AAFP MSK/Neuro
A 15-year-old white male is being evaluated after a fall down one flight of stairs. He was transported by the local rescue squad with his cervical spine immobilized. He walked briefly at the scene and did not lose consciousness. His only complaint is a mild, generalized headache. One episode of vomiting occurred shortly after the accident. No weakness or numbness has been noted. Vital signs, mental status, and neurologic findings are normal. Radiologic evaluation of the cervical spine is remarkable only for an air-fluid level in the sphenoid sinus. Which one of the following abnormalities is most likely to be associated with this radiologic finding? (check one) A. A basilar skull fracture B. An orbital floor fracture C. An epidural hematoma D. A zygomatic arch fracture E. A mandible fracture
A. A basilar skull fracture. A post-traumatic air-fluid level in the sphenoid sinus is associated with basilar skull fractures. This finding is frequently noted on cervical spine films. Orbital floor fractures may be associated with double vision, fluid in the maxillary sinus, an air-fluid level in the maxillary sinus, and diplopia. Epidural hematomas are more frequently associated with skull fractures in the area of the meningeal artery. Zygomatic arch fractures are more visible on Towne's view. Characteristic swelling and lateral orbital bruising are typically present. Mandible fractures may be associated with dental misalignment or bleeding. Panoramic views are often diagnostic.
Which one of the following side effects induced by traditional neuroleptic agents responds to treatment with beta-blockers? (check one) A. Akathisia B. Rigidity C. Dystonia D. Sialorrhea E. Stooped posture
A. Akathisia. Rigidity, sialorrhea, and stooped posture are parkinsonian side effects of neuroleptic drugs. These are treated with anticholinergic drugs such as benztropine or amantadine. Dystonia, often manifested as an acute spasm of the muscles of the head and neck, also responds to anticholinergics. Akathisia (motor restlessness and an inability to sit still) can be treated with either anticholinergic drugs or beta-blockers.
A 60-year-old male presents with an acute onset of pain and swelling in the right big toe. He can recall no mechanism of injury. He has hypertension which is well controlled with hydrochlorothiazide. On examination the area around the base of the toe is reddened, slightly warm, and very tender on palpation. Which one of the following should be AVOIDED in this patient at this time? (check one) A. Allopurinol (Zyloprim) B. Colchicine C. NSAIDs D. Prednisone E. Aspiration of the joint
A. Allopurinol (Zyloprim). This patient likely has gout. Aspiration should be attempted to get a specific diagnosis. The initial treatment for gout is NSAIDs, colchicine, or cortisone injections (SOR B). Allopurinol should be avoided until the episode of gout is controlled, because it may cause temporary worsening. In addition to medication, recommended management includes addressing risk factors such as obesity, diuretic use, high-purine diet, and alcohol intake (SOR B).
A 27-year-old white male presents to the emergency department 2 hours after being bitten by a rattlesnake. He complains of weakness, abdominal cramping, left leg pain, and left leg swelling. His speech is slurred, and his breath smells of alcohol. Physical Findings Temperature 37.0° C (98.6° F) Blood pressure 100/60 mm Hg Pulse 122 beats/min Respirations 24/min Skin diaphoretic; ecchymoses on both forearms; bite puncture site just above left lateral malleolus Lungs clear to auscultation Cardiac normal heart tones, 1+ posterior tibial pulses Abdomen flat; hypoactive bowel sounds; no masses or guarding Extremities visible swelling of left leg and thigh; skin tightness of left leg Neurologic decreased sensation to light touch and sharp sensation in left foot Which one of the following therapeutic interventions is indicated? (check one) A. Antivenin administration B. Venom extractor use C. Tourniquet application at the upper thigh D. Surgical consultation for decompression fasciotomy E. Administration of platelets and fresh frozen plasma
A. Antivenin administration. This patient presents with a history of snakebite, swelling of an entire extremity, weakness, and ecchymosis. This is consistent with a grade III envenomation and merits antivenin therapy. Production of equine-derived antivenin has stopped, but may still be indicated where available. The ovine product, CroFab, is less allergenic but still scarce due to limited production. Venom extractors are thought to be useful only in the first few minutes after a bite. Two hours is too late to be of any use. Tourniquets are thought to be contraindicated when used to compress an artery. Low-pressure constriction of lymphatic and venous vessels is controversial. Fasciotomy has not proved useful. Antivenin is indicated before any consideration of compartment syndrome. Pressure measurements would be required because of the clinical similarities between envenomation injury and compartment syndrome. Coagulation factors and blood products are rapidly inactivated. They are indicated only in the presence of exsanguination.
A 33-year-old white female has a 12-year history of headache occurring 3-4 times per month, accompanied by nausea and vomiting. She takes over-the-counter analgesics, but relief is usually obtained only when she falls asleep. This is her first visit to you for this problem. You diagnose migraine without aura. Although the patient is willing to consider prescription drugs, she says that she would prefer "something that is natural and without side effects." Which one of the following would be the best recommendation? (check one) A. Biofeedback B. Ma huang C. Oxygen D. Epley canalith respositioning maneuver E. Phototherapy
A. Biofeedback. Of the listed options covering the realm of complementary and alternative medicine, only biofeedback has been shown to have a therapeutic effect on migraine. Specifically, the modality that seeks to control physiologic response to skin temperature and skin conductance appears to be the most successful. It is best performed in a medical office by caring, supportive staff members under physician supervision. Oxygen is used to treat cluster headaches. The Epley maneuver is used for managing benign positional vertigo, and phototherapy is useful in seasonal affective disorder. Ma huang, a Chinese herb, has ephedrine properties but is not useful in treating migraine headaches.
A 56-year-old female has been on combined continuous hormone therapy for 6 years. This is associated with a reduced risk for which one of the following? (check one) A. Bone fracture B. Myocardial infarction C. Stroke D. Breast cancer E. Venous thromboembolism
A. Bone fracture. Hormone replacement therapy that includes estrogen has been shown to decrease osteoporosis and bone fracture risk. The risk for colorectal cancer also is reduced after 5 years of estrogen use. The risk for myocardial infarction, stroke, breast cancer, and venous thromboembolism increases with long-term use.
