AAFP 2 Flashcards
A 16-year-old female presents with a complaint of pelvic cramps with her menses over the past 2 years. She describes her periods as heavy, and says they occur once a month and last for 7 days, with no spotting in between. She has never been sexually active and does not expect this to change in the foreseeable future. An abdominal examination is normal. Which one of the following would be the most appropriate next step?
Naproxen prior to and during menses
(does not need pap smear)
This patient is experiencing primary dysmenorrhea, a common finding in adolescents, with estimates of prevalence ranging from 20% to 90%. Because symptoms started at a rather young age and she has pain only during menses, endometriosis or other significant pelvic pathology is unlikely. An infection is doubtful, considering that she is not sexually active and that symptoms have been present for 2 years. In the absence of red flags, a pelvic examination, laboratory evaluation, and pelvic ultrasonography are not necessary at this time. However, they can be ordered if she does not respond to simple treatment. NSAIDs such as naproxen have a slight effect on platelet function, but because they inhibit prostaglandin synthesis they actually decrease the volume of menstrual flow and lessen the discomfort of pelvic cramping. Acetaminophen would have no effect on prostaglandins
A 34-year-old female who delivered a healthy infant 18 months ago complains of a milky discharge from both nipples. She reports that normal periods have resumed since cessation of breastfeeding 6 months ago. She takes ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) for birth control. A complete review of systems is otherwise negative. The most likely cause of the discharge is
a medication side effect
This patient has galactorrhea, which is defined as a milk-like discharge from the breast in the absence of pregnancy in a non-breastfeeding patient who is more than 6 months post partum. It is more common in women ages 20-35 and in women who are previously parous. It also can occur in men. Medication side effect is the most common etiology. The most common pharmacologic cause of galactorrhea is oral contraceptives. Oral contraceptives that contain estrogen can both suppress prolactin inhibitory factor and stimulate the pituitary directly, both of which can cause galactorrhea. Other medications that can cause galactorrhea include metoclopramide, cimetidine, risperidone, methyldopa, codeine, morphine, verapamil, SSRIs, butyrophenones, dopamine-receptor blockers, tricyclics, phenothiazines, and thioxanthenes. Breast cancer is unlikely to present with a bilateral milky discharge. The nipple discharge associated with cancer is usually unilateral and bloody. Pituitary tumors are a pathologic cause of galactorrhea due to the hyperprolactinemia that is caused by the blockage of dopamine from the hypothalamus, or by the direct production of prolactin. However, patients often have symptoms such as headache, visual disturbances, temperature intolerance, seizures, disordered appetite, polyuria, and polydipsia. Patients with prolactinomas often have associated amenorrhea. These tumors are associated with marked levels of serum prolactin, often >200 ng/mL. Hypothalamic lesions such as craniopharyngioma, primary hypothalamic tumor, metastatic tumor, histiocytosis X, tuberculosis, sarcoidosis, and empty sella syndrome are significant but infrequent causes of galactorrhea, and generally cause symptoms similar to those of pituitary tumors, particularly headache and visual disturbances. It is rare for primary hypothyroidism to cause galactorrhea in adults. Symptoms that would be a clue to this diagnosis include fatigue, constipation, menstrual irregularity, weight changes, and cold intolerance.
The most common cause of abnormal vaginal discharge in a sexually active 19-year-old female is
A. Candida albicans B. Trichomonas vaginalis C. Staphylococcus D. Group B Streptococcus E. Bacterial vaginosis
Bacterial vaginosis
Bacterial vaginosis (BV) is the most common cause of acute vaginitis, accounting for up to 50% of cases in some populations. It is usually caused by a shift in normal vaginal flora. BV is considerably more common as a cause of vaginal discharge than C. albicans and T. vaginalis.
A 35-year-old female is planning a second pregnancy. Her last pregnancy was complicated by placental abruption caused by a large fibroid tumor of the uterus, which is still present. Which one of the following would be the most appropriate treatment for the fibroid tumor?
Myomectomy
There are numerous options for the treatment of uterine fibroids. When pregnancy is desired, myomectomy offers the best chance for a successful pregnancy when prior pregnancies have been marked by fibroid-related complications.
Endometrial ablation eliminates fertility, and there is a lack of long-term data on fertility after uterine artery embolization. Observation without treatment would not remove the risk for recurrent complications during subsequent pregnancies.
An asymptomatic 24-year-old white female comes to your office for a refill of oral contraceptive pills. A speculum examination is normal with the exception of a slightly friable, well-demarcated, 1.4-cm raised lesion involving a portion of the cervix. All previous Papanicolaou (Pap) tests have been normal and she has no history of abnormal bleeding or leukorrhea. What’s the appropriate management of this patient?
A Pap test and a colposcopically-directed biopsy
The finding of a red, raised, friable lesion on the cervix, or a well-demarcated cervical lesion, mandates a biopsy to exclude cervical carcinoma, and treatment for chronic cervicitis should not be started until the biopsy results are available. A Papanicolaou test by itself is insufficient if there is a grossly visible lesion, as false-negatives occur in 10%-50% of tests.
In patients with breast cancer, the most reliable predictor of survival is
stage (not grade)
The most reliable predictor of survival in breast cancer is the stage at the time of diagnosis. Tumor size and lymph node involvement are the main factors to take into account. Other prognostic parameters (tumor grade, histologic type, and lymphatic or blood vessel involvement) have been proposed as important variables, but most microscopic findings other than lymph node involvement correlate poorly with prognosis. Estrogen receptor (ER) status may also predict survival, with ER-positive tumors appearing to be less aggressive than ER-negative tumors.
Which fetal ultrasound measurements gives the most accurate estimate of gestational age in the first trimester (up to 14 weeks)?
Crown-rump length
Because the growth pattern of the fetus varies throughout pregnancy, the accuracy of measurements and their usefulness in determining gestational age and growth vary with each trimester. Crown-rump length is the distance from the top of the head to the bottom of the fetal spine. It is most accurate as a measure of gestational age at 7-14 weeks. After that, other measurements are more reliable. In the second trimester, biparietal diameter and femur length are used. During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age.
Late decelerations on fetal monitoring are thought to indicate :
Uteroplacental insufficiency
Late decelerations are thought to be associated with uteroplacental insufficiency and fetal hypoxia due to decreased blood flow in the placenta. This pattern is a warning sign and is associated with increasing fetal compromise, worsening fetal acidosis, fetal central nervous system depression, and/or direct myocardial hypoxia. Early decelerations are thought to result from vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity. Variable decelerations are thought to be due to acute, intermittent compression of the umbilical cord between fetal parts and the contracting uterus.
