67-year-old white male with hypertension and chronic kidney disease presents with the recent onset of excessive thirst, frequent urination, and blurred vision. Laboratory testing reveals a fasting blood glucose level of 270 mg/dL, a hemoglobin A 1c of 8.5%, a BUN level of 32 mg/dL, and a serum creatinine level of 2.3 mg/dL. His calculated glomerular filtration rate is 28 mL/min. Which one of the following medications should you start at this time? (check one) A. Glipizide (Glucotrol) B. Metformin (Glucophage) C. Glyburide (DiaBeta) D. Acarbose (Precose)
answer: Glipizide Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia. Acarbose should be avoided in patients with chronic kidney disease, as it has not been evaluated in these patients. Glipizide does not have an active metabolite, and is safe in patients with chronic renal disease.
A 27-year-old female presents to the emergency department with a complaint of bloody diarrhea and abdominal cramping. A few days ago she ate a rare hamburger at a birthday party for her 4-year-old son. He ate hot dogs instead, and has not been ill. A stool specimen is positive for Escherichia coli O:157. Which one of the following should you do next?
answer: Monitor her renal function Escherichia coli O:157 is an increasingly common cause of serious gastrointestinal illness. The usual source is undercooked beef. The child is at risk, since at least 20% of cases result from secondary spread. Transmission is frequent in children's day-care facilities and nurseries. Some cases are asymptomatic, but the great majority are symptomatic, and patients present with bloody diarrhea. Levofloxacin is not useful for prophylaxis in contacts. This patient has a 10%-15% risk of developing hemolytic uremic syndrome secondary to her E. coli O:157 infection, making close monitoring of renal function essential.
A patient with chronic kidney disease presents with chronic normocytic anemia with a hemoglobin level of 7.8 g/dL. The best outcome is predicted if you raise the hemoglobin level to: (check one) A. 8-10 g/dL B. 10-12 g/dL C. 12-14 g/dL D. >14 g/dL
answer: between 10-12 The Cardiovascular risk Reduction by Early Anemia Treatment with Epoetin Beta (CREATE) trial, the Correction of Hemoglobin and Outcomes in Renal insufficiency (CHOIR) trial, and the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) have shown that patients who had hemoglobin levels targeted to normal ranges did worse than patients who had hemoglobin levels of 10-12 g/dL
In a patient with a sudden onset of dyspnea, which one of the following makes a pulmonary embolus more likely?
answer: chest pain Associated with PE. When evaluating a patient with PE, look for fever( infectious) wheezing ( ashtma or COPD), rhonchi ( heart failure) and orthopnea ( heart failure).
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.
answer: 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
The most appropriate advice for a 50-year-old female who has passed six calcium oxalate stones over the past 4 years is to: (check one) A. restrict her calcium intake B. restrict her intake of yellow vegetables C. increase her sodium intake D. increase her dietary protein intake E. take potassium citrate with meals
answer: take potassium citrate with meals Most common renal stones: calcium oxalate Potassium citrate should be taken at mealtime to increase urinary pH and urinary citrate
You examine an 11-month-old male who has had several paroxysms of abdominal pain in the last 2 hours. The episodes last 1-2 minutes; the infant screams, turns pale, and doubles up. Afterward, he seems normal. A physical examination is normal except for a possible fullness in the right upper quadrant of the abdomen.
answer:D. intussusception This is a classic presentation for intussusception, which usually occurs in children under the age of 2 years and is characterized by paroxysms of colicky abdominal pain. A mass is palpable in about two-thirds of patients.
TCA
it may be effective but are no longer considered first line treatments because of side effects and they can be cardiotoxic
A 2-year-old child stumbles, but his mother keeps him from falling by pulling up on his right hand. An hour later the child refuses to use his right arm and cries when his mother tries to move it. The most likely diagnosis is (
subluxation of the head of the radius "Nursemaid's elbow" is one of the most common injuries in children under 5 years of age. It occurs when the child's hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.
Trazodone
useful for insomina but not as primary antidepressant because it cause sedation and orthostatic hypotension