A 70-year-old female consults you about osteoporosis treatment. Two years ago her DEXA scan T score was -2.6, and she began taking risedronate (Actonel), 35 mg/week. Her BMI is 24 kg/m2, she takes appropriate doses of calcium and vitamin D, and she takes walks almost every day. Her current T score is -2.5, and she is concerned about the minimal change in spite of therapy. She has never had a fracture, but asks if more could be done to reduce her fracture risk. Which one of the following would be the most appropriate recommendation? (check one) A. Continue current treatment B. Stop risedronate and start alendronate (Fosamax) C. Stop risedronate and start teriparatide (Forteo) D. Add raloxifene (Evista) E. Order a bone biopsy to evaluate bone architecture
A. Continue current treatment. There is not a linear correlation between bone mineral density and fracture risk. Bone architecture may be changed by bisphosphonate therapy, which may result in a decreased fracture risk. This patient has not had a fracture and is on adequate medical therapy that should be continued.
An 87-year-old African-American female is admitted to your hospital with a hip fracture. She lives alone and has been self-sufficient. She has been able to drive, go to the grocery, and balance her own checkbook. She does well in the hospital until the second postoperative day, when she develops agitated behavior, tremor, and disorientation. She attempts to remove her Foley catheter repeatedly. She exhibits alternating periods of somnolence and agitation, and describes seeing things in the room that are not there. Which one of the following is the most likely diagnosis? (check one) A. Delirium B. Alzheimer's disease C. Senile dementia D. Schizophrenia E. Psychosis
A. Delirium. This individual is exhibiting symptoms of delirium. Diagnostic criteria for delirium, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), include the following: A. Disturbance of consciousness (i.e., reduced clarity of awareness about the environment) with reduced ability to focus, sustain, or shift awareness. B. A change in cognition (e.g., memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C. Development over a short period of time (usually hours to days) with a tendency to fluctuate during the course of a day. D. Evidence from the history, physical examination, or laboratory findings that indicates the disturbance is caused by direct physiologic consequences of a general medical condition. In the case described, the patient's history does not indicate preexisting problems and she had a relatively abrupt onset of disturbance of consciousness and change in cognition, related to the hospitalization for hip fracture.
You see a 5-year-old white female with in-toeing due to excessive femoral anteversion. She is otherwise normal and healthy, and her mobility is unimpaired. Her parents are greatly concerned with the cosmetic appearance and possible future disability, and request that she be treated. You recommend which one of the following? (check one) A. Observation B. Medial shoe wedges C. Torque heels D. Sleeping in a Denis Browne splint for 6 months E. Derotational osteotomy of the femur
A. Observation. There is little evidence that femoral anteversion causes long-term functional problems. Studies have shown that shoe wedges, torque heels, and twister cable splints are not effective. Surgery should be reserved for children 8-10 years of age who still have cosmetically unacceptable, dysfunctional gaits. Major complications of surgery occur in approximately 15% of cases, and can include residual in-toeing, out-toeing, avascular necrosis of the femoral head, osteomyelitis, fracture, valgus deformity, and loss of position. Thus, observation alone is appropriate treatment for a 5-year-old with uncomplicated anteversion.
A 62-year-old white male complains of fatigue and proximal extremity discomfort without any localized joint pain. Which one of the following conditions is associated with a consistently normal creatine kinase enzyme level at all phases of disease? (check one) A. Polymyalgia rheumatica B. Polymyositis C. Dermatomyositis D. Drug-induced myopathy E. Hypothyroid endocrinopathy
A. Polymyalgia rheumatica. Polymyalgia rheumatica is a disease of the middle-aged and elderly. Discomfort is common in the neck, shoulders, and hip girdle areas. There is an absence of objective joint swelling, and findings tend to be symmetric. Characteristically, the erythrocyte sedimentation rate and C-reactive protein levels are significantly elevated; however, these tests are nonspecific. Occasionally there are mild elevations of liver enzymes, but muscle enzymes, including creatine kinase, are not elevated in this disorder. Elevation of muscle enzymes strongly suggests another diagnosis. Polymyositis and dermatomyositis are associated with variable levels of muscle enzyme elevations during the active phases of the disease. Drug-induced myopathies such as those seen with the cholesterol-lowering statin medications tend to produce some elevation of muscle enzymes during the course of the disorder. Hypothyroidism is associated with creatine kinase elevation. It should be strongly considered in the patient with unexplained, otherwise asymptomatic creatine kinase elevation found on a routine chemistry profile. Hyperthyroidism may cause muscle disease and loss of muscle, but it is not associated with creatine kinase elevation.
A 3-year-old female is brought to your office for evaluation of mild intoeing. The child's patellae face forward, and her feet point slightly inward. Which one of the following would be most appropriate? (check one) A. Reassurance B. Foot stretching exercises C. Use of orthotics D. Use of night splints E. Surgery
A. Reassurance. Intoeing, as described, is usually caused by internal tibial torsion. This problem is believed to be caused by sleeping in the prone position, and sitting on the feet. In 90% of cases, internal tibial torsion gradually resolves without intervention by the age of 8. Avoiding prone sleeping enhances resolution of the problem. Night splints, orthotics, and shoe wedges are ineffective. Surgery (osteotomy) has been associated with a high complication rate, and is therefore not recommended in mild cases before the age of 8.
A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure. Which one of the following would be the most appropriate next step? (check one) A. Referral for orthopedic consultation B. Reassurance that the problem resolves spontaneously in 90% of cases, and follow-up in 2 weeks C. Triple diapering and follow-up in 2 weeks D. A radiograph of the pelvis
A. Referral for orthopedic consultation. Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia. Experts are divided with regard to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4-6 months of age, but prior to that time the ossification centers are too immature to be seen. Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech girls, breech boys (optional), and girls with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of overtreating.