A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications. With respect to her amenorrhea, you advise her
to increase her caloric intake
Amenorrhea is an indicator of inadequate calorie intake, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. Young athletes may develop a combination of conditions, including eating disorders, amenorrhea, and osteoporosis (the female athlete triad). Amenorrhea usually responds to increased calorie intake or a decrease in exercise intensity. It is not necessary for patients such as this one to stop running entirely, however.
A 2-year-old white male is brought to your office by his mother, who says he has “infected ant bites.” He was playing in his cousin’s yard yesterday in south Texas and cried when small brown ants crawled on his feet and legs. A physical examination is normal except for about 20 pustular-appearing lesions on erythematous bases on his lower extremities. The lesions are 1–2 mm in size. The most appropriate management of this problem is to:
Recommend that the lesions be kept clean
The lesions described are typical of fire ant bites and are not infected. Fire ants are aggressive and these lesions do not imply abuse or neglect of the child. The lesions should be thoroughly cleaned with soap and water. Corticosteroids should be employed in severe cases, although their maximum effect is not achieved until several hours after administration.
A diabetic patient has a deep 2×3-cm dorsal foot ulcer, and you are concerned about the presence of osteomyelitis. Which one of the following would be most cost-effective for evaluating this problem?
Probing for bone at the base of the ulcer
From CURRENT: Open wounds should be probed with a sterile cotton swab or other appropriate instrument to evaluate the extent of involvement of deeper structures, such as tendons, joints, and bone. A positive probe-to-bone test usually indicates the presence of osteomyelitis.
AAFP: A recent study of foot ulcers in diabetics showed that finding palpable bone at the base of an ulcer with no intervening soft tissue had a higher positive predictive value than any type of imaging study, and correlated highly with the presence of underlying osteomyelitis. Other tests listed (MRI, CT scan, bone scan) are less likely to be diagnostic and are much more expensive than simple probing of a wound (NEJM 2000)
A 6-month-old white male is brought to your office because he has “blisters” in his diaper area. You find large bullae filled with cloudy yellow fluid. Some of the blisters have ruptured and the bases are covered with a thin crust. What is the most appropriate management of this condition?
A course of a penicillinase-resistant penicillin or a cephalosporin
Bullous impetigo is a localized skin infection characterized by large bullae; it is caused by a group 2 phage type of Staphylococcus aureus. Cultures of fluid from an intact blister will reveal the causative agent.
A 3-month-old infant is brought to your office with small pustules on the soles of the feet and a few similar lesions on the palms of her hands. Scabies is identified in scrapings of the lesions. Treatment?
prescribe permethrin (Elimite) 5% cream to be applied to the entire body, including the scalp
Scabies is usually not seen on the head, neck, palms, and soles in adults, but these areas are often affected in infants. Lindane may be hazardous to young infants because of its percutaneous absorption and potential neurotoxicity. Permethrin is at least equally effective, and because it is poorly absorbed and rapidly metabolized, its toxicity is low. Crotamiton cream and sulphur in petrolatum are safe options, but must be applied continuously over 3–5 days. Laundering of clothing and bedclothes is sufficient to prevent reinfestation. In fact, clothes may simply be hung outside for 3–4 days, because the isolated mite dies within 2–3 days.
A 7-year-old male with moderately severe atopic dermatitis has been treated with a variety of moisturizers and topical corticosteroid preparations over the past year. The results have been less than satisfactory. Which topical medication is appropriate at this time?
Tacrolimus (Protopic)
Tacrolimus is an immunomodulator indicated for the treatment of atopic dermatitis when corticosteroids and other conventional remedies are inadvisable, ineffective, or not tolerated. It is approved for use in patients over 2 years of age.
Cutaneous larva migrans is transmitted via:
[Picture: Cutaneous Larva Migrans. A serpiginous, linear, raise, tunnel-like erythematous lesion outlining the path of migration in the larva. Upon palpation, it feels like a thread within the superficial layers of the skin.]
Skin contact with soil
Larva migrans is transmitted by skin contact with soil contaminated with hookworm larvae from dog and cat feces in tropical and subtropical areas. Wearing shoes and sitting on a towel rather than directly on the ground are protective measures. Ref: Kitchen LW: Case studies in international travelers.
In the evaluation of foot ulcerations, a neuropathic etiology is suggested by which one of the following? A. Distal foot pain when supine B. Absence of toe hair C. Erectile dysfunction D. Thickened toenails E. Abnormal monofilament testing
Abnormal monofilament testing
Arterial insufficiency is suggested by a history of underlying cardiac or cerebrovascular disease, leg claudication, impotence, or pain in the distal foot when the patient is supine (the “rest pain” syndrome). Findings of diminished or absent pulses, pallor on elevation, redness of the foot on lowering of the leg (dependent rubor), sluggish refilling of toe capillaries, and thickened nails or absence of toe hair are consistent with impaired arterial perfusion to the foot. Measurement of cutaneous pressure perception with the use of Semmes-Weinstein monofilaments has been widely considered an ideal method of screening because of its simplicity, sensitivity, and low cost. (NEJM 2000)
About a month after returning from the Middle East, an American soldier develops a papule on his forearm that subsequently ulcerates to form a shallow annular lesion with a raised margin. The lesion shows no signs of healing 3 months after it first appeared. He has no systemic symptoms. The most likely diagnosis is:
Leishmaniasis
A 35-year-old female volleyball coach consults you about a pruritic, vesicular eruption on the medial aspect of both feet, which she says has spread to her hands, causing a vesicular eruption resembling dyshidrosis. She is not using any drugs internally or topically. The most likely diagnosis is:
Tinea pedis
This presentation is typical of tinea pedis, with the associated dermatophytid reaction. Treatment of the fungal illness will usually control both conditions.
What would be considered first-line therapy for mild to moderately severe psoriasis confined to the elbows and knees?
A. Phototherapy using ultraviolet B light
B. Methotrexate
C. Etretinate (Tegison)
D. Betamethasone dipropionate (Diprolene)
Betamethasone dipropionate (Diprolene)
The majority of psoriasis patients can be managed with topical agents such as betamethasone dipropionate. Systemic treatment is reserved for patients with disabling psoriasis that does not respond to topical treatment. This would include phototherapy, methotrexate, and etretinate.
What is the most effective initial treatment of head lice in an 8-year-old child?
Malathion (Ovide)
Malathion is currently the most effective treatment for head lice and is less toxic than lindane. Permethrin and pyrethrins are less effective than malathion, although they are acceptable alternatives. These insecticides, as well as lindane, are not recommended in children 2 years of age or younger. Wet combing may be effective, but is less than half as effective as malathion. Head shaving is only temporarily effective and is traumatic. Petrolatum is not proven to be effective.
How is scabies transmitted?
The scabies mite is predominantly transmitted by direct personal contact. Infestation from indirect contact with clothing or bedding is believed to be infrequent. Hats are frequent transmitters of head lice, but not scabies.
You see a healthy 7-year-old male who was bitten on the cheek 1 hour ago by a neighbor’s dog. On examination you find a jagged laceration about 2 cm long that extends into the fatty tissue. What is the appropriate management of this injury?
Copiously irrigate the wound with normal saline and suture
Dog bites are a common medical problem. Timely and copious irrigation with normal saline or Ringer’s lactate will reduce the rate of infection markedly. Recent wounds and wounds on the face are usually closed primarily. Cultures are usually not helpful unless the wound appears infected. Amoxicillin/clavulanate is the antibiotic of choice for a dog bite. Since this is a neighbor’s dog, it can be observed at home for 10 days if the rabies vaccination is current, or at a veterinarian’s office if vaccination status is unknown. Ref: Presutti RJ: Prevention and treatment of dog bites.
A 23-year-old Hispanic female at 18 weeks’ gestation presents with a 4-week history of a new facial rash. She has noticed worsening with sun exposure. Her past medical history and review of systems is normal. On examination, you note symmetric, hyperpigmented patches on her cheeks and upper lip. The remainder of her examination is normal. The most likely diagnosis is:
Melasma (chloasma)
Melasma or chloasma is common in pregnancy, with approximately 70% of pregnant women affected. It is an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip. The pathogenesis is not known. UV sunscreen is important, as sun exposure worsens the condition. Melasma often resolves or improves post partum. Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist. The facial rash of lupus is usually more erythematous, and lupus is relatively rare. Pemphigoid gestationis is a rare autoimmune disease with extremely pruritic, bullous skin lesions that usually spare the face. Prurigo gestationis involves pruritic papules on the extensor surfaces and is usually associated with significant excoriation by the uncomfortable patient.
You see a 16-year-old white female for a preparticipation evaluation for sports, and she asks for advice about the treatment of acne. She has a few inflammatory papules on her face. No nodules are noted. She says she has not tried any over-the-counter acne treatments. Which one of the following would be considered first-line therapy for this condition?
Topical benzoyl peroxide
The American Academy of Dermatology grades acne as mild, moderate, and severe. Mild acne is limited to a few to several papules and pustules without any nodules. Patients with moderate acne have several to many papules and pustules with a few to several nodules. Patients with severe acne have many or extensive papules, pustules, and nodules. The patient has mild acne according to the American Academy of Dermatology classification scheme. Topical treatments including benzoyl peroxide, retinoids, and topical antibiotics are useful first-line agents in mild acne. Topical sulfacetamide is not considered first-line therapy for mild acne. Oral antibiotics are used in mild acne when there is inadequate response to topical agents and as first-line therapy in more severe acne. Caution must be used to avoid tetracycline in pregnant females. Oral isotretinoin is used in severe nodular acne, but also must be used with extreme caution in females who may become pregnant. Special registration is required by physicians who use isotretinoin, because of its teratogenicity
The most appropriate initial treatment for scabies in an 8-year-old male is:
5% permethrin cream (Elimite)
In adults and children over 5 years of age, 5% permethrin cream is standard therapy for scabies. This agent is highly effective, minimally absorbed, and minimally toxic.
Painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy are best treated by:
Excision of the lateral nail plate combined with lateral matricectomy
Excision of the lateral nail plate with lateral matricectomy yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy. Antibiotic therapy and cotton-wick elevation are acceptable for very mildly inflamed ingrown toenails. Partial nail avulsion often leaves a spicule of nail that will grow and become an ingrown nail. Phenol produces irregular tissue destruction and significant inflammation and discharge after the matricectomy procedure.
A 55-year-old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions. Which one of the following organisms would be the most likely cause of cellulitis in this patient?
Non-group A Streptococcus
Cellulitis in patients after breast lumpectomy is thought to be related to lymphedema. Axillary dissection and radiation predispose to these infections. Non–group A hemolytic Streptococcus is the most common organism associated with this infection. The onset is often several weeks to several months after surgery.
A 12-year-old male middle-school wrestler comes to your office complaining of a recurrent painful rash on his arm. There appear to be several dry vesicles. Most likely diagnosis?
Herpes gladiatorum
The most common infection transmitted person-to-person in wrestlers is herpes gladiatorum caused by the herpes simplex virus. Molluscum contagiosum causes keratinized plugs. Human papillomavirus causes warts. Tinea corporis is ringworm, which is manifested by round to oval raised areas with central clearing.
You are evaluating a 45-year-old male construction worker with regard to his skin and sun exposure history. Which one of the following lesions should be considered premalignant?
A. Sebaceous hyperplasia B. Actinic keratosis C. Seborrheic keratosis D. A de Morgan spot E. A halo nevus
Actinic keratosis
Family physicians should advise patients of the dangers of sun exposure especially those with a fair complexion who work outdoors. Although malignant melanoma is the most serious condition of those listed, actinic keratosis may lead to squamous cell carcinoma with significant morbidity
The preferred method for diagnosing psychogenic nonepileptic seizures is:
video-electroencephalography (vEEG) monitoring
Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.
Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2 , and neuron-specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.
MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.
A 4-year-old white male is brought to your office because he has had a low-grade fever and decreased oral intake over the past few days. On examination you note shallow oral ulcerations confined to the posterior pharynx. Most likely diagnosis?
Herpangina
Herpangina is a febrile disease caused by coxsackieviruses and echoviruses. Vesicles and subsequent ulcers develop in the posterior pharyngeal area (SOR C). Herpes infection causes a gingivostomatitis that involves the anterior mouth. Mononucleosis may be associated with petechiae of the soft palate, but does not usually cause pharyngeal lesions. The exanthem in roseola usually coincides with defervescence. Mucosal involvement is not noted. Rubella may cause an enanthem of pinpoint petechiae involving the soft palate (Forschheimer spots), but not the pharynx.
A 45-year-old female presents with a rash on the central portion of her face. She states that she has intermittent flushing and intense erythema that feels as if her face is stinging. She has noticed that her symptoms can be worsened by sun exposure, emotional stress, alcohol, or eating spicy foods. She has been in good health and has taken conjugated estrogens (Premarin), 0.625 mg daily, since a hysterectomy for benign reasons. A general examination is normal except for erythema of the cheeks and chin. No pustules or comedone formation is noted around her eyes, but telangiectasias are present.
Most appropriate management of this problem?