A positive flexion abduction external rotation (FABER) test that elicits posterior pain indicates involvement of which joint? (check one) A. Sacroiliac B. Shoulder C. Ankle D. Wrist E. Knee
A. Sacroiliac. When the flexion abduction external rotation (FABER) test elicits pain posteriorly, it indicates sacroiliac involvement. Anterior pain indicates hip involvement.
A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running. An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated. Which one of the following is the most likely diagnosis? (check one) A. Sesamoid fracture B. Gout C. Morton's neuroma D. Cellulitis
A. Sesamoid fracture. Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury. Gout commonly involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton's neuroma commonly occurs between the third and fourth toes, causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized. Sesamoiditis is often hard to differentiate from a true sesamoid fracture. Radiographs should be obtained, but at times they are nondiagnostic. Treatment, fortunately, is similar, unless the fracture is open or widely displaced. Limiting weight bearing and flexion to control discomfort is the first step. More complex treatments may be needed if the problem does not resolve in 4-6 weeks.
In addition to calcium and vitamin D supplementation, patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day) should also receive (check one) A. bisphosphonate therapy B. calcitonin C. estrogen replacement therapy D. recombinant human parathyroid hormone E. raloxifene (Evista)
A. bisphosphonate therapy. The American College of Rheumatology recommends that patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day), or an equivalent, receive bisphosphonate therapy in addition to calcium and vitamin D supplementation, regardless of their DEXA-scan T score. The other treatments are not recommended for prevention of glucocorticoid-induced osteoporosis.
A 20-year-old white male presents to your office after a fall on an outstretched hand while skateboarding. He has pain at the anatomic snuffbox with no abrasion. Radiographs are negative. Which one of the following would be the most appropriate management? (check one) A. A long arm cast for 8 weeks B. A thumb spica splint and follow-up radiographs in 2 weeks C. A sugar tong splint and follow-up radiographs in 2 weeks D. An Ace bandage and follow-up radiographs in 2 weeks E. An Ace bandage and follow-up in 2 weeks if the patient is still experiencing pain
B. A thumb spica splint and follow-up radiographs in 2 weeks. This is a classic presentation of a possible scaphoid fracture. This fracture is important to diagnose and treat appropriately because of a high rate of non-union. If radiographs are negative, the patient should be placed in a thumb spica splint and have repeat radiographs in 2 weeks, because initial studies may be negative. An Ace bandage or a sugar tong splint would be inappropriate because they do not immobilize the thumb. A long arm cast for 8 weeks would immobilize the thumb, but could lead to loss of function, and may overtreat the injury if it is not truly a scaphoid fracture.
Which one of the following therapeutic agents is most appropriate for daily use in the prevention of migraine headache? (check one) A. Dihydroergotamine (D.H.E. 45) B. Amitriptyline (Elavil) C. Sumatriptan (Imitrex) D. Aspirin/caffeine/butalbital (Fiorinal) E. Acetaminophen/hydrocodone bitartrate (Vicodin)
B. Amitriptyline (Elavil). Beta-adrenergic blockers, antidepressants, anticonvulsants, calcium channel blockers, NSAIDs, and serotonin antagonists are the major classes of drugs used for preventive migraine therapy. All of these medications result in about a 50% reduction in the frequency of headaches. The other drugs listed are useful for the treatment of acute migraine, but not for prevention.
A 79-year-old male is admitted to the hospital because of a sudden inability to ambulate. He has a past history of gout. On examination his temperature is 38.2°C (100.8°F) and he has bilateral knee effusions. His WBC count is 14,000/mm3 with 82% segs. His serum uric acid level is 8.5 mg/dL (N <6.5). Which one of the following would be most appropriate at this point? (check one) A. 24-hour urine collection for uric acid B. Arthrocentesis C. Initiation of allopurinol D. Initiation of antibiotics E. Initiation of furosemide (Lasix)
B. Arthrocentesis. Polyarticular arthritis often presents with fever, knee and other joint effusions, and leukocytosis. A 24-hour urine collection is not routine, is difficult for the patient, and typically does not change therapy. Especially in cases where a joint effusion is accompanied by fever, diagnostic arthrocentesis should be performed to help guide therapy. Allopurinol should not be initiated during an acute gouty attack, but may be started after a patient has recovered. Diuretics increase uric acid levels.
A 27-year-old white male has been in rehabilitation for C6 complete quadriplegia. His health had been good prior to a diving accident 2 months ago which caused his paralysis. The patient has been catheterized since admission and his recovery has been steady. His vital signs have been normal and stable. The nurse calls and tells you that for the past hour the patient has experienced sweating, rhinorrhea, and a pounding headache. His heart rate is 55/min and his blood pressure is 220/115 mm Hg. His temperature and respirations are reported as normal. There has been no vomiting and his neurologic examination is unchanged. The most likely diagnosis is: (check one) A. Cluster headache B. Autonomic hyperreflexia C. Sepsis D. Intracranial hemorrhage E. Progression of the spinal cord lesion
B. Autonomic hyperreflexia. Autonomic hyperreflexia is characterized by the sudden onset of headache and hypertension in a patient with a lesion above the T6 level. There may be associated bradycardia, sweating, dilated pupils, blurred vision, nasal stuffiness, flushing, or piloerection. It usually occurs several months after the injury and has an incidence as high as 85% in quadriplegic patients. Frequently, it subsides within 3 years of injury, but it can recur at any time. Bowel and bladder distention are common causes. Hypertension is the major concern because of associated seizures and cerebral hemorrhage. Cluster headaches have a constant unilateral orbital localization. The pain is steady (non-throbbing) and lacrimation and rhinorrhea may be part of the syndrome. Sepsis is usually manifested by chills, fever, nausea, and vomiting. Common signs include tachycardia and hypotension rather than bradycardia and hypertension. Signs and symptoms of intracranial hemorrhage vary depending upon the site of the hemorrhage, but the unchanged neurologic status and the lack of a history of hypertension decrease the likelihood of this diagnosis. There are no neurologic findings or history which suggest progression of the patient's lesion at C6.