Metronidazole gel (MetroGel)
Rosacea is a relatively common condition seen most often in women between the ages of 30 and 60. Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules. Facial edema also may occur. Some patients develop rhinophyma due to hypertrophy of the subcutaneous glands of the nose. The usual presenting symptoms are central facial erythema and flushing that many patients find socially embarrassing. Flushing can be triggered by food, environmental, chemical, or emotional triggers. Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis.
Management includes avoidance of precipitating factors and use of sunscreen. Oral metronidazole, doxycycline, or tetracycline also can be used, especially if there are ocular symptoms. These are often ineffective for the flushing, so low-dose clonidine or a nonselective β-blocker may be added.
Topical treatments such as metronidazole and benzoyl peroxide may also be effective, particularly for mild cases. Other illnesses to consider include acne, photodermatitis, systemic lupus erythematosus, seborrheic dermatitis, carcinoid syndrome, and mastocytosis.
Which one of the following confirmed findings in a 3-year-old female is diagnostic of sexual abuse? A. Bacterial vaginosis B. Genital herpes C. Gonorrhea D. Anogenital warts E. Hepatitis
Gonorrhea
The diagnosis of any sexually transmitted or associated infection in a postnatal prepubescent child should raise immediate suspicion of sexual abuse and prompt a thorough physical evaluation, detailed historical inquiry, and testing for other common sexually transmitted diseases. Gonorrhea, syphilis, and postnatally acquired Chlamydia or HIV are virtually diagnostic of sexual abuse, although it is possible for perinatal transmission of Chlamydia to result in infection that can go unnoticed for as long as 2–3 years. Although a diagnosis of genital herpes, genital warts, or hepatitis B should raise a strong suspicion of possible inappropriate contact and should be reported to the appropriate authorities, other forms of transmission are common. Genital warts or herpes may result from autoinoculation, and most cases of hepatitis B appear to be contracted from nonsexual household contact. Bacterial vaginosis provides only inconclusive evidence for sexual contact, and is the only one of the options listed for which reporting is neither required nor strongly recommended.
A 63-year-old male with type 2 diabetes mellitus is seen in the emergency department for an acute, superficial, previously untreated infected great toe. Along with Staphylococcus aureus, which one of the following is the most common pathogen in this situation?
Streptococcus
The most common pathogens in previously untreated acute superficial foot infections in diabetic patients are aerobic gram-positive Staphylococcus aureus and β-hemolytic streptococci (groups A, B, and others). Previously treated and deep infections are often polymicrobial.
An obese, hypertensive 53-year-old physician suffers a cardiac arrest while making rounds. He is resuscitated after 15 minutes of CPR, but remains comatose.
Which one of the following is associated with the lowest likelihood of neurologic recovery in this situation?
A. Duration of CPR >10 minutes
B. No pupillary light reflex at 30 minutes
C. No corneal reflex at 2 hours
D. No motor response to pain at 6 hours
E. Myoclonic status epilepticus at 24 hours
Myoclonic status epilepticus at 24 hours
It is difficult to establish a prognosis in a comatose patient after a cardiac arrest. The duration of CPR is not a factor, and the absence of pupillary and corneal reflexes, as well as motor responses to pain, are not reliable predictors before 72 hours. Myoclonic status epilepticus at 24 hours suggests no possibility of a recovery.
A 61-year-old female is found to have a serum calcium level of 11.6 mg/dL (N 8.6–10.2) on routine laboratory screening. To confirm the hypercalcemia you order an ionized calcium level, which is 1.49 mmol/L (N 1.14–1.32). Additional testing reveals an intact parathyroid hormone level of 126 pg/mL (N 15–75) and a urine calcium excretion of 386 mg/24 hr (N 100–300).
What is the most likely cause of the patient’s hypercalcemia?
Primary hyperparathyroidism
Primary hyperparathyroidism and malignancy account for more than 90% of hypercalcemia cases. These conditions must be differentiated early to provide the patient with optimal treatment and an accurate prognosis. Humoral hypercalcemia of malignancy implies a very limited life expectancy—often only a matter of weeks. On the other hand, primary hyperparathyroidism has a relatively benign course. Intact parathyroid hormone (PTH) will be suppressed in cases of malignancy-associated hypercalcemia, except for extremely rare cases of parathyroid carcinoma. Thyrotoxicosis-induced bone resorption elevates serum calcium, which also results in suppression of PTH.
Patients with familial hypocalciuric hypercalcemia (FHH) have moderate hypercalcemia but relatively low urinary calcium excretion. PTH levels can be normal or only mildly elevated despite the hypercalcemia. This mild elevation can lead to an erroneous diagnosis of primary hyperparathyroidism. The conditions can be differentiated by a 24-hour urine collection for calcium; calcium levels will be high or normal in patients with hyperparathyroidism and low in patients with FHH.
A 40-year-old male who recently immigrated from central Africa presents to a public health clinic where you are working. He was referred by a physician in the local emergency department, who made a diagnosis of type 2 diabetes mellitus. The patient has no history of fever or night sweats, weight loss, or cough. He does have a history of receiving bacille Calmette-Guérin (BCG) vaccine in the past. Screening tests for HIV and hepatitis performed in the emergency department were negative.
What do you know about screening for latent tuberculosis infection by in vitro interferon-gamma release assay (IGRA) compared to screening by the traditional targeted tuberculin skin test (TST) in this patient?
IGRA differentiates Mycobacterium tuberculosis from nontuberculous mycobacteria
In vitro interferon-gamma release assays (IGRAs) are a new way of screening for latent tuberculosis infection. One of the advantages of IGRA is that it targets antigens specific to Mycobacterium tuberculosis. These proteins are absent from the BCG vaccine strains and from commonly encountered nontuberculous mycobacteria. Unlike skin testing, the results of IGRA are objective. It is unnecessary for IGRA to be done in tandem with skin testing, and it eliminates the need for two-step testing in high-risk patients. IGRAs are labor intensive, however, and the blood sample must be received by a qualified laboratory and incubated with the test antigens within 8-16 hours of the time it was drawn,depending upon the brand of cuurently available IGRAs
An 11-year-old female has been diagnosed with “functional abdominal pain” by a pediatric gastroenterologist. Her mother brings her to see you because of concerns that another diagnosis may have been overlooked despite a very thorough and completely normal evaluation for organic causes.
What’s the “next step” you would recommend?
Stress reduction and participation in usual activities as much as possible
The diagnosis of functional abdominal pain is made when no structural, infectious, inflammatory, or biochemical cause for the pain can be found. It is the most common cause of recurrent abdominal pain in children 4–16 years of age. The use of medications may be helpful in reducing (but rarely eradicating) functional symptoms, and remaining open to the possibility of a previously unrecognized organic disorder is appropriate. However, continuing to focus on organic causes, invasive tests, or physician visits can actually perpetuate a child’s complaints and distress.
It is estimated that approximately 30%–50% of children with functional abdominal pain will have resolution of their symptoms within 2 weeks of diagnosis. Recommendations for managing this problem include focusing on participation in normal age-appropriate activities, reducing stress and addressing emotional distress, and teaching the family to cope with the symptoms in a way that prevents secondary gain on the part of the child.
Amiodarone (Cordarone) is most useful for which one of the following?
A. Prophylactic perioperative use for emergency surgery
B. Primary prevention of nonischemic cardiomyopathy
C. Treatment of atrial flutter
D. Treatment of multi-focal premature ventricular contractions following acute myocardial infarction
E. Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability
Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability
Amiodarone is one of the most frequently prescribed antiarrhythmic medications in the U.S. It is useful in the acute management of sustained ventricular tachyarrhythmias, regardless of hemodynamic stability. Amiodarone is appropriate first-line treatment for atrial fibrillation only in symptomatic patients with left ventricular dysfunction and heart failure. It has a very limited role in the treatment of atrial flutter. The only role for prophylactic amiodarone is in the perioperative period of cardiac surgery. The use of prophylactic antiarrhythmic agents in the face of “warning dysrhythmias” or after myocardial infarction is no longer recommended. Prophylactic amiodarone is not indicated for primary prevention in patients with nonischemic cardiomyopathy.
A 75-year-old white female presents with back pain of several months’ duration, which is worsened by movement. Her examination is unremarkable except for mild pallor. She takes furosemide (Lasix) for hypertension. Laboratory Findings Hemoglobin 10.0 g/dL (N 12.0–16.0) Serum creatinine 2.0 mg/dL (N 0.6–1.5) BUN 40 mg/dL (N 8–25) Serum uric acid 8.0 mg/dL (N 3.0–7.0) Serum calcium 12.0 mg/dL (N 8.5–10.5) Total serum protein 9.8 g/dL (N 6.0–8.4) Globulin 6.1 g/dL (N 2.3–3.5) Albumin 3.7 g/dL (N 3.5–5.0) Serum IgG 3700 mg/dL (N 639–1349) Urine positive for Bence-Jones protein Which one of the following would be most appropriate at this point?
Obtain a bone marrow examination
This patient has typical symptoms and laboratory findings of multiple myeloma, which accounts for 1% of all malignant diseases and has a mean age at diagnosis of 61 years. The diagnosis is confirmed by a bone marrow examination showing >10% plasma cells in the marrow. The serum level of M-protein is typically >3 g/dL.
A 34-year-old white male letter carrier has developed progressively worsening dysphagia for liquids and solids over the past 3 months. He says that he has lost about 30 lb during that time. On examination, you note that he is emaciated and appears ill. His pulse rate is 98 beats/min, temperature 37.8° C (100.2° F), respiratory rate 24/min, and blood pressure 95/60 mm Hg. His weight is 45 kg (99 lb) and his height is 170 cm (67 in). His dentition is poor, and there is evidence of oral thrush. His mucous membranes are dry. You palpate small posterior cervical and axillary nodes. The heart, lung, and abdominal examinations are normal. You promptly consult a gastroenterologist, who performs upper endoscopy which reveals numerous small ulcers scattered throughout the esophagus with otherwise normal mucosa. As you continue to investigate, you take a more detailed history. Which one of the following findings is most likely to be related to the patient’s problem?
Intravenous drug use
A young man with weight loss, oral thrush, lymphadenopathy, and ulcerative esophagitis is likely to have HIV infection. Intravenous drug use is responsible for over a quarter of HIV infections in the United States. Esophageal disease develops in more than half of all patients with advanced infection during the course of their illness. The most common pathogens causing esophageal ulceration in HIV-positive patients include Candida, herpes simplex virus, and cytomegalovirus. Identifying the causative agent through culture or tissue sampling is important for providing prompt and specific therapy.
The mother of a 5-day-old white male brings the infant to your office because of profuse bleeding from his circumcision site. A plastibell technique was used, and the bell is partially on. The mother reports that there was some scrotal bruising after the procedure. The remainder of the pre- and postnatal history is unremarkable. The infant appears healthy and vigorous. There is no heart murmur. Capillary refill is good. There is no bruising and no petechiae. Laboratory Findings Hematocrit 54% (N 41–65) Hemoglobin 18.0 g/dL (N 13.4–19.8) WBCs 14,000/mm3 (N 6000–17,500) Platelets 278,000/mm3 (N 150,000–400,000) Prothrombin time 12 sec (N 10–16) Activated partial pro- thrombin time 87 sec (N 31–54) Which one of the following additional tests will most likely help you to make the correct diagnosis?
Factor VIII level
Hemophilia is X-linked and occurs in approximately 1 in 5000 male births, with 85% having factor VIII deficiency (hemophilia A) and the remaining 15% having factor IX (hemophilia B) and factor XI (hemophilia C) deficiency. Because factor VIII does not cross the placenta, bleeding symptoms may be present from birth, with the most dreaded manifestation being intracranial hemorrhage. About 30% of affected male infants will bleed from the circumcision site. The only “routine” laboratory test that is affected by a reduced level of factor VIII is the activated partial thromboplastin time. Once hemophilia is suspected, the specific assay for factor VIII will confirm the diagnosis. Factor VIII levels in affected persons vary from less than 1% to approximately 25% of normal activity. Clinical severity of the disease varies with the degree of deficiency of factor VIII activity. Recently developed recombinant factor VIII for treating patients with hemophilia can help prevent transfusion-related infections. Deficiencies of antithrombin III, protein S and protein C, and mutations of the gene for factor V (factor V Leiden) are associated with thrombotic conditions, not bleeding.
What intervention has proven most useful in preventing vertical transmission of HIV infection from mother to neonate?
Zidovudine (Retrovir) for both the mother and neonate
Antiretroviral treatment has been proven to reduce vertical transmission of HIV from mother to child. Benefits have been shown for antenatal, intrapartum, and postpartum treatments. Zidovudine and nevirapine have the most well-established track record.
A 72-year-old female is found to have a complex splenic mass on a CT scan done for another reason. Because of concerns regarding possible malignancy and the potential for spontaneous splenic rupture, an elective splenectomy is planned. What immunizations should be given prior to her surgery?
Pneumococcal vaccine (Pneumovax)
Asplenic and functionally asplenic patients are susceptible to overwhelming infection from encapsulated organisms, and should be immunized with pneumococcal, meningococcal, and Hib vaccines. The vaccines’ immunogenicity may be reduced when given after splenectomy or during chemotherapy; thus, they should be given at least 2 weeks before performing elective splenectomy or starting chemotherapy if possible.