A 66-year-old white male is brought to your office for evaluation of progressive memory loss over the last several months. The problem seems to wax and wane significantly over the course of days and weeks. At times when he is more confused, he tends to have visual and auditory hallucinations that he is back fighting in Vietnam, thinking a ringing telephone is calling in fighter jets. He has also been falling occasionally. On physical examination, he has a resting tremor in his left leg, and rigidity of his upper body and face. A full medical workup, including standard blood work and a CT scan, shows no abnormalities that suggest delirium, stroke, or other primary etiologies. Which one of the following is the most likely diagnosis? (check one) A. Alzheimer's disease B. Dementia with Lewy bodies C. Fronto-temporal dementia D. Multi-infarct dementia E. Pseudodementia
B. Dementia with Lewy bodies. Dementia with Lewy bodies is currently considered one of the most common etiologies of dementia in elderly patients, representing up to 20%-30% of those with significant memory loss. The clinical presentation consists of parkinsonian symptoms (rigidity, tremor), fluctuating levels of alertness and cognitive abilities, and behavior sometimes mimicking acute delirium. Significant visual hallucinations are common, and delusions and auditory hallucinations are seen to a lesser degree. On pathologic examination, Lewy bodies (seen in the substantia nigra in patients with Parkinson's disease) are present diffusely in the cortex. There is currently no specific treatment.
A 12-year-old white male is brought to your office after accidentally cutting his left hand with a pocketknife. On examination you find a deep 2-cm laceration at the base of the thenar eminence. To test for motor injury to the median nerve you would have the patient: (check one) A. Extend the thumb and fingers B. Oppose the thumb and little finger C. Flex the wrist D. Abduct the thumb and index finger
B. Oppose the thumb and little finger. The ability to touch the tip of the thumb to the tip of the little finger indicates normal motor function of the median nerve. The radial nerve controls extension of the thumb and fingers. The median nerve partially controls flexion of the wrist, but the site of innervation is proximal to the wound site at the base of the thumb. Abduction of the thumb is a function of the radial nerve. Finger abduction is a function of the ulnar nerve.
Osteoporotic bone loss can be caused or accelerated by prolonged use of which one of the following medications? (check one) A. Hydrochlorothiazide B. Phenytoin C. Raloxifene (Evista) D. Diazepam (Valium) E. Fluoxetine (Prozac)
B. Phenytoin. Secondary osteoporosis can result from a variety of endocrine, nutritional, or genetic disorders, as well as from prolonged use of certain medications. Anticonvulsants such as phenytoin increase the hepatic metabolism of vitamin D, thereby reducing intestinal calcium absorption. Other medications that adversely affect bone mineral density include glucocorticoids, cyclosporine, phenobarbital, and heparin. Thiazide diuretics reduce urinary calcium loss and are believed to preserve bone density with long-term use. Benzodiazepines and SSRIs have not been associated with increases in bone loss or in hip fractures. Raloxifene, a selective estrogen receptor modulator, is indicated for the prevention and treatment of osteoporosis in postmenopausal women.
A 65-year-old male has recently undergone coronary artery bypass graft (CABG) surgery. Generally, he has recovered well from his surgery. However, his cardiac surgeon referred him back to you because of symptoms suggestive of depression. Which one of the following is true in this situation? (check one) A. Patients with chronic cardiac symptoms prior to surgery are more likely to develop postoperative depression B. Postoperative depression increases the risk for subsequent cardiovascular events C. Treatment of postoperative depression with antidepressants decreases the rate of subsequent cardiovascular events D. Enrollment in a cardiac rehabilitation program often worsens depression
B. Postoperative depression increases the risk for subsequent cardiovascular events. In patients who are depressed after coronary artery bypass graft (CABG) surgery, impaired memory and cognition are seen more frequently than other depressive symptoms. Patients with rapid progression of cardiac symptoms before surgery are at particular risk of depressive symptoms after surgery. Newly depressed patients are at higher risk than non-depressed patients for long-term cardiovascular events and death from cardiovascular causes. The Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) showed that antidepressant use was associated with a slight, but not significant, reduction in the rates of cardiovascular events. The Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial showed that although it did not reduce the risk of cardiac events, participation in a cardiac rehabilitation program reduced depressive symptoms and increased social ties.
Contraindications to thrombolytic therapy in acute stroke include which one of the following? (check one) A. Age >80 B. Resolving transient ischemic attack C. Blood glucose >200 mg/dL D. Deficit present for >1 hour
B. Resolving transient ischemic attack. Thrombolysis is now an approved treatment for acute stroke. The critical time frame is 3 hours after the onset of the deficit. Beyond that time span, the use of thrombolytic agents is contraindicated. Advanced age per se is not a contraindication to thrombolytic therapy. Contraindications include blood glucose levels <50 mg/dL or >400 mg/dL, resolving transient ischemic attack, and hemorrhage visible on a CT scan.
Of the following, an 11-year-old who presents with knee pain is most likely to have: (check one) A. Gout B. Tibial apophysitis C. A popliteal cyst D. Inflammatory arthropathy E. Pes anserine bursitis
B. Tibial apophysitis. The three most common knee conditions in children and adolescents are patellar subluxation, tibial apophysitis, and patellar tendinitis. Gout, osteoarthritis, and popliteal cysts present in older adults. Inflammatory arthritis is more common in adults than in children.
A mother brings in her 2-month-old infant for a routine checkup. The baby is exclusively breastfed, and the mother has no concerns or questions. Which one of the following would you recommend at this time in addition to continued breastfeeding? (check one) A. Iron supplementation B. Vitamin D supplementation C. A multivitamin D. 8 oz of water daily E. 4 oz of cereal daily
B. Vitamin D supplementation. Although breast milk is the ideal source of nutrition for healthy term infants, supplementation with 200 IU/day of vitamin D is recommended beginning at 2 months of age and continuing until the child is consuming at least 500 mL/day of formula or milk containing vitamin D (SOR B). The purpose of supplementation is to prevent rickets. Unless the baby is anemic or has other deficiencies, neither iron nor a multivitamin is necessary. Parents often mistakenly think babies need additional water, which can be harmful because it decreases milk intake and can cause electrolyte disturbances. Cereal should not be started until 4 to 6 months of age.