Which vitamin deficiency is most likely in a child who is fed a strict vegetarian diet which excludes meat, eggs, and dairy products?
Vitamin B12
There is no known vegetable source for vitamin B12. If the diet contains milk and eggs, however, the requirement will be satisfied. Vitamin C is present in high concentrations in fruits and vegetables. Vitamin A is found in green, leafy vegetables. Thiamine is present in grains, especially the outer coatings.
You regularly volunteer your professional services to a free clinic in an underserved community in a large U.S. city where various infectious diseases are prevalent. You are helping the staff develop some recommendations regarding infectious diseases that place infants at risk during breastfeeding. Which maternal infectious disease should be included as an ABSOLUTE contraindication to breastfeeding in otherwise healthy infants?
HIV infection
HIV and HTLV-1 (human T-cell lymphotropic virus) infections are the only infectious diseases that are considered absolute contraindications to breastfeeding in developed countries such as the U.S. The other infections listed may require temporary isolation of the baby from the mother, prophylactic treatment, or immunization of the baby and/or feeding pumped breast milk, but none are absolute contraindications to breastfeeding. For example, if the diagnosis of maternal hepatitis A is made within the period of contagiousness (approximately 3 weeks), careful handwashing by the mother is appropriate, and the infant can receive immunoglobulin and hepatitis A virus vaccine. Studies have shown that in full-term, healthy infants, acquisition of cytomegalovirus from breast milk does not result in significant clinical disease and is considered natural vaccination. Since breast milk does not contain tubercle bacilli, mothers with active tuberculosis may pump their milk to be bottle-fed to the infant by another person. For some common infections, such as the common cold, infants have already been exposed by maternal contact during the prodromal period, and interrupting breastfeeding would be counterproductive given that it provides the infant with antibodies and other anti-inflammatory and immunomodulating substances.
What is the best initial screening test for hereditary hemochromatosis?
Serum transferrin saturation
The diagnosis of hereditary hemochromatosis is based on a combination of clinical, laboratory, and pathologic criteria. Serum transferrin saturation is the best initial screening value. Serum ferritin concentration is a sensitive measure of iron overload, but ferritin is an acute-phase reactant and is therefore elevated in a variety of infectious and inflammatory conditions in the absence of iron overload.
A 40-year-old female is scheduled for a cholecystectomy and you wish to estimate her risk for postoperative bleeding. What is the most sensitive method for identifying her risk?
Bleeding history
Bleeding time, activated partial thromboplastin time (aPTT), and prothrombin time (PT) are relatively poor predictors of bleeding risk. Studies have shown that baseline coagulation assays do not predict postoperative bleeding in patients undergoing general or vascular surgery who have no history that suggests a bleeding disorder. Obtaining a history for evidence of prior bleeding problems is the most sensitive and accurate method of determining a patient’s risk.
A 1-year-old infant is brought to your office for a well child visit. A screening CBC reveals her hemoglobin to be 10.5 g/dL (N 11.0–14.0) with a mean corpuscular volume of 69 µm3 (N 70–84). What is the most likely cause of her anemia?
Iron deficiency
This child has evidence of a mild microcytic anemia, which is most commonly caused by iron deficiency related to reduced dietary intake. Less common causes are thalassemia and lead poisoning. Hemolysis usually causes a normocytic anemia with an elevated reticulocyte count. Chronic liver disease and hypothyroidism result in macrocytic anemias.
A 6-day-old white male is brought to your office with a 12-hour history of the sudden onset of vomiting and apparent abdominal pain. The emesis was initially clear, but over the last few hours it has become quite bilious. The pregnancy was uncomplicated and the child was delivered at term. On examination the child is lethargic with a tender abdomen, but no bowel distention. Of the following, which one is the most likely diagnosis? A. Duodenal atresia B. Malrotation and midgut volvulus C. Pyloric stenosis D. Necrotizing enterocolitis E. Jejunoileal atresia
Malrotation and midgut volvulus
Infants with malrotation and midgut volvulus often present in the first week of life with symptoms of bilious vomiting and bowel obstruction. Both duodenal and jejunoileal atresia most commonly present within the first 24 hours of life. Vomiting associated with pyloric stenosis is always non-bilious, and the diagnosis is most commonly made after the first week of life. Necrotizing enterocolitis may also be associated with bilious vomiting, but typically occurs at 10–12 days of life and is accompanied by abdominal distention and visible and/or palpable loops of bowel.
A 65-year-old white female comes to your office with evidence of a fecal impaction which you successfully treat. She relates a history of chronic laxative use for most of her adult years. After proper preparation, you perform sigmoidoscopy and note that the anal and rectal mucosa contain scattered areas of bluish-black discoloration. What is the most likely explanation for the sigmoidoscopic findings?
Melanosis coli
This patient has typical findings of melanosis coli, the term used to describe black or brown discoloration of the mucosa of the colon. It results from the presence of dark pigment in large mononuclear cells or macrophages in the lamina propria of the mucosa. The coloration is usually most intense just inside the anal sphincter and is lighter higher up in the sigmoid colon. The condition is thought to result from fecal stasis and the use of anthracene cathartics such as cascara sagrada, senna, and danthron.
What is the most common cause of bleeding in patients with Meckel’s diverticulum?
Ectopic (heterotrophic) gastric mucosa causing acid-induced bleeding of ileal mucosa
Most bleeding in Meckel’s diverticulum is secondary to heterotrophic gastric mucosa, causing acid-induced ileal ulceration. Helicobacter pylori has not been shown to be an etiologic agent. Intussusception is fairly common in patients with Meckel’s diverticulum but is not a frequent cause of bleeding.
A 55-year-old white male smoker has had daily severe gastroesophageal reflux symptoms unrelieved by intensive medical therapy with proton pump inhibitors. A recent biopsy performed during upper endoscopy identified Barrett’s esophagus. What is true about this condition?
It is associated with an increased risk of adenocarcinoma
Barrett’s esophagus is an acquired intestinal metaplasia of the distal esophagus associated with longstanding gastroesophageal acid reflux, although a quarter of patients with Barrett’s esophagus have no reflux symptoms. It is more common in white and Hispanic men over 50 with longstanding severe reflux symptoms, and possible risk factors include obesity and tobacco use. It is a risk factor for adenocarcinoma of the esophagus, with a rate of about one case in every 200 patients with Barrett’s esophagus per year. Treatment is directed at reducing reflux, thus reducing symptoms. Neither medical nor surgical treatment has been shown to reduce the carcinoma risk. One reasonable screening suggestion is to perform esophagoduodenoscopy in all men over 50 with gastroesophageal reflux disease (GERD), but these recommendations are based only on expert opinion (level C evidence), and no outcomes-based guidelines are available.