A 55-year-old African-American male with osteoarthritis of the knees asks for advice on improving the function of his knees and controlling arthritis pain. Which one of the following would be appropriate advice? (check one) A. Topical capsaicin (Zostrix) applied twice daily will improve both pain and function B. Glucosamine will improve both pain and function C. A therapeutic exercise program will improve both pain and function D. An intra-articular corticosteroid injection will provide at least 6 months of pain relief E. NSAIDs will slow the progression of the disease
C. A therapeutic exercise program will improve both pain and function. A therapeutic exercise program will reduce both pain and disability in patients with osteoarthritis of the knee (SOR A). There is no evidence to support the use of capsaicin cream, but NSAIDs will reduce pain and there are proven therapies that will improve function of the patients knee. While intra-articular corticosteroids are effective in relieving pain in the short term (up to 4 weeks), there is no evidence for long-term efficacy. There is not good evidence to support the use of glucosamine for treating osteoarthritis of the knee. One systematic review found it no more effective than placebo.
As a member of the local emergency response management team you are asked about the treatment of nerve gas (e.g., sarin) poisoning. Which one of the following is most effective in reversing the symptoms of nerve gas toxicity? (check one) A. Albuterol (Proventil, Ventolin) via inhalation B. Ciprofloxacin (Cipro) C. Atropine D. Parenteral verapamil (Calan, Isoptin) E. Parenteral corticosteroids
C. Atropine. Nerve gas agents such as sarin resemble organophosphate insecticides and inactivate anticholinesterase, leading to the accumulation of acetylcholine at nerve endings. Respiratory symptoms include rhinorrhea, bronchorrhea, bronchospasm, and respiratory muscle paralysis. Gastrointestinal symptoms include nausea, vomiting, and diarrhea. Central nervous system symptoms include headache, vertigo, agitation, seizures, and coma. Exposed patients benefit from treatment with atropine, which competitively inhibits acetylcholine. Pralidoxine chloride and diazepam are also beneficial. Although beta-agonists and corticosteroids are beneficial in the general treatment of bronchospasm, atropine is preferred in this situation. Verapamil and ciprofloxacin have no role in the treatment of nerve gas exposure.
The most serious complication of a slipped capital femoral epiphysis is: (check one) A. Osteomyelitis B. Pathologic fracture C. Avascular necrosis D. Chondrolysis
C. Avascular necrosis. Avascular necrosis is the most serious complication of a slipped capital femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and total hip replacement early in adulthood.
An 83-year-old female presents with pain, swelling, and erythema of her left knee. She first noticed this problem last night before going to bed. She is generally healthy and takes no medications. She has not been sexually active since being widowed 15 years ago, and she currently lives with her sister. She states that she developed pain and swelling in her left ankle 2 years ago that lasted only a couple of days and resolved spontaneously. Blood testing shows a very elevated erythrocyte sedimentation rate but a normal rheumatoid factor and uric acid level. Which one of the following is the most likely diagnosis? (check one) A. Gonococcal arthritis B. Gout C. Pseudogout (calcium pyrophosphate disease) D. Rheumatoid arthritis E. Rupture of the anterior cruciate ligament
C. Pseudogout (calcium pyrophosphate disease). Acute monoarthritis in adults is most commonly caused by infection, trauma, or crystal deposition. Rheumatoid arthritis seldom presents as monoarthritis, and more often has a subacute course with multiple, symmetric joints involved. Although osteoporosis may result in a fracture of the knee joint without trauma at this age, there is no reason to believe that this patient has a torn anterior cruciate ligament. Gonococcal arthritis is one of the most common causes of septic arthritis, but is highly unlikely in this elderly, sexually inactive patient. Nongonococcal septic arthritis (especially due to staphylococcal and streptococcal bacteria) is still a consideration and should be ruled out by aspiration of fluid to be sent for culture. This patient's presentation is most consistent with pseudogout. Having a normal uric acid level suggests against gout, but does not rule it out. Also, gout is seven times more likely to be seen in males, whereas pseudogout is 1.5 times more frequent in females. Pseudogout most often affects the elderly, and usually affects the knee, wrist, and ankle. Gout presents most commonly in the first metatarsophalangeal joint and insteps of the feet, but also can occur in the knee, wrist, finger, and olecranon bursa. Differentiating between gout and pseudogout can be difficult and is best done by analysis of joint fluid. In patients with gout, this fluid contains highly negative birefringent, needle-shaped urate crystals, whereas in pseudogout the fluid contains rhomboid-shaped, weakly positive birefringent calcium pyrophosphate crystals.
Which one of the following should be avoided in the treatment and prophylaxis of migraine during early pregnancy? (check one) A. Calcium channel blockers B. Beta-blockers C. Triptans D. NSAIDS
C. Triptans. Headaches, and migraines in particular, are very common in women of childbearing age. Migraine sufferers usually have improvement of symptoms in pregnancy and many have complete remission. Most medications used for prophylaxis and abortive treatment of migraines in the nonpregnant patient can also be used in pregnant patients. Most beta-blockers and calcium channel blockers are safe. Acetaminophen and narcotics can be used for acute pain. Ibuprofen can also be used but should be avoided late in pregnancy because it is associated with premature closure of the ductus arteriosus and oligohydramnios. Ergotamines should be avoided as they are uterotonic and have abortifacient properties. They have also been associated with case reports of fetal birth defects. Triptans have the potential to cause vasoconstriction of the placental and uterine vessels and should be used only if the benefit clearly outweighs the harm.