What animal has been shown to transmit Salmonella infections to humans?
Iguanas
Pet-associated salmonellosis was a significant problem in the 1970s. In 1975, Canada banned the importation of turtles, and in the same year the FDA prohibited the sale of small turtles in the U.S. However, the popularity of iguanas and other reptiles is increasing; these reptiles can also transmit Salmonella to humans. Reptile-associated salmonellosis causes febrile gastroenteritis, septicemia, and meningitis.
What is the most common cause of bacterial diarrhea?
Campylobacter jejuni
A 25-year-old white male truck driver complains of 1 day of throbbing rectal pain. Your examination shows a large, thrombosed external hemorrhoid. What is the preferred initial treatment for this patient?
Elliptical excision of the thrombosed hemorrhoid
The appropriate management of a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia (i.e., 0.5% bupivacaine hydrochloride [Marcaine] in 1:200,000 epinephrine) infiltrated slowly with a small (27 gauge) needle for patient comfort. Incision and clot removal may provide inadequate drainage with rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots which may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids. Banding an external hemorrhoid would cause exquisite pain. When pain is already subsiding or more time has elapsed (in the absence of necrosis or ulceration), measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may all be helpful. Some local anesthetics carry the risk of sensitization, however counseling to avoid precipitating factors (e.g., prolonged standing/sitting, constipation, delay of defecation) is also appropriate.
A positive spot urine test for homovanillic acid (HMA) and vanillylmandelic acid (VMA) is a marker for which condition?
Neuroblastoma
Tumor markers are useful in determining the diagnosis and sometimes the prognosis of certain tumors. They can aid in assessing response to therapy and detecting tumor recurrence. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors.
A slender 22-year-old female is concerned about a recent weight loss of 10 lb, frequent mild abdominal pain, and significant diarrhea of 2 months’ duration. Her physical examination is unremarkable, and laboratory studies reveal only a moderate microcytic, hypochromic anemia. Based on this presentation, what is the most likely diagnosis?
Celiac disease
This constellation of symptoms strongly suggests celiac disease, a surprisingly common disease with a prevalence of 1:13 in the U.S. Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.
A 72-year-old male has had persistent interscapular pain with movement since rebuilding his deck 1 week ago. He rates the pain as 6 on a 10-point scale. A chest radiograph shows a thoracic vertebral compression fracture.
What’s the appropriate next step?
Markedly decreased activity until the pain lessens, and follow-up in 1 week
This patient has suffered a thoracic vertebral compression fracture. Most can be managed conservatively with decreased activity until the pain is tolerable, possibly followed by some bracing. Vertebroplasty is an option when the pain is not improved in 2 weeks. Complete bed rest is unnecessary and could lead to complications. Physical therapy is not indicated, and NSAIDs should be used with caution.
On his first screening colonoscopy, a 67-year-old male is found to have a 0.5-cm adenomatous polyp with low-grade dysplasia.
According to current guidelines, when should this patient have his next colonoscopy?
5 years
Overuse of colonoscopy has significant costs. In response to these concerns, the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer collaborated on a consensus guideline on the use of surveillance colonoscopy. According to these guidelines, patients with one or two small (
A 25-year-old female has been trying to conceive for over 1 year without success. Her menstrual periods occur approximately six times per year. Laboratory evaluation of her hormone status has been negative, and her husband has a normal semen analysis. Her only other medical problem is hirsutism, which has not responded to topical treatment. Pelvic ultrasonography of her uterus and ovaries is unremarkable.
What would be the most appropriate treatment for her infertility?
Metformin (Glucophage)
This patient fits the criteria for polycystic ovary syndrome (oligomenorrhea, acne, hirsutism, hyperandrogenism, infertility). Symptoms also include insulin resistance. Evidence of polycystic ovaries is not required for the diagnosis.
Metformin has the most evidence supporting its use in this situation, and is the only treatment listed that is likely to decrease hirsutism and improve insulin resistance and menstrual irregularities. Metformin and clomiphene alone or in combination are first-line agents for ovulation induction.
When treating acute adult asthma in the emergency department, using a metered-dose inhaler (MDI) with a spacer has been shown to result in what outcome measures, compared to use of a nebulizer?
Shorter stays in the emergency department
Compared to nebulizers, MDIs with spacers have been shown to lower pulse rates, provide greater improvement in peak-flow rates, lead to greater improvement in arterial blood gases, and decrease required albuterol doses. They have also been shown to lower costs, shorten emergency department stays, and significantly lower relapse rates at 2 and 3 weeks compared to nebulizers. There is no difference in hospital admission rates.
A 31-year-old female who is a successful professional photographer complains of hoarseness that started suddenly 3 weeks ago. She says she can remember exactly what day it was, because her divorce became final the next day. The day the problem began, she was only able to whisper from the time she woke up, and she is able to speak only in a weak whisper while relating her history. She does not appear to strain while speaking. She does not smoke, has had no symptoms of an upper respiratory infection, and has no pain, cough, or wheezing.
She is on a proton pump inhibitor prescribed by an urgent care provider 2 weeks ago. This has not changed her symptoms. She takes no other medications and has no known allergies. A head and neck examination, including indirect laryngoscopy, is within normal limits.
Which one of the following is the most likely diagnosis?
A. Muscle tension aphonia B. Laryngopharyngeal reflux C. Spasmodic dysphonia D. Vocal abuse E. Conversion aphonia
Conversion aphonia
This patient has conversion aphonia. In this condition, the patient loses his or her spoken voice, but the whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce) (SOR C).
Muscle tension aphonia presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example. The patient with laryngopharyngeal reflux presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing.
The patient with spasmodic dysphonia (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm. The hoarseness of vocal abuse is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.
A 62-year-old diabetic with stage 2 renal dysfunction is evaluated for knee pain that has mildly interfered with his usual activities over the past 3 months. On examination he is mildly tender over the medial joint line. A knee radiograph shows moderate medial joint space narrowing.
In addition to low-impact exercise, which one of the following would you recommend initially?
A. Intra-articular hyaluronic acid B. Intra-articular corticosteroids C. Celecoxib (Celebrex) D. Naproxen E. Acetaminophen
Acetaminophen
Intra-articular injections should not be considered first-line treatment for symptomatic osteoarthritis of the knee. They are recommended for short-term pain control, with the evidence for hyaluronic acid being somewhat weak. Renal dysfunction is a contraindication to the use of NSAIDs. Acetaminophen is the first-line treatment in this case.