A 79-year-old white male with a previous history of prostate cancer has a lumbar spine film suggesting osteopenia. Subsequent bone density studies show a T score of -2.7. Which one of the following would be appropriate therapy? (check one) A. Testosterone B. Calcitonin nasal spray (Micalcin) C. Raloxifene (Evista) D. Alendronate (Fosamax)
D. Alendronate (Fosamax). The only approved treatments for male osteoporosis are alendronate and recombinant parathyroid hormone. Several drugs have been tested in clinical trials, and more pharmacologic treatments should become available in the future as male osteoporosis is increasingly recognized. Testosterone should not be used in this patient because of his history of prostate cancer.
The Mini-Mental State Examination (MMSE) tests for: (check one) A. Mood B. Behavior C. Intelligence quotient D. Cognitive function E. Functional impairment
D. Cognitive function. The MMSE is most commonly used in clinical settings. It is considered valuable because it assesses a broad range of cognitive abilities (i.e., memory, language, spatial ability, set shifting) in a simple and straightforward manner. In addition, the wide use of the MMSE in epidemiologic studies has yielded cutoff scores that facilitate the identification of patients with cognitive dysfunction.
A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain began suddenly while he was shoveling snow. Which one of the following is true regarding this patients injury? (check one) A. Systemic corticosteroids speed recovery B. Exercises specific to low back injuries speed recovery C. Opioids have significant advantages for symptom relief when compared with NSAIDs or acetaminophen D. Continued activity rather than bed rest helps speed recovery E. Trigger-point injections are superior to placebo in relieving acute back pain
D. Continued activity rather than bed rest helps speed recovery. Multiple studies have demonstrated that bed rest is detrimental to recovery from low back pain. Patients should be encouraged to remain as active as possible. Exercises designed specifically for the treatment of low back pain have not been shown to be helpful. Neither opioids nor trigger-point injections have shown superiority over placebo, NSAIDs, or acetaminophen in relieving acute back pain. There is no good evidence to suggest that systemic corticosteroids are effective for low back pain with or without sciatica.
A 21-year-old white female presents to the emergency department with a history consistent with a lateral ankle sprain that occurred 2 hours ago while she was playing softball. She complains of pain over the distal anterior talofibular ligament, but is able to bear weight. There is mild swelling, mild black and blue discoloration, and moderate tenderness to palpation over the insertion of the anterior talofibular ligament, but the malleoli are nontender to palpation. Which one of the following statements is true regarding the management of this case? (check one) A. Anteroposterior, lateral, and 30 degrees internal oblique (mortise view) radiographs should be done to rule out fracture B. Stress radiographs will be needed to rule out a major partial or complete ligamentous tear C. The patient should use crutches and avoid weight bearing for 10-14 days D. Early range-of-motion exercises should be initiated to maintain flexibility E. For best results, functional rehabilitation should begin within the first 24 hours after injury
D. Early range-of-motion exercises should be initiated to maintain flexibility. This patient has an uncomplicated lateral ankle sprain and requires minimal intervention. The Ottawa ankle rules were developed to determine when radiographs are needed for ankle sprains. In summary, ankle radiographs should be done if the patient has pain at the medial or lateral malleolus and either bone tenderness at the back edge or tip of the lateral or medial malleolus, or an inability to bear weight immediately after the injury or in the emergency department, or both. If the patient complains of midfoot pain and/or bone tenderness at the base of the fifth metatarsal or navicular, or an inability to bear weight, radiographs should be ordered. Sprains can be differentiated from major partial or complete ligamentous tears by anteroposterior, lateral, and 30 degrees internal oblique (mortise view) radiographs. If the joint cleft between either malleolus and the talus is >4 mm, a major ligamentous tear is probable. Stress radiographs in forced inversion are sometimes helpful to demonstrate stability, but ankle instability can be present with a normal stress radiograph. Grade I and II ankle sprains are best treated with RICE (rest, ice, compression, elevation) and an air splint for ambulation. NSAIDs are used for control of pain and inflammation. Heat should not be applied. Early range-of-motion exercises should be initiated to maintain flexibility. Weight bearing is appropriate as tolerated and functional rehabilitation should be started when pain permits. Exercises on a balance board will help develop coordination.
You evaluate an 80-year-old white male who is a heavily medicated chronic schizophrenic. You note constant, involuntary chewing motions and repetitive movements of his legs. Which one of the following is the most likely diagnosis? (check one) A. Neuroleptic malignant syndrome B. Acute dystonia C. Huntington's disease D. Tardive dyskinesia E. Oculogyric crisis
D. Tardive dyskinesia. The patient has classic signs of tardive dyskinesia. Repetitive movement of the mouth and legs is caused by antipsychotic agents such as phenothiazines and haloperidol. Neuroleptic malignant syndrome consists of fever, autonomic dysfunction, and movement disorder. Acute dystonia involves twisting of the neck, trunk, and limbs into uncomfortable positions. Huntington's disease causes choreic movements, which are flowing, not repetitive. Oculogyric crisis involves the eyes.
The daily intake of vitamins and minerals recommended by the Food and Nutrition Board varies according to sex, age, and condition. The recommended daily allowance of vitamin D is greatest for which one of the following? (check one) A. A 15-year-old nonpregnant female B. A 25-year-old pregnant female C. A 35-year-old lactating female D. A 55-year-old female E. A 75-year-old female
E. A 75-year-old female. The current Dietary Reference Intake (DRI - which has replaced RDA's) recommendation for vitamin D is 200 IU/day for all women between the ages of 9 and 50 years; pregnancy or lactation does not affect the recommendation. The DRI doubles to 400 IU daily for women age 51-70 and triples to 600 IU daily for women over the age of 70. The maximum daily oral intake of vitamin D thought to be safe is 2000 IU/day for all females over the age of 12 months.