A 24-year-old female presents with pelvic pain. She says that the pain is present on most days, but is worse during her menses. Ibuprofen has helped in the past but is no longer effective. Her menses are normal and she has only one sexual partner. A physical examination is normal.
What’s the next step in the work-up of this patient?
Transvaginal ultrasonography
The initial evaluation for chronic pelvic pain should include a urinalysis and culture, cervical swabs for gonorrhea and Chlamydia, a CBC, an erythrocyte sedimentation rate, a β-hCG level, and pelvic ultrasonography. CT and MRI are not part of the recommended initial diagnostic workup, but may be helpful in further assessing any abnormalities found on pelvic ultrasonography. Referral for diagnostic laparoscopy is appropriate if the initial workup does not reveal a source of the pain, or if endometriosis or adhesions are suspected. Colonoscopy would be indicated if the history or examination suggests a gastrointestinal source for the pain after the initial evaluation
A 7-year-old male presents with a fever of 38.5°C (101.3°F), a sore throat, tonsillar inflammation, and tender anterior cervical adenopathy. He does not have a cough or a runny nose. His younger sister was treated for streptococcal pharyngitis last week and his mother would like him to be treated for streptococcal infection.
Is empiric antibiotic treatment for streptococcal pharyngitis is warranted?
Yes
The patient has a score of 5 under the Modified Centor scoring system for management of sore throat. Patients with a score ≥4 are at highest risk (at least 50%) of having group A β-hemolytic streptococcal (GABHS) pharyngitis, and empiric treatment with antibiotics is warranted. Various national and international organizations disagree about the best way to manage pharyngitis, with no consensus as to when or how to test for GABHS and who should receive treatment.
A 24-year-old female with a 2-year history of dyspnea on exertion has been diagnosed with exercise-induced asthma by another physician. Which one of the following findings on pulmonary function testing would raise concerns that she actually has vocal cord dysfunction?
Flattening of the inspiratory portion of the flow-volume loop, but a normal expiratory phase
The diagnosis of vocal cord dysfunction should be considered in patients diagnosed with exercise-induced asthma who do not have a good response to β-agonists before exercise. Pulmonary function testing with a flow-volume loop typically shows a normal expiratory portion but a flattened inspiratory phase (SOR C). A decreased FEV1 and normal FVC would be consistent with asthma.
A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-leg heel raise.
What’s the appropriate next step in the management of this patient?
Immobilization in a cast boot for 3 weeks is indicated
The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity.
The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture.
Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem.
While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2–3 weeks.
A 70-year-old male presents to your office for a follow-up visit for hypertension. He was started on lisinopril (Prinivil, Zestril), 20 mg daily, 1 month ago. Laboratory tests from his last visit, including a CBC and a complete metabolic panel, were normal except for a serum creatinine level of 1.5 mg/dL (N 0.6–1.5). A follow-up renal panel obtained yesterday shows a creatinine level of 3.2 mg/dL and a BUN of 34 mg/dL (N 8–25).
Which one of the following is the most likely cause of this patient’s increased creatinine level?
Bilateral renal artery stenosis
Classic clinical clues that suggest a diagnosis of renal-artery stenosis include the onset of stage 2 hypertension (blood pressure >160/100 mm Hg) after 50 years of age or in the absence of a family history of hypertension; hypertension associated with renal insufficiency, especially if renal function worsens after the administration of an agent that blocks the renin-angiotensin-aldosterone system; hypertension with repeated hospital admissions for heart failure; and drug-resistant hypertension (defined as blood pressure above the goal despite treatment with three drugs of different classes at optimal doses).
A 58-year-old male presents with a several-day history of shortness of breath with exertion, along with pleuritic chest pain. His symptoms started soon after he returned from a vacation in South America. He has a history of deep-vein thrombosis (DVT) in his right leg after surgery several years ago, and also has a previous history of prostate cancer. You suspect pulmonary embolism (PE.).
Which one of the following is true regarding the evaluation of this patient?
A. CT angiography would reliably either confirm or rule out PE
B. Compression ultrasonography of the lower extremities will reveal a DVT in the majority of patients with PE
C. No further testing is needed if a ventilation-perfusion lung scan shows a low probability of PE
D. No further testing is needed if a D-dimer level is normal
E. An elevated D-dimer level would confirm the diagnosis of PE
CT angiography would reliably either confirm or rule out PE
This patient has a high clinical probability for pulmonary embolism (PE). About 40% of patients with PE will have positive findings for deep-vein thrombosis in the lower extremities on compression ultrasonography. A normal ventilation-perfusion lung scan rules out PE, but inconclusive findings are frequent and are not reassuring. A normal D-dimer level reliably rules out the diagnosis of venous thromboembolism in patients at low or moderate risk of pulmonary embolism, but the negative predictive value of this test is low for high-probability patients. A positive D-dimer test does not confirm the diagnosis; it indicates the need for further testing, and is thus not necessary for this patient. A multidetector CT angiogram or ventilation-perfusion lung scan should be the next test, as these are reliable to confirm or rule out PE.
A 30-year-old white gravida 2 para 1 who has had no prenatal care presents for urgent care at 33 weeks gestation. Her symptoms include vaginal bleeding, uterine tenderness, uterine pain between contractions, and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term.
Which one of the following is the most likely diagnosis?
Placental abruption
Late pregnancy bleeding may cause fetal morbidity and/or mortality as a result of uteroplacental insufficiency and/or premature birth. The condition described here is placental abruption (separation of the placenta from the uterine wall before delivery).
There are several causes of vaginal bleeding that can occur in late pregnancy that might have consequences for the mother, but not necessarily for the fetus, such as cervicitis, cervical polyps, or cervical cancer. Even advanced cervical cancer would be unlikely to cause the syndrome described here. The other conditions listed may bring harm to the fetus and/or the mother.
Uterine rupture usually occurs during active labor in women with a history of a previous cesarean section or with other predisposing factors, such as trauma or obstructed labor. Vaginal bleeding is an unreliable sign of uterine rupture and is present in only about 10% of cases. Fetal distress or demise is the most reliable presenting clinical symptom. Vasa previa (the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment) is typically manifested by the onset of hemorrhage at the time of amniotomy or by spontaneous rupture of the membranes. There are no prior maternal symptoms of distress. The hemorrhage is actually fetal blood, and exsanguination can occur rapidly. Placenta previa (placental implantation that overlies or is within 2 cm of the internal cervical os) is clinically manifested as vaginal bleeding in the late second or third trimester, often after sexual intercourse. The bleeding is typically painless, unless labor or placental abruption occurs.