A 75-year-old male has not seen a physician in 25 years and presents with advanced Parkinson's disease. The best initial treatment would be: (check one) A. Referral to a neurosurgeon for thalamotomy B. Amantadine (Symmetrel) C. Benztropine (Cogentin) D. Pramipexole (Mirapex) E. Carbidopa/levodopa (Sinemet)
E. Carbidopa/levodopa (Sinemet). While anticholinergics such as benztropine and amantadine may provide some improvement of symptoms, these effects wane within a few months. Such medications are not a good option in this patient with advanced disease. Dopamine agonists provide some improvement in motor complications, but are mainly used to delay the introduction of levodopa in younger patients, to avoid levodopa-related adverse reactions. Carbidopa/levodopa is better for initial therapy in older patients, and those who present with more severe symptoms. Slow-release versions of this combination may decrease motor fluctuations. Stereotactic thalamotomy is used to ameliorate tremors that have become disabling. This procedure has been replaced by other surgical options such as pallidotomy and high-frequency, deep-brain stimulation of specific nuclei.
Which one of the following drugs used to treat rheumatoid arthritis can delay the progression of the disease? (check one) A. Aspirin B. Ibuprofen C. Indomethacin (Indocin) D. Capsaicin (Zostrix) E. Hydroxychloroquine (Plaquenil)
E. Hydroxychloroquine (Plaquenil). Hydroxychloroquine, originally developed as an antimalarial drug, is a well-known disease-modifying agent that can slow the progression of rheumatoid arthritis. Aspirin, indomethacin, and ibuprofen are anti-inflammatory agents. They relieve pain and improve mobility, but do not alter the progression of the disease. Capsaicin, a topical substance-P depleter, can relieve pain symptoms.
Which one of the following is the most effective drug for the treatment of alcohol dependence? (check one) A. Disulfiram (Antabuse) B. Diazepam (Valium) C. Amitriptyline (Elavil) D. Fluoxetine (Prozac) E. Naltrexone (ReVia)
E. Naltrexone (ReVia). Drug therapy should be considered for all patients with alcohol dependence who do not have medical contraindications to the use of the drug and who are willing to take it. Of the several drugs studied for the treatment of dependence, the evidence of efficacy is strongest for naltrexone and acamprosate. Naltrexone is currently available in the U.S.; acamprosate and tiapride are currently available in Europe but not in the U.S.
Which one of the following is a risk factor for osteoarthritis of the hip? (check one) A. Low bone mass B. Young age C. Participation in swimming D. Hyperthyroidism E. Obesity
E. Obesity. Risk factors for osteoarthritis of the hip include obesity, high bone mass, old age, participation in weight-bearing sports, and hypothyroidism.
A 44-year-old African-American female reports diffuse aching, especially in her upper legs and shoulders. The aching has increased, and she now has trouble going up and down stairs because of weakness. She has no visual symptoms, and a neurologic examination is normal except for proximal muscle weakness. Laboratory tests reveal elevated levels of serum creatine kinase and aldolase. Her symptoms improve significantly when she is treated with corticosteroids. Which one of the following is the most likely diagnosis? (check one) A. Duchenne's muscular dystrophy B. Myasthenia gravis C. Amyotrophic lateral sclerosis D. Aseptic necrosis of the femoral head E. Polymyositis
E. Polymyositis. The patient described has an inflammatory myopathy of the polymyositis/dermatomyositis group. Proximal muscle involvement and elevation of serum muscle enzymes such as creatine kinase and aldolase are characteristic. Corticosteroids are the accepted treatment of choice. It is extremely unlikely that Duchenne's muscular dystrophy would present after age 30. In amyotrophic lateral sclerosis, an abnormal neurologic examination with findings of upper motor neuron dysfunction is characteristic. Patients with myasthenia gravis characteristically have optic involvement, often presenting as diplopia. The predominant symptom of aseptic necrosis of the femoral head is pain rather than proximal muscle weakness.
A case of meningococcal meningitis has just been confirmed at a day-care center. The susceptibility of the microorganism is not yet known. At this point, you should do which one of the following for the day-care center contacts? (check one) A. Culture their nasopharyngeal secretions B. Administer meningococcal vaccine C. Prescribe sulfadiazine D. Prescribe chloramphenicol (Chloromycetin) E. Prescribe rifampin (Rifadin)
E. Prescribe rifampin (Rifadin). Rifampin, in the absence of major contraindications, is the drug of choice for preventing the spread of meningococcal disease when the susceptibility of the organism is not known. In this situation, meningococcal vaccines are of no value because their protective effects take a few days to develop, and because they do not protect against group B meningococci, the most prevalent strain for meningococcal disease. Sulfadiazine is the drug of choice if the meningococcus is known to be susceptible to it. Chloramphenicol and penicillin, which are effective in treating the disease, are ineffective in eliminating nasopharyngeal carriers of meningococci, possibly because they do not appear in high concentrations in saliva. Culturing contacts for meningococcal carriage in the nasopharynx has no value for identifying those at risk for meningococcal disease.
Which one of the following is true concerning falls in the elderly? (check one) A. Treating depression with SSRIs reduces the risk of falling B. Patients tend to fall less often immediately after coming home from the hospital C. Ambulatory blood pressure monitoring should be ordered for all patients who fall D. Arthritis and vision impairment are not associated with an increased risk of falling E. Reducing the number of medications a patient takes reduces the risk of falling
E. Reducing the number of medications a patient takes reduces the risk of falling. Falling is one of the most common adverse events associated with drugs. The elderly frequently take many medications; reducing these medications also reduces the risk of falling. SSRIs, tricyclic antidepressants, benzodiazepines, and anticonvulsants have the strongest association with falls in the elderly. The highest risk for falling occurs immediately after hospital stays and lasts for about a month. Ambulatory blood pressure monitoring is associated with so many false-negative and false-positive results that it cannot be recommended for all patients who fall. Arthritis and vision problems are both strongly associated with an increased risk of falls.
A 9-month-old male is seen for a routine well-baby examination. There have been no health problems and developmental milestones are normal. Review of the growth chart shows that length, weight, and head circumference have continued to remain at the 75th percentile. The examination is normal with the exception of the anterior fontanelle being closed. Proper management at this time would include: (check one) A. A CT scan of the head B. MRI of the head C. A CBC, a metabolic profile, and thyroid studies D. Referral to a neurologist E. Serial measurement of head circumference
E. Serial measurement of head circumference. The anterior fontanelle in the newborn is normally 0.6-3.6 cm, with the mean size being 2.1 cm. It may actually enlarge the first few months, but the medial age of closure is 13.8 months. The anterior fontanelle closes at 3 months in 1% of cases, and by 1 year, 38% are closed. While early closure of the anterior fontanelle may be normal, the head circumference must be carefully monitored. The patient needs to be monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development. When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation. If craniosynostosis is seen on the film, a CT scan should be obtained.
An overweight 13-year-old male presents with a 3-week history of right lower thigh pain. He first noticed the pain when jumping while playing basketball, but now it is present even when he is just walking. On examination he can bear his full weight without an obvious limp. There is no localized tenderness, and the patella tracks normally without subluxation. Internal rotation of the hip is limited on the right side compared to the left. Based on the examination alone, which one of the following is the most likely diagnosis? (check one) A. Avascular necrosis of the femoral head (Legg-Calvé-Perthes disease) B. Osteosarcoma C. Meralgia paresthetica D. Pauciarticular juvenile rheumatoid arthritis E. Slipped capital femoral epiphysis
E. Slipped capital femoral epiphysis. This is a classic presentation for slipped capital femoral epiphysis (SCFE) in an adolescent male who has probably had a recent growth spurt. Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy. Obese males are affected more often. The pain is typically in the anterior thigh, but in a high percentage of patients the pain may be referred to the knee, lower leg, or foot. Limited internal rotation of the hip, especially with the hip in 90°; flexion, is a reliable and specific finding for SCFE and should be looked for in all adolescents with hip, thigh, or knee pain. Meralgia paresthetica is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing. Legg-Calvé-Perthes disease (avascular or aseptic necrosis of the femoral head) is more likely to occur between the ages of 4 and 8 years. Juvenile rheumatoid arthritis typically is associated with other constitutional symptoms including stiffness, fever, and pain in at least one other joint, with the pain not necessarily associated with activity.
A 16-year-old white female is brought to your office because she has been "passing out." She tells you that on several occasions while playing in the high-school band at the end of the half-time show she has "blacked out." She describes feeling lightheaded with spots before her eyes and tunnel vision just prior to falling. Friends in the band have told her that she appears to be pale and sweaty when these episodes occur. No seizure activity has ever been observed. In each instance she regains consciousness almost immediately; there is no postictal state. She has been seen in the emergency department for this on two occasions with normal vital signs, physical findings, and neurologic findings. A CBC, a metabolic profile, and an EKG are also normal. Which one of the following tests is most likely to yield the correct diagnosis? (check one) A. A sleep-deprived EEG B. 24-hour Holter monitoring C. A pulmonary/cardiac stress test D. An echocardiogram E. Tilt table testing
E. Tilt table testing. Reflex syncope is a strong diagnostic consideration for episodes of syncope associated with a characteristic precipitating factor. The major categories of syncope include carotid sinus hypersensitivity, and neurally mediated and situational syncopes. The most common and benign forms of syncope are neurally mediated or vasovagal types with sudden hypotension, frequently accompanied by bradycardia. Other terms for this include neurocardiogenic, vasomotor, neurovascular, or vasodepressive syncope. Most patients are young and otherwise healthy. The mechanism of the syncope seems to be a period of high sympathetic tone (often induced by pain or fear), followed by sudden sympathetic withdrawal, which then triggers a paradoxical vasodilatation and hypotension. Attacks occur with upright posture, often accompanied by a feeling of warmth or cold sweating, lightheadedness, yawning, or dimming of vision. If the patient does not lie down quickly he or she will fall, with the horizontal position allowing a rapid restoration of central profusion. Recovery is rapid, with no focal neurologic sense of confusion or headache. The event can be duplicated with tilt testing, demonstrating hypotension and bradycardia.
A 74-year-old African-American female has moderately severe pain due to osteoarthritis. However, she is also on medication for a seizure disorder. When choosing medications to manage her chronic pain, which one of the following should be used with caution because of her history of seizures? (check one) A. Salsalate (Disalcid) B. Celecoxib (Celebrex) C. Hydrocodone (Lortab) D. Oxycodone (OxyContin) E. Tramadol (Ultram)
E. Tramadol (Ultram). According to the American Geriatrics Society 2002 clinical practice guidelines for management of persistent pain in older persons, tramadol has efficacy and safety similar to those of equianalgesic doses of codeine and hydrocodone. However, because of the threat of seizures (rare but potential), tramadol should be used with caution in patients with a history of seizure disorder or those taking other medications that lower seizure thresholds.
The most common cause of fainting is: (check one) A. Cardiac dysrhythmia B. Medications C. Orthostatic hypotension D. Psychiatric disorders E. Vasovagal syncope
E. Vasovagal syncope. Neurally mediated syncope (also termed neurocardiogenic or vasovagal syncope) comprises the largest group of disorders causing syncope. These disorders result from reflex-mediated changes in vascular tone or heart rate.
A 75-year-old white female presents with severe pain of the carpometacarpal joint at the base of her thumb. Examination of her hands also reveals hypertrophic changes of the distal interphalangeal and proximal interphalangeal joints of her fingers. These findings are most consistent with (check one) A. rheumatoid arthritis B. gout C. systemic lupus erythematosus D. scleroderma E. osteoarthritis
E. osteoarthritis. Osteoarthritis causes changes predominantly in the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the hands known as Bouchard's and Heberden's nodes respectively, and the carpometacarpal joints of the thumbs. While rheumatoid arthritis commonly causes subluxations in the metacarpophalangeal joints, this patient's hypertrophic changes are most likely due to osteoarthritis. The other choices are less likely to cause this presentation.
